- Email: [email protected]
Physical activity maintenance in elders with cardiac problems
Feature Article
Physical Activity Maintenance in Elders with Cardiac Problems Molly J. Allison, PhD, RN, CNS, and Colleen Keller, PhD, RN, FNP
Abstract: Clinicians who work with elderly people after acute cardiac events need strategies to facilitate the continuance of physical activity learned in cardiac rehabilitation programs. This exploratory study examined three factors related to this maintenance in 31 men and women: self-efficacy, stages of change, and social support for exercise. Self-efficacy was significantly correlated to stages of change and physical activity. Clinicians can use these factors to develop strategies to enhance the maintenance of exercise in elders with cardiac problems. (Geriatr Nurs 1999;21:200-3)
T
he relationships between physical activity (PA) and cardiovascular health are well established.1-3 Unfortunately, more than half the people who begin a physical activity program drop out within 6 months.4 The difficulty associated with elders engaging in physical activity has led investigators to examine strategies that strengthen behavior changes necessary for health promotion.5 Two of every five people age 65 and older report sedentary lifestyles and increase their death risk by 5% to 6%.6-8 Knowledge of the underlying processes that influence the older adult to initiate and maintain lifestyle changes is an important prerequisite to the development of a physical activity intervention. The purpose of this exploratory study was to examine the relationships between variables associated with the initiation and maintenance of physical activity in older individuals after a cardiac event. The specific aims were to determine the relationships between self-efficacy, stages of change, and social support and the level of physical activity sustained in older adults after cardiac rehabilitation.
BACKGROUND AND SIGNIFICANCE Adults are encouraged to engage in 30 minutes or more of moderately intense physical activity most, if not all, days of the week.9,10 In the study of health behavior and the elderly, a number of factors have been shown to be strongly related to the initiation and maintenance of exercise behavior, including social cognitive theory or self-efficacy, stages of change, and social support.11 Self-efficacy. A particularly important idea in Bandura’s Social Cognitive Theory is that of self-efficacy. 12-14 Perceived selfefficacy, the individual’s belief concerning his or her ability to ex-
200
Geriatric Nursing 2000 • Volume 21 • Number 4
ecute a specified course of action, has a powerful influence on behavior. 12 Considerable research provides support for the use of self-efficacy in predicting physical activity participation in healthy adults,15 adults with coronary heart disease, and those undergoing cardiac rehab exercise. 16-21 Stages of Change. The stages of change model22 that has been used to explain exercise behavior23-25 suggests that an individual engaging in a new behavior moves through certain stages. Two studies26,27 addressed the stages of change with older adults and concluded that the model effectively differentiated stages of readiness for exercise. In addition, the integration of both the model and self-efficacy demonstrated significant relationships between self-efficacy and the stage of exercise behavior.24,28 Social support. Social support is a theoretical construct that describes interpersonal support behaviors and relationships and is thought of in terms of its enhancement of positive health behaviors.29 Social support has been correlated with positive health practices,30 has been identified as a predictor of psychologic and emotional adjustment to lifestyle alterations after myocardial infarction,31 and has been positively correlated to exercise32 and exercise adherence.33 These three factors have been shown to be strongly associated with an individual’s engagement in physical activity. However, little is known about the nature and strength of these relationships to exercise maintenance in the older adult after cardiac rehab.
METHOD Sample A convenience sample of 31 English-speaking elders 65 years or older were recruited from a cardiac rehab program in a rural Southwest community. Inclusion in the study required a cardiac event (myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery), participation in cardiac rehab (Phase I), and lack of angina or chest pain on exertion.
Data Collection After informed consent was given, each participant completed five questionnaires: Self-Efficacy Expectation Scale, Stages of Exercise Adoption, Personal Resource Questionnaire, Physical Activity Scale for the Elderly, and a demographic survey.
