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AN INDEPENDENT VOICE FOR NURSING
A Concept Analysis of Self-Efficacy and Adolescent Sexual Risk-Taking Behavior Monique Jenkins, BS, MA, MS, RN-BC, APRN, FNP-BC Monique Jenkins, BS, MA, MS, RN-BC, APRN, FNP-BC, is Nurse Practitioner, Departments of Nursing and Pediatric Surgery, Maimonides Medical Center, Brooklyn, NY; and is Doctoral Student, Department of Nursing, CUNY The Graduate Center, New York, NY. Keywords Best practices, concept analysis, women’s health Correspondence Monique Jenkins, BS, MA, MS, RN-BC, APRN, FNP-BC, Department of Nursing, CUNY The Graduate Center, New York, NY E-mail: [email protected]
TOPIC. Concept Analysis: Self-efficacy and Sexual Risk-Taking Behaviors of Adolescents PURPOSE. This paper provides an in-depth analysis of the concept of self-efficacy and adolescent sexual risk-taking behaviors CONCLUSIONS. Using the Walker and Avant framework of concept analysis, the concept of self-efficacy has shown to be an important part in changing unhealthy behaviors. It has also shown that the concept of self-efficacy can be pivotal in health promotion activities of adolescents in a variety of settings, especially as it relates to adolescent sexual risk-taking behaviors. PRACTICE IMPLICATIONS. The concept of self-efficacy as it relates to adolescent sexual risk-taking behaviors has clear nursing implications and usage among the adolescent population. Self-efficacy is a key concept to be used in health promotion. Health promotion activities are pivotal in the prevention of sexually transmitted infections in the adolescent population. Knowledge of the self-efficacy level of the adolescent patient can give the nurse greater insight in the meaning of the patient’s response in a given situation. This also helps the nurse identify which adolescents would benefit from early intervention with regard to sexual health.
There are 65 million Americans who have at least one viral sexually transmitted infection (STI) (Centers for Disease Control [CDC], 2009, 2012). Many of the cases were adolescents and young adults between the ages of 15–24. Of the approximate 19 million new cases of STIs diagnosed per year, half of them are among those aged 15–24 years (CDC, 2009). Adolescents have been known to engage in multiple highrisk sexual behaviors that can negatively affect their health. These risky behaviors may substantially increase the risk of premature death, disability, and STIs among today’s youth and young adults. Chlamydia is one of the most prominent STIs among the adolescent population compared with other age groups. The number of reported cases of chlamydia in the United States was 1,307,893 in 2010
(CDC, 2012). This is an increase from the 1,108,374 cases that were reported in 2007. There had been a national increase of chlamydia cases of about 9.2% from 2007 to 2008. This increase was attributed to an actual rise in the disease, more sensitive testing, increased screening, and more accurate reporting (CDC, 2009). In 2008, the total number of chlamydia cases in the United States was 1,210,523 (CDC, 2009) and rose to 1.3 million in 2010 (CDC, 2012). Females 15–19 years old had the largest number of reported cases of this disease; followed by those females 20–24 years old. Because of this increase, chlamydia is considered the most widespread STI in the United States (Avert, 2009). STIs are a major public health challenge in the United States (CDC, 2009). Because some STIs are 1
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume ••, No. ••, ••-•• 2014
Self-Efficacy and Risk-Taking Behavior asymptomatic, the incidence and prevalence of STIs is difficult to diagnose. Many STIs can only be diagnosed by screening. Of the approximate 19 million new STI cases per year, half of them are between the ages of 15 and 24 years. Also, 65 million Americans have at least one viral STI in their lifetime (CDC, 2009). Adolescents and young adults 15–24 years of age represent 50% of all reported STIs, and they represent only about 25% of the sexually active population (Moscicki, 2005). Because of this, there is a clear concern about the adolescent risk for pregnancy and STIs. The decisions made by adolescents regarding their sexual choices shape their well-being and future sexual experiences (Pearson, 2006). Understanding the concept of self-efficacy as it relates to the adolescent population will assist nurses in addressing sexual risk-taking behaviors within this population. Purpose The purpose of this paper is to analyze the concept of self-efficacy as it relates to the adolescent population and their sexual risk-taking behaviors. The framework for this analysis is based on Walker and Avant’s (2005) eight-step process (see Table 1). The identification of the concept and purpose of the analysis have already been addressed. Next steps will be identification of uses of the concept and determination of defining attributes. Model, borderline, related, and contrary cases have been developed to clarify what the concept of selfefficacy and adolescent sexual risk-taking behavior is and is not. Invented and illegitimate cases will be eliminated for the purpose of this paper. The framework of Walker and Avant (2005) concludes with antecedents, consequences, and empirical referents.
Table 1. Walker and Avant’s Eight Steps of Concept Analysis 1. 2. 3. 4. 5. 6.