Instruments The Self-Efficacy Expectation Scale (SES)34 is a series of paper and pencil scales designed to measure selfefficacy expectation for a sample of behaviors related to recovery from a cardiac event. Selected scales include walking, lifting, general activities, climbing stairs, and work. Respondents were asked how confident they were
Geriatric Nursing 2000 • Volume 21 • Number 4
Evidence of Increasing and Decreasing Self-efficacy for Exercise Increasing • Walking for longer periods for greater distances • Climbing stairs without difficulty • Attending organized exercise programs regularly • Including or joining others in exercise, such as walking, dancing, swimming
Decreasing • Being unable to attend scheduled exercise • Being unable to walk for prescribed time or distance • Being uncertain of ability to schedule time for exercise • Not having an exercise partner • Being unable to exercise because of weather
at the current moment to perform activities on a scale of 0 (no confidence) to 10 (total confidence). Because we were interested in cardiac recovery behaviors, we used a cumulative score. SES scores ranged from 220 to 620 with a mean score of 449.81 + 117.87. Whereas the level of confidence for recovery behaviors in this sample varied from low to high, most participants had high levels of self-efficacy (mode 620). Sixty-seven percent had confidence that they could walk a mile, 35.5% were confident they could walk two miles, and 12.9% believed they could walk four miles. Fortyfive percent reported confidence that they could lift 50 pounds, and 48% thought they could climb four flights of stairs. Eighty-three percent had confidence in activities of daily living, but one subject reported a lack of confidence in such activities as getting dressed, writing a letter/bill, making a bed, going out, or taking a trip. Stages of Exercise Adoption35 is an 11-point scale in the shape of a ladder. Each rung is associated with a number (0-10), and five of the rungs include written labels to serve as anchor points. The formal names for stages were not included on the rungs. Participants were instructed to mark the rung that best described their exercise behavior.24,25,35 Twenty-three subjects (74%) exercised regularly for longer than 6 months. One subject (3.2%) reported no exercise, six (19.4%) reported exercising some but not regularly, and one (3.2%) reported regular exercise for less than 6 months. The Personal Resource Questionnaire (PRQ),36 a measure of the multidimensional characteristics of social support, had two parts: Part I consisted of multiplechoice answers from 10 life situations in which a person may need assistance. Part II was a 25-item, seven-point Likert-type scale developed along an ordered continuum to measure perceived level of social support. PRQ scores ranged from 43 to 175 with a mean score of 156 ± 22.34. Scores were negatively skewed, indicating that most participants reported high levels of social support.
201
Stages of Readiness for Exercise
Application to Practice Self-efficacy
Increased by role modeling, verbal persuasion, physical cues, vicarious experience
Stages of change Increasing knowledge about exercise, setting exercise goals, planning for exercise, reinforcing exercise, decreasing barriers to exercise Social support
Finding an exercise partner, setting mutual goals, making exercise part of family outings
The Physical Activity Scale for the Elderly (PASE)37 was used to estimate the volume of physical activity and exercise engaged in by the participants. The PASE uses both a Likert-type scale and yes or no answers to 12 types of physical activity, including leisure, household, and work/volunteer activities. PASE scores ranged from 33.57 to 374.18 with a mean score of 164.50 ± 82.18 on a scale of 0 to 400. In this sample, the most common activities included walking, light and heavy housework, and lawn work. Twenty-five percent of the sample reported work for pay/volunteer activities. The time since the participants’ cardiac event ranged from 2 to 30 months (averaged 10 months). The scores on each instrument were totaled; means and standard deviations were computed and scatterplots developed to determine data distribution. Pearson’s product moment correlation was used to estimate the relationship between self-efficacy expectations, social support, and stages of change and level of physical activity. Selfefficacy was significantly correlated with physical activity (PASE) (r = .564, P = .002) and stages of change (r = .542, P = .002).
DISCUSSION The results of this exploratory study indicate that self-efficacy is strongly associated with the stage of exercise behavior change and exercise behavior. These findings are congruent with other investigations in which self-efficacy was related to the participants’ current stage of exercise change and with the amount of physical activity they pursued.23,28 Interestingly, no relationship existed between social support and stages of change or exercise behavior, a finding not confirmed by other research. However, in this study, the scores on the social support index (PRQ) were all very high, which may account for the discrepancy between this study and previous research.30-33 Counseling the older individual in health promotion is a critical aspect of the clinician’s role. Using information regarding an elder’s current physical activity level and choice of activity, his or her social support, self-efficacy (confidence) for recovery activities, and the stage of exercise adoption (readiness to change) will allow the clinician to individualize a meaningful health
202
Precontemplation
Not intending to make changes
Contemplation
Considering changes
Preparation
Making small changes
Action
Actively engaging in new behavior
Maintenance
Sustaining the change over time
promotion plan. Whereas most of the elders in this study needed only to be supported in their already established physical activity patterns, at least seven needed close supervision and a clearly defined cardiac recovery plan. Clinicians may need to coach or boost confidence levels, suggest opportunities for social support, and/or suggest activities. This investigation and others can help the clinician develop interventions based on established relationships between factors that work in physical activity interventions.