Identification of the concept Presentation of the purpose of the analysis Identification of uses of the concept Determination of defining attributes Construction of model case Construction of borderline, related, and contrary cases 7. Identification of antecedents and consequences 8. Defining empirical referents
2 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume ••, No. ••, ••-•• 2014
M. Jenkins Findings Uses of the Concept Efficacy is defined as having the power or capacity to produce a desired effect (Merriam-Webster Dictionary and Thesaurus online, 2012). The word is derived from the Latin word “efficacia,” meaning power (MerriamWebster Dictionary and Thesaurus online, 2012). Synonyms for the word efficacy include effectiveness, efficaciousness, efficacity, productiveness, and effectualness (Merriam-Webster Dictionary and Thesaurus online, 2012). Self-efficacy’s history begins within Bandura’s social learning theory that was renamed social cognitive theory. Self-efficacy is one of the major concepts of the Social Cognitive Theory (Bandura, 1977a). In a landmark study, Bandura (1977a) concluded that self-efficacy has an effect on the way individuals think, feel, and behave. In addition, selfefficacy influences an individual’s choice of activities. Bandura (1977b) describes the two types of expectations related to self-efficacy: outcome expectations and efficacy expectations. An outcome expectation stems from the belief that a particular behavior will lead to a particular outcome. Efficacy expectations stem from the belief that an individual can successfully perform a behavior to yield a desired outcome. In another historical study, Bandura (1994) contends that there are four main interests of self-efficacy. The most effective way to develop a strong sense of self-efficacy is through mastering experiences. Individuals must reflect on and learn from their experiences. Another way to develop a strong sense of self-efficacy is through vicarious experiences. These are achieved by watching others complete a task and feeling confident that they can complete the same task. Another way to develop a strong sense of selfefficacy is through social influences. Through their behaviors, models are able to transmit knowledge and teach skills to manage situations within the environment. Verbal persuasion by others can also help develop self-efficacy. Through verbal persuasion, an individual is being convinced by another that they can complete the task. Finally, Bandura asserted that the physiological state of the individual can have an effect on self-efficacy. Alterations in physical state can have either a positive or negative effect on self-efficacy. Positive moods can increase self-efficacy, whereas a negative mood can cause self-efficacy to diminish. In another pivotal study, Cothran and White (2002) proposed the use of the self-efficacy model to
M. Jenkins help decrease risky behaviors in the adolescent population. Cothran and White further asserted that the self-efficacy model links belief and behavior. This model may be beneficial to those individuals who, for example, lack the necessary skills to enforce condom use during sexual activity. The self-efficacy model does not predict behavior perfectly, but it does increase the likelihood that desired behaviors will occur. This model can be effective in decreasing the rate of STIs in the adolescent population. An increase in the self-efficacy of adolescents may increase the likelihood that they make safe decisions regarding their sexual health. Increasing self-efficacy is only one part of the problem regarding adolescents making safe sexual health decisions (Cothran & White, 2002). Self-efficacy can be an important determinant in behaviors and has been shown to be an important predictor in such behaviors as smoking cessation and the use of condoms (Hendriksen, Pettifor, Lee, Coates, & Rees, 2007). With an increased selfefficacy, individuals were able to consistently perform the task as well as show that they have the strength and certainty to perform the task (Hendriksen et al., 2007). Defining Attributes Defining attributes are those characteristics of the concept that are essential and must be present (Walker & Avant, 2005). Key characteristics of self-efficacy were uncovered in the literature review. They are as follows: a. Individual must believe that the task can be completed (confidence) (Bandura, 1994; Cothran & White, 2002). b. Individual must be able to carry out the task (capability) (Cothran & White, 2002). c. Individual must be able to be persistent and maintain the task over time (persistence) (Hendriksen et al., 2007). d. Individual must have the strength to complete the task (strength) (Hendriksen et al., 2007) e. Individual has the desire or motivation to carry out the task or change a behavior (Cothran & White, 2002). Model Case A model case is one in which all defining attributes of the concept are illustrated. In addition, no defining
Self-Efficacy and Risk-Taking Behavior attributes from another concept are exhibited. The model case presents a pure case of the concept (Walker & Avant, 2005). The following is a model case for self-efficacy and adolescent sexual risk-taking behaviors. JC and RK are both 17 years old and have been dating since their sophomore year in high school. They are currently seniors and are ranked in the top half of their class. JC is a cheerleader and looking forward to graduation this June. RK is on the basketball team and has obtained a college scholarship for his athletic abilities. Although they have been dating for a couple of years, JC believes strongly that she will not compromise her academics by engaging in sexual activity. JC and RK have spoken about delaying sexual initiation and have agreed to wait. Despite RK’s desire to want to initiate sexual activity, his love for JC prevails. He is confident that when she is ready, things will happen. JC is confident that RK will wait until she is ready. They both have participated in and completed the interactive STI prevention course at their school and have obtained information regarding safe sexual activity. Both individuals are motivated and desire to wait before initiating sexual activity. Based on this case, all attributes of self-efficacy have been presented. Both teens have the confidence that they will wait for each other and delay initiation of sexual activity. They have the attribute of capability as well. They have participated in and completed the interactive STI prevention course at school. Persistence is illustrated by their efforts to maintain the relationship. The length of time in the relationship is about 2 years. In addition, both physical and emotional strength have been illustrated.
Borderline Case Borderline cases are those in which some attributes of the concept are illustrated (Walker & Avant, 2005). The following case contains most but not all of the defining attributes. JP and SP have been dating on and off for about 6 months. Both have been active in sports and in their school, and both are doing well in their classes. They have decided to delay initiation of sexual intercourse until a later time and are willing to wait until they feel the time is right. There is an interactive STI prevention course at their school in which they have not participated. In this case, both attributes of confidence and strength are illustrated; however, it is lacking the attributes of capability, motivation, and persistence. 3
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume ••, No. ••, ••-•• 2014
Self-Efficacy and Risk-Taking Behavior
M. Jenkins
Related Case
Antecedents
Related cases are those cases that are similar to the concept of self-efficacy, but they do not contain all of the attributes of the concept. Related cases are somehow connected to the concept but are not true illustrations of it (Walker & Avant, 2005). HL and SP have been dating each other for 5 months, and the relationship is progressing well. HL is class President and SP is active in her church. They have participated in oral sex, but have not had sexual intercourse. SP is contemplating having sexual intercourse with HL, but wants to learn more about the consequences of having sex. Her plan is to talk to the nurse practitioner at the school-based clinic. This case is considered a related case because it contains motivation. Motivation is an element needed in order for self-efficacy to exist (Resnick, 2004). SP has the motivation to learn about sex and its consequences, but this does not have any relation to her level of self-efficacy.
The antecedents of a concept are those events that must take place prior the concept occurring (Walker & Avant, 2005). Based on the literature review, the antecedents of self-efficacy are as follows:
Contrary Case The contrary case is one in which none of the attributes are illustrated. This case is a clear example of what the concept is not (Walker & Avant, 2005). MT and LW attend the same high school and have been dating for 2 weeks. They are both average students, and both have been involved in multiple relationships over the past year. MT has been pressuring LW to initiate sexual intercourse, but she refuses to do so. Although she refuses to have sex with him, she questions her decision. There is an interactive STI prevention course available at their school; however, neither of them has participated in it. In this case, none of the attributes of self-efficacy have been illustrated. LW lacks confidence as she is questioning her decision to delay initiation of sexual activity. Capability to make safe decisions is lacking as they have not used the resource of the interactive STI prevention course available at their school. The short length of time that they have been in their relationship, as well as the fact that they have been involved in multiple relationships over the past year, does not illustrate persistence. In addition, this couple does not have the motivation to participate in the interactive STI prevention course. In this instance, there has not been an illustration of either physical or emotional strength. 4 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume ••, No. ••, ••-•• 2014
a. Social experiences—An individual’s social experiences precede self-efficacy. In addition, these social experiences help determine whether or not the individual’s levels of self-efficacy are high or low (Zulkosky, 2009). b. Self-reflections on personal experiences—Bandura (1977a) asserts that self-efficacy can be defined by the appraisals of an individual’s mastery of previous experiences. c. Performance accomplishments—The more successes a person has in performing a particular behavior, the higher their self-efficacy will be for that particular behavior (Bandura, 1994). The adolescent who is successful in one or more behaviors may be more apt to make healthy decisions regarding their sexual health. d. Vicarious experiences—This involves observing someone perform a task, and then the individual feels comfortable performing the same task and receiving a positive outcome (Zulkosky, 2009). The adolescent who sees their peers making healthy sexual decisions is more apt to make healthy decisions regarding their own sexual health. e. Verbal persuasion—This involves an individual speaking to another and convincing them that they are capable of being successful at performing a particular activity (Zulkosky, 2009). Adolescents who are able to speak to others regarding avoiding risky sexual behaviors will be more likely to avoid such behaviors. f. Physiological cues—Sometimes individuals judge their abilities based on their physical cues. These cues could be anxiety, fear, or any other physical cues (Zulkosky, 2009). Before an individual can sense self-efficacy, they must be able to complete a task successfully, observe someone else perform a task with success, obtain positive feedback with regard to completing a task, or rely on physiological cues (Zulkosky, 2009). Consequences Consequences of a concept are those events that take place as a result of the concept occurring
M. Jenkins (Walker & Avant, 2005). In relation to adolescent sexual risk-taking behaviors, the consequences of high self-efficacy can result in healthier sexual health behaviors, limited or no risky behaviors, higher motivation levels, and an increased sense of control over the situation. The consequences of low self-efficacy can result in participation in unhealthy sexual behaviors, increased participation in risky behaviors, low motivational level, and a decrease in sense of control over the situation (Zulkosky, 2009). Some consequences of increased self-efficacy include increased accessibility of community resources and increase in health promotion (Block, Vanner, Keys, Rimmer, & Skeels, 2010).
Empirical Referents The final step in this concept analysis is to determine empirical referents that help identify the concept’s existence in practice (Walker & Avant, 2005). The concept of self-efficacy as it relates to adolescent sexual risk-taking behaviors has clear nursing implications and usage among the adolescent population. Nurses are in the perfect position to make contact with sexually active adolescents. Programs can be offered at schools or in clinics. The programs can combine sexuality education with activities that increase selfefficacy for adolescents offering support, care, and a safe place. Self-efficacy is a key concept to be used in health promotion. Health promotion activities are pivotal in the prevention of STIs in the adolescent population. These activities can help increase the level of general self-efficacy in the teenager who has low self-efficacy. This is accomplished by increasing their sense of personal competence when it comes to sexual behaviors and their consequences. In addition, the health promotion activities can help adolescents personalize their sexual issues and develop specific skills needed to negotiate actions pertaining to their sexual health. Knowledge of the level of self-efficacy in the adolescent patient offers the nurse greater insight into the meaning of the patient’s response in a given situation. This also helps the nurse identify which adolescents would benefit from early intervention with regard to sexual health. In an effort to promote selfefficacy by supporting and empowering adolescents, nurses can a. Facilitate adolescent education regarding new behaviors related to healthy sexual behaviors.