REFERENCES 1. Blair SN. Physical activity, fitness, and coronary heart disease. In: Bouchard C, Shephard RJ, Stephens T, editors. Physical activity, fitness, and health: international proceedings and consensus statement. Champaign (IL): Human Kinetics; 1994. p. 579-90. 2. Blair SN, Kampert JB, Kohl HW, et al. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 1996;276:205-10. 3. Haskell WL. Physical activity, lifestyle, and health in America. In: NIH consensus development conference on physical activity and cardiovascular health (December 18-20). Bethesda (MD): National Institutes of Health; 1995. 4. Dishman RK. Increasing and maintaining exercise and physical activity. Behavior Therapy 1991;22:345-78. 5. Dzewaltowski DA, Noble JM, Shaw JM. Physical activity participation: social cognitive theory versus the theories of reasoned action and planned behavior. J Sports Exerc Psychol 1990;12:388-405. 6. McGinnis JM. The public health burden of a sedentary lifestyle. Med Sci Sports Exerc 1992;24:S196-S200. 7. Powell KE, Blair SN. The public health burdens of sedentary living habits: theoretical but realistic estimates. Med Sci Sports Exerc 1993;26:851-6. 8. Blair SN, Kohl HW, Barlow CE, Paffenbarger RS, Gibbons LW, Macera CA. Changes in physical fitness and all-cause mortality: a prospective study of healthy and unhealthy men. JAMA 1995;273:1093-8. 9. Pate R, Pratt M, Blair S, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-7. 10. U.S. Department of Health and Human Services. Physical activity and health: a report of the surgeon general. Atlanta: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996. 11. Sidani S, Braden CJ. Evaluating nursing interventions: a theory-driven approach. Thousand Oaks (CA): Sage; 1998. 12. Bandura A. Social learning theory. Englewood Cliffs (NJ): Prentice-Hall; 1977. 13. Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs (NJ): Prentice-Hall; 1986. 14. Bandura A. Self-efficacy: the exercise of control. New York: W.H. Freeman & Co.; 1997. 15. Dzewaltowski DA. Physical activity determinants: a social cognitive approach. Med Sci Sports Exerc 1994;26:1395-99. 16. Gortner SR, Gilliss CL, Shinn JA, Sparacino PA, Rankin S, Leavitt M, et al. Improving recovery following cardiac surgery: a randomized clinical trial. J Adv Nurs 1988;13:649-61. 17. Gilliss CL, Gortner SR, Hauck WW, Shinn JA, Sparacino PA. A randomized clinical trial of nursing care for recovery from cardiac surgery. Heart & Lung 1993;22:125-33.
Geriatric Nursing 2000 • Volume 21• Number 4
18. Robertson D, Keller C. Relationships among health beliefs, self-efficacy, and exercise adherence in patients with coronary artery disease. Heart & Lung 1992;21:56-63. 19. Vidmar PM, Rubinson L. The relationship between self-efficacy and exercise compliance in the cardiac population. J Cardpulm Rehabil 1994;14:246-54. 20. Ewart CK, Taylor CB, Reese LB, DeBusk RF. Effects of early postmyocardial infarction exercise testing on self-perception and subsequent physical activity. Am J Cardiol 1983;51:1076-80. 21. Grembowski D, Patrick D, Diehr P, et al. Self-efficacy and health behavior among older adults. J Health Soc Behav 1993;34:89-104. 22. DiClemente CC, Prochaska JO. Self-change and therapy change of smoking behavior: a comparison of processes of change in cessation and maintenance. Addict Behav 1983;7:133-42. 23. Marcus BH, Banspach SW, Lefebvre RC, Rossi JS, Carleton RC, Abrams DB. Using the stages of change model to increase the adoption of physical activity among community participants. Am J Health Promotion 1992;6:424-9. 24. Marcus BH, Rossi JS, Selby VC, Niaura RS, Abrams DB. The stages of processes of exercise adoption and maintenance in a worksite sample. Health Psychol 1992;11:386-95. 25. Marcus BH, Simkin LR. The stages of exercise behavior. J Sports Med Phys Fitness 1993;33:83-8. 26. Barke CR, Nicholas DR. Physical activity in older adults: the stages of change. J Appl Gerontol 1990;9:216-23. 27. Courney KS. Understanding readiness for regular physical activity in older individuals: an application of the theory of planned behavior. Health Psychol 1995;14:80-7. 