Self-Efficacy and Risk-Taking Behavior b. Facilitate adolescents in modifying or completely eliminating risky sexual behaviors. c. Encourage demonstration and modeling; realizing that they are important ways for individuals to learn a new behavior. d. Enhance verbal persuasion through heath education and counseling about the consequences of sexual activity. e. Encourage role play to facilitate positive responses in situations perceived to be threatening by the adolescent. f. Develop interventions to aid in behavior modifications. g. Provide education that depicts the importance of healthy decision making with regard to sexual health. h. Provide education that depicts the consequences of risky sexual behaviors. i. Practice the new behavior that will aid the individual in accomplishing a positive change. This can be done with role play activities. With continued practice and success, the individual’s sense of self-efficacy will increase. It is also very important for nurses to have a strong sense of self-efficacy as well. A nurse’s strong sense of self-efficacy serves as a model for the patient (Bandura, 1977a).
Conclusion The analysis of the concept of self-efficacy has shown to be an important part in changing unhealthy behaviors. It can be pivotal in health promotion activities of adolescents in a variety of settings as it relates to adolescent sexual risk-taking behaviors. In addition to adolescents needing the knowledge and motivation related to a particular behavior, they also need the perceived capacity and ability to carry out the task and reach their goal. With the development of high levels of self-efficacy, adolescents will be able to make better decisions regarding their sexual health. Making better decisions will lead to a decrease in the number of STIs among this vulnerable population. Nurses have the burden of educating and being role models for adolescents so that positive change can be made. The concept analysis within this paper can provide a basis for nurses to develop effective STI prevention programs in a variety of settings for adolescents. 5
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume ••, No. ••, ••-•• 2014
Self-Efficacy and Risk-Taking Behavior References Avert. (2009). STD statistics in America. Retrieved from http:// www.avert.org/stds-america.htm Bandura, A. (1977a). Self-efficacy: The exercise of control. New York: W. H. Freeman. Bandura, A. (Ed.) (1977b). Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall. Bandura, A. (1994). Self-efficacy. In V. S. Ramachaudran (Ed.), Encyclopedia of human behavior (Vol. 4, pp. 71–81). New York: Academic Press. Block, P., Vanner, E., Keys, C., Rimmer, J., & Skeels, S. (2010). Project shake-it-up: Using health promotion, capacity building and a disability studies framework to increase self-efficacy. Disability and Rehabilitation, 32, 741– 754. doi:10.3109/09638280903295466 Centers for Disease Control. (2009). Sexually transmitted diseases in the United States, 2008. Retrieved from http:// www.cdc.gov Centers for Diseases Control. (2012). Sexually transmitted disease surveillence 2010. Retrieved from http://www.cdc .gov/std/stats10/surv2010.pdf Cothran, M., & White, J. (2002). Adolescent behavior and sexually transmitted diseases: The dilemma of human papillomavirus. Health Care for Women International, 23, 306–319. doi:10.1080/073993302317346352 Hendriksen, E. S., Pettifor, A., Lee, S. J., Coates, T. J., & Rees, H. V. (2007). Predictors of condom use among young
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M. Jenkins adults in South Africa: The reproductive health and HIV research unit national youth survey. American Journal of Public Health, 97, 1241–1248. Retrieved from http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC1913066 Merriam-Webster Dictionary and Thesaurus online. (2012). Retrieved from http://www.merriam-webster.com/ Moscicki, A. (2005). Impact of HPV infection in adolescent populations. Journal of Adolescent Health, 37, S3–S9. Retrieved from http://leadership.mchtraining.net/ images/stories/Teleconference_Materials_10-06/ moscicki2005HPVreview_JAH.pdf Pearson, J. (2006). Personal control, self-efficacy in sexual negotiation, and contraceptive risk among adolescents: The role of gender. Sex Roles, 54, 615–625. Retrieved from http://www.utexas.edu/cola/orgs/etag/_files/pdfs/ articles/2006/Pearson%202006.pdf Resnick, B. (2004). Self-efficacy. In S. J. Peterson & T. S. Bredow (Eds.), Middle range theories: Application to nursing research (pp. 97–117). Philadelphia: Lippincott Williams & Wilkins. Walker, L., & Avant, K. (2005). Strategies for theory construction in nursing (4th ed.). Upper Saddle River, NJ: Pearson/ Prentice Hall. Zulkosky, K. (2009). Self-efficacy: A concept analysis. Nursing Forum, 44(2), 93–102. doi:10.1111/j.1744-6198 .2009.00132.x
AN INDEPENDENT VOICE FOR NURSING