28. Hovell MF, Hofstetter CR, Sallis JF, Rauh MJ, Barrington E. Correlates of change in walking for exercise: an exploratory analysis. Res Q Exerc Sport 1992;63:425-34. 29. Tildon UP. Issues of conceptualization and measurement of social support in the construction of nursing theory. Res Nurs Health 1985;8:199-206. 30. Muhlenkamp AF, Sayles JA. Self-esteem, social support, and positive health practices. Nurs Res 1986;35:334-8. 31. Conn VS, Taylor SG, Abele PB. Myocardial infarction survivors: age and gender differences in physical health, psychosocial state, and regimen adherence. J Adv Nurs 1991;16:1026-34. 32. Rose SK, Conn VS, Rodeman BJ. Anxiety and self-care following myocardial infarction. Issues Ment Health Nurs 1994;5:433-44. 33. Godin G, Valois P, Shepard RJ, Desharnais R. Predictions of leisure-time exercise behavior: a path analysis (LISREL V) model. J Behav Med 1987;10:145-58. 34. Jenkins L. Jenkins instruments: self-efficacy expectation scales and activity check-lists for selected cardiac recovery behaviors [unpublished manuscript]. University of Wisconsin-Milwaukee; 1989. 35. Marcus BH, Eaton CA, Rossi JS, Harlow LL. Self-efficacy, decision-making, and stages of change: an integrative model of physical exercise. J Appl Soc Psychol 1994;24:489-508. 36. Brandt PA, Weinert C. The PRQ: a social support measure. Nurs Res 1981;30:277-80. 37. Washburn RA, Smith KW, Jette AM, Janney CA. The physical activity scale for the elderly (PASE): development and evaluation. J Chronic Epidemiol 1993;46:153-62.
MOLLY J. ALLISON, PhD, RN, CNS, is an assistant professor at Angelo State University Department of Nursing in San Angelo, Texas. COLLEEN KELLER, PhD, RN, FNP, is a professor at the University of Texas Health Science Center Department of Family Care Nursing in San Antonio, Texas.
CALENDAR OF EVENTS SEPTEMBER 15-17, 2000 National Gerontological Nursing Association 15th Annual Convention, “World Aging: The Challenge of the Future,” Crystal Gateway Marriott, Washington, D.C. Contact: NGNA, phone (800) 723-0560, fax (850) 484-8762, E-mail [email protected]
SEPTEMBER 20-23, 2000 National Conference of Gerontological Nurse Practitioners, Atlanta, Ga. Contact: Wanda Bonnel, phone (913) 588-1644, E-mail [email protected], website www.ncgnp.org
SEPTEMBER 22-24, 2000 17th Annual Conference of the American Association for the History of Nursing, Villanova, Pa. Contact: phone (609) 693-7250, website www.aahn.org
SEPTEMBER 28–OCTOBER 1, 2000 American College of Nurse Practitioners National Clinical Symposium, Salt Lake City, Utah. Contact: ACNP, phone (202) 546-4825, fax (202) 546-4797, Email [email protected]
OCTOBER 11-14, 2000 First International Geriatric Palliative Care Congress, Roosevelt Hotel, New York. Contact: Events International Meeting Planners, Inc., phone (514) 286-0855, fax (514) 286-6066, E-mail: [email protected]
OCTOBER 11-14, 2000 Association of Rehabilitation Nurses’ 26th Annual Education Conference, “Choices and Challenges: Rehabilitation for the New Millenium,” Reno Hilton, Reno, Nev. Contact: phone (800) 229-7530, website www.rehabnurse.org
OCTOBER 12-14, 2000 Acknowledgment: Support for this article was provided by Sigma Theta Tau, Delta Alpha Chapter. Copyright © 2000 by Mosby, Inc. 0197-4572/2000/$8.00 + 0
34/1/1100
doi: 10.1067/mgn.2000.1100
World Foundation for Medical Studies in Female Health Annual Clinical Conference, Intercontinental Hotel, New Orleans. Contact: phone (516) 944-3192, fax (516) 944-8663, E-mail [email protected], website www.wffh.org
OCTOBER 20-22, 2000 Neurology for the Nonneurologist, sponsored by Bays Medical Society, Panama City Beach, Fla. Contact: Nancy Sabatini, phone (850) 784-2090, fax (850) 784-0068
Geriatric Nursing 2000 • Volume 21 • Number 4
203
Physical Activity Maintenance in Elders with Cardiac Problems Molly J. Allison, PhD, RN, CNS, and Colleen Keller, PhD, RN, FNP
Abstract: Clinicians who work with elderly people after acute cardiac events need strategies to facilitate the continuance of physical activity learned in cardiac rehabilitation programs. This exploratory study examined three factors related to this maintenance in 31 men and women: self-efficacy, stages of change, and social support for exercise. Self-efficacy was significantly correlated to stages of change and physical activity. Clinicians can use these factors to develop strategies to enhance the maintenance of exercise in elders with cardiac problems. (Geriatr Nurs 1999;21:200-3)
T
he relationships between physical activity (PA) and cardiovascular health are well established.1-3 Unfortunately, more than half the people who begin a physical activity program drop out within 6 months.4 The difficulty associated with elders engaging in physical activity has led investigators to examine strategies that strengthen behavior changes necessary for health promotion.5 Two of every five people age 65 and older report sedentary lifestyles and increase their death risk by 5% to 6%.6-8 Knowledge of the underlying processes that influence the older adult to initiate and maintain lifestyle changes is an important prerequisite to the development of a physical activity intervention. The purpose of this exploratory study was to examine the relationships between variables associated with the initiation and maintenance of physical activity in older individuals after a cardiac event. The specific aims were to determine the relationships between self-efficacy, stages of change, and social support and the level of physical activity sustained in older adults after cardiac rehabilitation.
BACKGROUND AND SIGNIFICANCE Adults are encouraged to engage in 30 minutes or more of moderately intense physical activity most, if not all, days of the week.9,10 In the study of health behavior and the elderly, a number of factors have been shown to be strongly related to the initiation and maintenance of exercise behavior, including social cognitive theory or self-efficacy, stages of change, and social support.11 Self-efficacy. A particularly important idea in Bandura’s Social Cognitive Theory is that of self-efficacy. 12-14 Perceived selfefficacy, the individual’s belief concerning his or her ability to ex-
200
Geriatric Nursing 2000 • Volume 21 • Number 4
ecute a specified course of action, has a powerful influence on behavior. 12 Considerable research provides support for the use of self-efficacy in predicting physical activity participation in healthy adults,15 adults with coronary heart disease, and those undergoing cardiac rehab exercise. 16-21 Stages of Change. The stages of change model22 that has been used to explain exercise behavior23-25 suggests that an individual engaging in a new behavior moves through certain stages. Two studies26,27 addressed the stages of change with older adults and concluded that the model effectively differentiated stages of readiness for exercise. In addition, the integration of both the model and self-efficacy demonstrated significant relationships between self-efficacy and the stage of exercise behavior.24,28 Social support. Social support is a theoretical construct that describes interpersonal support behaviors and relationships and is thought of in terms of its enhancement of positive health behaviors.29 Social support has been correlated with positive health practices,30 has been identified as a predictor of psychologic and emotional adjustment to lifestyle alterations after myocardial infarction,31 and has been positively correlated to exercise32 and exercise adherence.33 These three factors have been shown to be strongly associated with an individual’s engagement in physical activity. However, little is known about the nature and strength of these relationships to exercise maintenance in the older adult after cardiac rehab.
METHOD Sample A convenience sample of 31 English-speaking elders 65 years or older were recruited from a cardiac rehab program in a rural Southwest community. Inclusion in the study required a cardiac event (myocardial infarction, percutaneous transluminal coronary angioplasty, or coronary artery bypass graft surgery), participation in cardiac rehab (Phase I), and lack of angina or chest pain on exertion.
Data Collection After informed consent was given, each participant completed five questionnaires: Self-Efficacy Expectation Scale, Stages of Exercise Adoption, Personal Resource Questionnaire, Physical Activity Scale for the Elderly, and a demographic survey.