A Concept Analysis of Self-Efficacy and Adolescent Sexual Risk-Taking Behavior Monique Jenkins, BS, MA, MS, RN-BC, APRN, FNP-BC Monique Jenkins, BS, MA, MS, RN-BC, APRN, FNP-BC, is Nurse Practitioner, Departments of Nursing and Pediatric Surgery, Maimonides Medical Center, Brooklyn, NY; and is Doctoral Student, Department of Nursing, CUNY The Graduate Center, New York, NY. Keywords Best practices, concept analysis, women’s health Correspondence Monique Jenkins, BS, MA, MS, RN-BC, APRN, FNP-BC, Department of Nursing, CUNY The Graduate Center, New York, NY E-mail: [email protected]
TOPIC. Concept Analysis: Self-efficacy and Sexual Risk-Taking Behaviors of Adolescents PURPOSE. This paper provides an in-depth analysis of the concept of self-efficacy and adolescent sexual risk-taking behaviors CONCLUSIONS. Using the Walker and Avant framework of concept analysis, the concept of self-efficacy has shown to be an important part in changing unhealthy behaviors. It has also shown that the concept of self-efficacy can be pivotal in health promotion activities of adolescents in a variety of settings, especially as it relates to adolescent sexual risk-taking behaviors. PRACTICE IMPLICATIONS. The concept of self-efficacy as it relates to adolescent sexual risk-taking behaviors has clear nursing implications and usage among the adolescent population. Self-efficacy is a key concept to be used in health promotion. Health promotion activities are pivotal in the prevention of sexually transmitted infections in the adolescent population. Knowledge of the self-efficacy level of the adolescent patient can give the nurse greater insight in the meaning of the patient’s response in a given situation. This also helps the nurse identify which adolescents would benefit from early intervention with regard to sexual health.
There are 65 million Americans who have at least one viral sexually transmitted infection (STI) (Centers for Disease Control [CDC], 2009, 2012). Many of the cases were adolescents and young adults between the ages of 15–24. Of the approximate 19 million new cases of STIs diagnosed per year, half of them are among those aged 15–24 years (CDC, 2009). Adolescents have been known to engage in multiple highrisk sexual behaviors that can negatively affect their health. These risky behaviors may substantially increase the risk of premature death, disability, and STIs among today’s youth and young adults. Chlamydia is one of the most prominent STIs among the adolescent population compared with other age groups. The number of reported cases of chlamydia in the United States was 1,307,893 in 2010
(CDC, 2012). This is an increase from the 1,108,374 cases that were reported in 2007. There had been a national increase of chlamydia cases of about 9.2% from 2007 to 2008. This increase was attributed to an actual rise in the disease, more sensitive testing, increased screening, and more accurate reporting (CDC, 2009). In 2008, the total number of chlamydia cases in the United States was 1,210,523 (CDC, 2009) and rose to 1.3 million in 2010 (CDC, 2012). Females 15–19 years old had the largest number of reported cases of this disease; followed by those females 20–24 years old. Because of this increase, chlamydia is considered the most widespread STI in the United States (Avert, 2009). STIs are a major public health challenge in the United States (CDC, 2009). Because some STIs are 1
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume ••, No. ••, ••-•• 2014
Self-Efficacy and Risk-Taking Behavior asymptomatic, the incidence and prevalence of STIs is difficult to diagnose. Many STIs can only be diagnosed by screening. Of the approximate 19 million new STI cases per year, half of them are between the ages of 15 and 24 years. Also, 65 million Americans have at least one viral STI in their lifetime (CDC, 2009). Adolescents and young adults 15–24 years of age represent 50% of all reported STIs, and they represent only about 25% of the sexually active population (Moscicki, 2005). Because of this, there is a clear concern about the adolescent risk for pregnancy and STIs. The decisions made by adolescents regarding their sexual choices shape their well-being and future sexual experiences (Pearson, 2006). Understanding the concept of self-efficacy as it relates to the adolescent population will assist nurses in addressing sexual risk-taking behaviors within this population. Purpose The purpose of this paper is to analyze the concept of self-efficacy as it relates to the adolescent population and their sexual risk-taking behaviors. The framework for this analysis is based on Walker and Avant’s (2005) eight-step process (see Table 1). The identification of the concept and purpose of the analysis have already been addressed. Next steps will be identification of uses of the concept and determination of defining attributes. Model, borderline, related, and contrary cases have been developed to clarify what the concept of selfefficacy and adolescent sexual risk-taking behavior is and is not. Invented and illegitimate cases will be eliminated for the purpose of this paper. The framework of Walker and Avant (2005) concludes with antecedents, consequences, and empirical referents.
Table 1. Walker and Avant’s Eight Steps of Concept Analysis 1. 2. 3. 4. 5. 6.