Instruments The Self-Efficacy Expectation Scale (SES)34 is a series of paper and pencil scales designed to measure selfefficacy expectation for a sample of behaviors related to recovery from a cardiac event. Selected scales include walking, lifting, general activities, climbing stairs, and work. Respondents were asked how confident they were
Geriatric Nursing 2000 • Volume 21 • Number 4
Evidence of Increasing and Decreasing Self-efficacy for Exercise Increasing • Walking for longer periods for greater distances • Climbing stairs without difficulty • Attending organized exercise programs regularly • Including or joining others in exercise, such as walking, dancing, swimming
Decreasing • Being unable to attend scheduled exercise • Being unable to walk for prescribed time or distance • Being uncertain of ability to schedule time for exercise • Not having an exercise partner • Being unable to exercise because of weather
at the current moment to perform activities on a scale of 0 (no confidence) to 10 (total confidence). Because we were interested in cardiac recovery behaviors, we used a cumulative score. SES scores ranged from 220 to 620 with a mean score of 449.81 + 117.87. Whereas the level of confidence for recovery behaviors in this sample varied from low to high, most participants had high levels of self-efficacy (mode 620). Sixty-seven percent had confidence that they could walk a mile, 35.5% were confident they could walk two miles, and 12.9% believed they could walk four miles. Fortyfive percent reported confidence that they could lift 50 pounds, and 48% thought they could climb four flights of stairs. Eighty-three percent had confidence in activities of daily living, but one subject reported a lack of confidence in such activities as getting dressed, writing a letter/bill, making a bed, going out, or taking a trip. Stages of Exercise Adoption35 is an 11-point scale in the shape of a ladder. Each rung is associated with a number (0-10), and five of the rungs include written labels to serve as anchor points. The formal names for stages were not included on the rungs. Participants were instructed to mark the rung that best described their exercise behavior.24,25,35 Twenty-three subjects (74%) exercised regularly for longer than 6 months. One subject (3.2%) reported no exercise, six (19.4%) reported exercising some but not regularly, and one (3.2%) reported regular exercise for less than 6 months. The Personal Resource Questionnaire (PRQ),36 a measure of the multidimensional characteristics of social support, had two parts: Part I consisted of multiplechoice answers from 10 life situations in which a person may need assistance. Part II was a 25-item, seven-point Likert-type scale developed along an ordered continuum to measure perceived level of social support. PRQ scores ranged from 43 to 175 with a mean score of 156 ± 22.34. Scores were negatively skewed, indicating that most participants reported high levels of social support.
201
Stages of Readiness for Exercise
Application to Practice Self-efficacy
Increased by role modeling, verbal persuasion, physical cues, vicarious experience
Stages of change Increasing knowledge about exercise, setting exercise goals, planning for exercise, reinforcing exercise, decreasing barriers to exercise Social support
Finding an exercise partner, setting mutual goals, making exercise part of family outings
The Physical Activity Scale for the Elderly (PASE)37 was used to estimate the volume of physical activity and exercise engaged in by the participants. The PASE uses both a Likert-type scale and yes or no answers to 12 types of physical activity, including leisure, household, and work/volunteer activities. PASE scores ranged from 33.57 to 374.18 with a mean score of 164.50 ± 82.18 on a scale of 0 to 400. In this sample, the most common activities included walking, light and heavy housework, and lawn work. Twenty-five percent of the sample reported work for pay/volunteer activities. The time since the participants’ cardiac event ranged from 2 to 30 months (averaged 10 months). The scores on each instrument were totaled; means and standard deviations were computed and scatterplots developed to determine data distribution. Pearson’s product moment correlation was used to estimate the relationship between self-efficacy expectations, social support, and stages of change and level of physical activity. Selfefficacy was significantly correlated with physical activity (PASE) (r = .564, P = .002) and stages of change (r = .542, P = .002).
DISCUSSION The results of this exploratory study indicate that self-efficacy is strongly associated with the stage of exercise behavior change and exercise behavior. These findings are congruent with other investigations in which self-efficacy was related to the participants’ current stage of exercise change and with the amount of physical activity they pursued.23,28 Interestingly, no relationship existed between social support and stages of change or exercise behavior, a finding not confirmed by other research. However, in this study, the scores on the social support index (PRQ) were all very high, which may account for the discrepancy between this study and previous research.30-33 Counseling the older individual in health promotion is a critical aspect of the clinician’s role. Using information regarding an elder’s current physical activity level and choice of activity, his or her social support, self-efficacy (confidence) for recovery activities, and the stage of exercise adoption (readiness to change) will allow the clinician to individualize a meaningful health
202
Precontemplation
Not intending to make changes
Contemplation
Considering changes
Preparation
Making small changes
Action
Actively engaging in new behavior
Maintenance
Sustaining the change over time
promotion plan. Whereas most of the elders in this study needed only to be supported in their already established physical activity patterns, at least seven needed close supervision and a clearly defined cardiac recovery plan. Clinicians may need to coach or boost confidence levels, suggest opportunities for social support, and/or suggest activities. This investigation and others can help the clinician develop interventions based on established relationships between factors that work in physical activity interventions.
REFERENCES 1. Blair SN. Physical activity, fitness, and coronary heart disease. In: Bouchard C, Shephard RJ, Stephens T, editors. Physical activity, fitness, and health: international proceedings and consensus statement. Champaign (IL): Human Kinetics; 1994. p. 579-90. 2. Blair SN, Kampert JB, Kohl HW, et al. Influences of cardiorespiratory fitness and other precursors on cardiovascular disease and all-cause mortality in men and women. JAMA 1996;276:205-10. 3. Haskell WL. Physical activity, lifestyle, and health in America. In: NIH consensus development conference on physical activity and cardiovascular health (December 18-20). Bethesda (MD): National Institutes of Health; 1995. 4. Dishman RK. Increasing and maintaining exercise and physical activity. Behavior Therapy 1991;22:345-78. 5. Dzewaltowski DA, Noble JM, Shaw JM. Physical activity participation: social cognitive theory versus the theories of reasoned action and planned behavior. J Sports Exerc Psychol 1990;12:388-405. 6. McGinnis JM. The public health burden of a sedentary lifestyle. Med Sci Sports Exerc 1992;24:S196-S200. 7. Powell KE, Blair SN. The public health burdens of sedentary living habits: theoretical but realistic estimates. Med Sci Sports Exerc 1993;26:851-6. 8. Blair SN, Kohl HW, Barlow CE, Paffenbarger RS, Gibbons LW, Macera CA. Changes in physical fitness and all-cause mortality: a prospective study of healthy and unhealthy men. JAMA 1995;273:1093-8. 9. Pate R, Pratt M, Blair S, et al. Physical activity and public health: a recommendation from the Centers for Disease Control and Prevention and the American College of Sports Medicine. JAMA 1995;273:402-7. 10. U.S. Department of Health and Human Services. Physical activity and health: a report of the surgeon general. Atlanta: Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion; 1996. 11. Sidani S, Braden CJ. Evaluating nursing interventions: a theory-driven approach. Thousand Oaks (CA): Sage; 1998. 12. Bandura A. Social learning theory. Englewood Cliffs (NJ): Prentice-Hall; 1977. 13. Bandura A. Social foundations of thought and action: a social cognitive theory. Englewood Cliffs (NJ): Prentice-Hall; 1986. 14. Bandura A. Self-efficacy: the exercise of control. New York: W.H. Freeman & Co.; 1997. 15. Dzewaltowski DA. Physical activity determinants: a social cognitive approach. Med Sci Sports Exerc 1994;26:1395-99. 16. Gortner SR, Gilliss CL, Shinn JA, Sparacino PA, Rankin S, Leavitt M, et al. Improving recovery following cardiac surgery: a randomized clinical trial. J Adv Nurs 1988;13:649-61. 17. Gilliss CL, Gortner SR, Hauck WW, Shinn JA, Sparacino PA. A randomized clinical trial of nursing care for recovery from cardiac surgery. Heart & Lung 1993;22:125-33.
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18. Robertson D, Keller C. Relationships among health beliefs, self-efficacy, and exercise adherence in patients with coronary artery disease. Heart & Lung 1992;21:56-63. 19. Vidmar PM, Rubinson L. The relationship between self-efficacy and exercise compliance in the cardiac population. J Cardpulm Rehabil 1994;14:246-54. 20. Ewart CK, Taylor CB, Reese LB, DeBusk RF. Effects of early postmyocardial infarction exercise testing on self-perception and subsequent physical activity. Am J Cardiol 1983;51:1076-80. 21. Grembowski D, Patrick D, Diehr P, et al. Self-efficacy and health behavior among older adults. J Health Soc Behav 1993;34:89-104. 22. DiClemente CC, Prochaska JO. Self-change and therapy change of smoking behavior: a comparison of processes of change in cessation and maintenance. Addict Behav 1983;7:133-42. 23. Marcus BH, Banspach SW, Lefebvre RC, Rossi JS, Carleton RC, Abrams DB. Using the stages of change model to increase the adoption of physical activity among community participants. Am J Health Promotion 1992;6:424-9. 24. Marcus BH, Rossi JS, Selby VC, Niaura RS, Abrams DB. The stages of processes of exercise adoption and maintenance in a worksite sample. Health Psychol 1992;11:386-95. 25. Marcus BH, Simkin LR. The stages of exercise behavior. J Sports Med Phys Fitness 1993;33:83-8. 