Identification of the concept Presentation of the purpose of the analysis Identification of uses of the concept Determination of defining attributes Construction of model case Construction of borderline, related, and contrary cases 7. Identification of antecedents and consequences 8. Defining empirical referents
2 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume ••, No. ••, ••-•• 2014
M. Jenkins Findings Uses of the Concept Efficacy is defined as having the power or capacity to produce a desired effect (Merriam-Webster Dictionary and Thesaurus online, 2012). The word is derived from the Latin word “efficacia,” meaning power (MerriamWebster Dictionary and Thesaurus online, 2012). Synonyms for the word efficacy include effectiveness, efficaciousness, efficacity, productiveness, and effectualness (Merriam-Webster Dictionary and Thesaurus online, 2012). Self-efficacy’s history begins within Bandura’s social learning theory that was renamed social cognitive theory. Self-efficacy is one of the major concepts of the Social Cognitive Theory (Bandura, 1977a). In a landmark study, Bandura (1977a) concluded that self-efficacy has an effect on the way individuals think, feel, and behave. In addition, selfefficacy influences an individual’s choice of activities. Bandura (1977b) describes the two types of expectations related to self-efficacy: outcome expectations and efficacy expectations. An outcome expectation stems from the belief that a particular behavior will lead to a particular outcome. Efficacy expectations stem from the belief that an individual can successfully perform a behavior to yield a desired outcome. In another historical study, Bandura (1994) contends that there are four main interests of self-efficacy. The most effective way to develop a strong sense of self-efficacy is through mastering experiences. Individuals must reflect on and learn from their experiences. Another way to develop a strong sense of self-efficacy is through vicarious experiences. These are achieved by watching others complete a task and feeling confident that they can complete the same task. Another way to develop a strong sense of selfefficacy is through social influences. Through their behaviors, models are able to transmit knowledge and teach skills to manage situations within the environment. Verbal persuasion by others can also help develop self-efficacy. Through verbal persuasion, an individual is being convinced by another that they can complete the task. Finally, Bandura asserted that the physiological state of the individual can have an effect on self-efficacy. Alterations in physical state can have either a positive or negative effect on self-efficacy. Positive moods can increase self-efficacy, whereas a negative mood can cause self-efficacy to diminish. In another pivotal study, Cothran and White (2002) proposed the use of the self-efficacy model to
M. Jenkins help decrease risky behaviors in the adolescent population. Cothran and White further asserted that the self-efficacy model links belief and behavior. This model may be beneficial to those individuals who, for example, lack the necessary skills to enforce condom use during sexual activity. The self-efficacy model does not predict behavior perfectly, but it does increase the likelihood that desired behaviors will occur. This model can be effective in decreasing the rate of STIs in the adolescent population. An increase in the self-efficacy of adolescents may increase the likelihood that they make safe decisions regarding their sexual health. Increasing self-efficacy is only one part of the problem regarding adolescents making safe sexual health decisions (Cothran & White, 2002). Self-efficacy can be an important determinant in behaviors and has been shown to be an important predictor in such behaviors as smoking cessation and the use of condoms (Hendriksen, Pettifor, Lee, Coates, & Rees, 2007). With an increased selfefficacy, individuals were able to consistently perform the task as well as show that they have the strength and certainty to perform the task (Hendriksen et al., 2007). Defining Attributes Defining attributes are those characteristics of the concept that are essential and must be present (Walker & Avant, 2005). Key characteristics of self-efficacy were uncovered in the literature review. They are as follows: a. Individual must believe that the task can be completed (confidence) (Bandura, 1994; Cothran & White, 2002). b. Individual must be able to carry out the task (capability) (Cothran & White, 2002). c. Individual must be able to be persistent and maintain the task over time (persistence) (Hendriksen et al., 2007). d. Individual must have the strength to complete the task (strength) (Hendriksen et al., 2007) e. Individual has the desire or motivation to carry out the task or change a behavior (Cothran & White, 2002). Model Case A model case is one in which all defining attributes of the concept are illustrated. In addition, no defining
Self-Efficacy and Risk-Taking Behavior attributes from another concept are exhibited. The model case presents a pure case of the concept (Walker & Avant, 2005). The following is a model case for self-efficacy and adolescent sexual risk-taking behaviors. JC and RK are both 17 years old and have been dating since their sophomore year in high school. They are currently seniors and are ranked in the top half of their class. JC is a cheerleader and looking forward to graduation this June. RK is on the basketball team and has obtained a college scholarship for his athletic abilities. Although they have been dating for a couple of years, JC believes strongly that she will not compromise her academics by engaging in sexual activity. JC and RK have spoken about delaying sexual initiation and have agreed to wait. Despite RK’s desire to want to initiate sexual activity, his love for JC prevails. He is confident that when she is ready, things will happen. JC is confident that RK will wait until she is ready. They both have participated in and completed the interactive STI prevention course at their school and have obtained information regarding safe sexual activity. Both individuals are motivated and desire to wait before initiating sexual activity. Based on this case, all attributes of self-efficacy have been presented. Both teens have the confidence that they will wait for each other and delay initiation of sexual activity. They have the attribute of capability as well. They have participated in and completed the interactive STI prevention course at school. Persistence is illustrated by their efforts to maintain the relationship. The length of time in the relationship is about 2 years. In addition, both physical and emotional strength have been illustrated.
Borderline Case Borderline cases are those in which some attributes of the concept are illustrated (Walker & Avant, 2005). The following case contains most but not all of the defining attributes. JP and SP have been dating on and off for about 6 months. Both have been active in sports and in their school, and both are doing well in their classes. They have decided to delay initiation of sexual intercourse until a later time and are willing to wait until they feel the time is right. There is an interactive STI prevention course at their school in which they have not participated. In this case, both attributes of confidence and strength are illustrated; however, it is lacking the attributes of capability, motivation, and persistence. 3
© 2014 Wiley Periodicals, Inc. Nursing Forum Volume ••, No. ••, ••-•• 2014
Self-Efficacy and Risk-Taking Behavior
M. Jenkins
Related Case
Antecedents
Related cases are those cases that are similar to the concept of self-efficacy, but they do not contain all of the attributes of the concept. Related cases are somehow connected to the concept but are not true illustrations of it (Walker & Avant, 2005). HL and SP have been dating each other for 5 months, and the relationship is progressing well. HL is class President and SP is active in her church. They have participated in oral sex, but have not had sexual intercourse. SP is contemplating having sexual intercourse with HL, but wants to learn more about the consequences of having sex. Her plan is to talk to the nurse practitioner at the school-based clinic. This case is considered a related case because it contains motivation. Motivation is an element needed in order for self-efficacy to exist (Resnick, 2004). SP has the motivation to learn about sex and its consequences, but this does not have any relation to her level of self-efficacy.
The antecedents of a concept are those events that must take place prior the concept occurring (Walker & Avant, 2005). Based on the literature review, the antecedents of self-efficacy are as follows:
Contrary Case The contrary case is one in which none of the attributes are illustrated. This case is a clear example of what the concept is not (Walker & Avant, 2005). MT and LW attend the same high school and have been dating for 2 weeks. They are both average students, and both have been involved in multiple relationships over the past year. MT has been pressuring LW to initiate sexual intercourse, but she refuses to do so. Although she refuses to have sex with him, she questions her decision. There is an interactive STI prevention course available at their school; however, neither of them has participated in it. In this case, none of the attributes of self-efficacy have been illustrated. LW lacks confidence as she is questioning her decision to delay initiation of sexual activity. Capability to make safe decisions is lacking as they have not used the resource of the interactive STI prevention course available at their school. The short length of time that they have been in their relationship, as well as the fact that they have been involved in multiple relationships over the past year, does not illustrate persistence. In addition, this couple does not have the motivation to participate in the interactive STI prevention course. In this instance, there has not been an illustration of either physical or emotional strength. 4 © 2014 Wiley Periodicals, Inc. Nursing Forum Volume ••, No. ••, ••-•• 2014
a. Social experiences—An individual’s social experiences precede self-efficacy. In addition, these social experiences help determine whether or not the individual’s levels of self-efficacy are high or low (Zulkosky, 2009). b. Self-reflections on personal experiences—Bandura (1977a) asserts that self-efficacy can be defined by the appraisals of an individual’s mastery of previous experiences. c. Performance accomplishments—The more successes a person has in performing a particular behavior, the higher their self-efficacy will be for that particular behavior (Bandura, 1994). The adolescent who is successful in one or more behaviors may be more apt to make healthy decisions regarding their sexual health. d. Vicarious experiences—This involves observing someone perform a task, and then the individual feels comfortable performing the same task and receiving a positive outcome (Zulkosky, 2009). The adolescent who sees their peers making healthy sexual decisions is more apt to make healthy decisions regarding their own sexual health. e. Verbal persuasion—This involves an individual speaking to another and convincing them that they are capable of being successful at performing a particular activity (Zulkosky, 2009). Adolescents who are able to speak to others regarding avoiding risky sexual behaviors will be more likely to avoid such behaviors. f. Physiological cues—Sometimes individuals judge their abilities based on their physical cues. These cues could be anxiety, fear, or any other physical cues (Zulkosky, 2009). Before an individual can sense self-efficacy, they must be able to complete a task successfully, observe someone else perform a task with success, obtain positive feedback with regard to completing a task, or rely on physiological cues (Zulkosky, 2009). Consequences Consequences of a concept are those events that take place as a result of the concept occurring
M. Jenkins (Walker & Avant, 2005). In relation to adolescent sexual risk-taking behaviors, the consequences of high self-efficacy can result in healthier sexual health behaviors, limited or no risky behaviors, higher motivation levels, and an increased sense of control over the situation. The consequences of low self-efficacy can result in participation in unhealthy sexual behaviors, increased participation in risky behaviors, low motivational level, and a decrease in sense of control over the situation (Zulkosky, 2009). Some consequences of increased self-efficacy include increased accessibility of community resources and increase in health promotion (Block, Vanner, Keys, Rimmer, & Skeels, 2010).
Empirical Referents The final step in this concept analysis is to determine empirical referents that help identify the concept’s existence in practice (Walker & Avant, 2005). The concept of self-efficacy as it relates to adolescent sexual risk-taking behaviors has clear nursing implications and usage among the adolescent population. Nurses are in the perfect position to make contact with sexually active adolescents. Programs can be offered at schools or in clinics. The programs can combine sexuality education with activities that increase selfefficacy for adolescents offering support, care, and a safe place. Self-efficacy is a key concept to be used in health promotion. Health promotion activities are pivotal in the prevention of STIs in the adolescent population. These activities can help increase the level of general self-efficacy in the teenager who has low self-efficacy. This is accomplished by increasing their sense of personal competence when it comes to sexual behaviors and their consequences. In addition, the health promotion activities can help adolescents personalize their sexual issues and develop specific skills needed to negotiate actions pertaining to their sexual health. Knowledge of the level of self-efficacy in the adolescent patient offers the nurse greater insight into the meaning of the patient’s response in a given situation. This also helps the nurse identify which adolescents would benefit from early intervention with regard to sexual health. In an effort to promote selfefficacy by supporting and empowering adolescents, nurses can a. Facilitate adolescent education regarding new behaviors related to healthy sexual behaviors.