26. Barke CR, Nicholas DR. Physical activity in older adults: the stages of change. J Appl Gerontol 1990;9:216-23. 27. Courney KS. Understanding readiness for regular physical activity in older individuals: an application of the theory of planned behavior. Health Psychol 1995;14:80-7. 28. Hovell MF, Hofstetter CR, Sallis JF, Rauh MJ, Barrington E. Correlates of change in walking for exercise: an exploratory analysis. Res Q Exerc Sport 1992;63:425-34. 29. Tildon UP. Issues of conceptualization and measurement of social support in the construction of nursing theory. Res Nurs Health 1985;8:199-206. 30. Muhlenkamp AF, Sayles JA. Self-esteem, social support, and positive health practices. Nurs Res 1986;35:334-8. 31. Conn VS, Taylor SG, Abele PB. Myocardial infarction survivors: age and gender differences in physical health, psychosocial state, and regimen adherence. J Adv Nurs 1991;16:1026-34. 32. Rose SK, Conn VS, Rodeman BJ. Anxiety and self-care following myocardial infarction. Issues Ment Health Nurs 1994;5:433-44. 33. Godin G, Valois P, Shepard RJ, Desharnais R. Predictions of leisure-time exercise behavior: a path analysis (LISREL V) model. J Behav Med 1987;10:145-58. 34. Jenkins L. Jenkins instruments: self-efficacy expectation scales and activity check-lists for selected cardiac recovery behaviors [unpublished manuscript]. University of Wisconsin-Milwaukee; 1989. 35. Marcus BH, Eaton CA, Rossi JS, Harlow LL. Self-efficacy, decision-making, and stages of change: an integrative model of physical exercise. J Appl Soc Psychol 1994;24:489-508. 36. Brandt PA, Weinert C. The PRQ: a social support measure. Nurs Res 1981;30:277-80. 37. Washburn RA, Smith KW, Jette AM, Janney CA. The physical activity scale for the elderly (PASE): development and evaluation. J Chronic Epidemiol 1993;46:153-62.
MOLLY J. ALLISON, PhD, RN, CNS, is an assistant professor at Angelo State University Department of Nursing in San Angelo, Texas. COLLEEN KELLER, PhD, RN, FNP, is a professor at the University of Texas Health Science Center Department of Family Care Nursing in San Antonio, Texas.
CALENDAR OF EVENTS SEPTEMBER 15-17, 2000 National Gerontological Nursing Association 15th Annual Convention, “World Aging: The Challenge of the Future,” Crystal Gateway Marriott, Washington, D.C. Contact: NGNA, phone (800) 723-0560, fax (850) 484-8762, E-mail [email protected]
SEPTEMBER 20-23, 2000 National Conference of Gerontological Nurse Practitioners, Atlanta, Ga. Contact: Wanda Bonnel, phone (913) 588-1644, E-mail [email protected], website www.ncgnp.org
SEPTEMBER 22-24, 2000 17th Annual Conference of the American Association for the History of Nursing, Villanova, Pa. Contact: phone (609) 693-7250, website www.aahn.org
SEPTEMBER 28–OCTOBER 1, 2000 American College of Nurse Practitioners National Clinical Symposium, Salt Lake City, Utah. Contact: ACNP, phone (202) 546-4825, fax (202) 546-4797, Email [email protected]
OCTOBER 11-14, 2000 First International Geriatric Palliative Care Congress, Roosevelt Hotel, New York. Contact: Events International Meeting Planners, Inc., phone (514) 286-0855, fax (514) 286-6066, E-mail: [email protected]
OCTOBER 11-14, 2000 Association of Rehabilitation Nurses’ 26th Annual Education Conference, “Choices and Challenges: Rehabilitation for the New Millenium,” Reno Hilton, Reno, Nev. Contact: phone (800) 229-7530, website www.rehabnurse.org
OCTOBER 12-14, 2000 Acknowledgment: Support for this article was provided by Sigma Theta Tau, Delta Alpha Chapter. Copyright © 2000 by Mosby, Inc. 0197-4572/2000/$8.00 + 0
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doi: 10.1067/mgn.2000.1100
World Foundation for Medical Studies in Female Health Annual Clinical Conference, Intercontinental Hotel, New Orleans. Contact: phone (516) 944-3192, fax (516) 944-8663, E-mail [email protected], website www.wffh.org
OCTOBER 20-22, 2000 Neurology for the Nonneurologist, sponsored by Bays Medical Society, Panama City Beach, Fla. Contact: Nancy Sabatini, phone (850) 784-2090, fax (850) 784-0068
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