Self-Efficacy and Risk-Taking Behavior b. Facilitate adolescents in modifying or completely eliminating risky sexual behaviors. c. Encourage demonstration and modeling; realizing that they are important ways for individuals to learn a new behavior. d. Enhance verbal persuasion through heath education and counseling about the consequences of sexual activity. e. Encourage role play to facilitate positive responses in situations perceived to be threatening by the adolescent. f. Develop interventions to aid in behavior modifications. g. Provide education that depicts the importance of healthy decision making with regard to sexual health. h. Provide education that depicts the consequences of risky sexual behaviors. i. Practice the new behavior that will aid the individual in accomplishing a positive change. This can be done with role play activities. With continued practice and success, the individual’s sense of self-efficacy will increase. It is also very important for nurses to have a strong sense of self-efficacy as well. A nurse’s strong sense of self-efficacy serves as a model for the patient (Bandura, 1977a).
Conclusion The analysis of the concept of self-efficacy has shown to be an important part in changing unhealthy behaviors. It can be pivotal in health promotion activities of adolescents in a variety of settings as it relates to adolescent sexual risk-taking behaviors. In addition to adolescents needing the knowledge and motivation related to a particular behavior, they also need the perceived capacity and ability to carry out the task and reach their goal. With the development of high levels of self-efficacy, adolescents will be able to make better decisions regarding their sexual health. Making better decisions will lead to a decrease in the number of STIs among this vulnerable population. Nurses have the burden of educating and being role models for adolescents so that positive change can be made. The concept analysis within this paper can provide a basis for nurses to develop effective STI prevention programs in a variety of settings for adolescents. 5
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Self-Efficacy and Risk-Taking Behavior References Avert. (2009). STD statistics in America. Retrieved from http:// www.avert.org/stds-america.htm Bandura, A. (1977a). Self-efficacy: The exercise of control. New York: W. H. Freeman. Bandura, A. (Ed.) (1977b). Social Learning Theory. Englewood Cliffs, NJ: Prentice-Hall. Bandura, A. (1994). Self-efficacy. In V. S. Ramachaudran (Ed.), Encyclopedia of human behavior (Vol. 4, pp. 71–81). New York: Academic Press. Block, P., Vanner, E., Keys, C., Rimmer, J., & Skeels, S. (2010). Project shake-it-up: Using health promotion, capacity building and a disability studies framework to increase self-efficacy. Disability and Rehabilitation, 32, 741– 754. doi:10.3109/09638280903295466 Centers for Disease Control. (2009). Sexually transmitted diseases in the United States, 2008. Retrieved from http:// www.cdc.gov Centers for Diseases Control. (2012). Sexually transmitted disease surveillence 2010. Retrieved from http://www.cdc .gov/std/stats10/surv2010.pdf Cothran, M., & White, J. (2002). Adolescent behavior and sexually transmitted diseases: The dilemma of human papillomavirus. Health Care for Women International, 23, 306–319. doi:10.1080/073993302317346352 Hendriksen, E. S., Pettifor, A., Lee, S. J., Coates, T. J., & Rees, H. V. (2007). Predictors of condom use among young
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M. Jenkins adults in South Africa: The reproductive health and HIV research unit national youth survey. American Journal of Public Health, 97, 1241–1248. Retrieved from http:// www.ncbi.nlm.nih.gov/pmc/articles/PMC1913066 Merriam-Webster Dictionary and Thesaurus online. (2012). Retrieved from http://www.merriam-webster.com/ Moscicki, A. (2005). Impact of HPV infection in adolescent populations. Journal of Adolescent Health, 37, S3–S9. Retrieved from http://leadership.mchtraining.net/ images/stories/Teleconference_Materials_10-06/ moscicki2005HPVreview_JAH.pdf Pearson, J. (2006). Personal control, self-efficacy in sexual negotiation, and contraceptive risk among adolescents: The role of gender. Sex Roles, 54, 615–625. Retrieved from http://www.utexas.edu/cola/orgs/etag/_files/pdfs/ articles/2006/Pearson%202006.pdf Resnick, B. (2004). Self-efficacy. In S. J. Peterson & T. S. Bredow (Eds.), Middle range theories: Application to nursing research (pp. 97–117). Philadelphia: Lippincott Williams & Wilkins. Walker, L., & Avant, K. (2005). Strategies for theory construction in nursing (4th ed.). Upper Saddle River, NJ: Pearson/ Prentice Hall. Zulkosky, K. (2009). Self-efficacy: A concept analysis. Nursing Forum, 44(2), 93–102. doi:10.1111/j.1744-6198 .2009.00132.x
