"I Don't Think I Can": Self-Efficacy Theory as a Borrowed Framework for Mobility in Hospitalized Older Adults
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Doctor of Nursing Practice Program, Aspen University
DNP 800: Theoretical and Scientific Underpinnings
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"I Don't Think I Can": Self-Efficacy Theory as a Borrowed Framework for Mobility in Hospitalized Older Adults
Nursing has always borrowed theory from other disciplines, and borrowing is legitimate when the theory fits a nursing problem and is adapted to the nursing context. One persistent problem in hospital care is that older adults who are physically able to walk often do not. Nurses hear the reasons daily: I don't think I can, I might fall, I'll wait for the therapist. This paper applies a theory borrowed from psychology, Bandura's theory of self-efficacy, to that problem. It describes the theory, explains why it fits, shows how its constructs translate into nursing actions, reviews evidence from function-focused care, a nursing approach consistent with the theory, and considers the limits of borrowing.
The Theory
Bandura (1977) proposed that behavior change depends heavily on self-efficacy, a person's conviction that they can successfully carry out the behavior required to produce an outcome. He distinguished efficacy expectations, beliefs about one's ability to perform a behavior, from outcome expectations, beliefs that acting will produce the hoped-for result. A patient may believe that walking will help her recover but doubt that she can walk to the bathroom safely; in that case, the outcome expectation is present but the efficacy expectation is not, and she will stay in bed.
Efficacy expectations, in Bandura's account, come from four sources. Performance accomplishments, succeeding at the task, are the most powerful. Vicarious experience, seeing others like oneself succeed, is another. Verbal persuasion, being told by a credible person that one can do it, has a weaker and less durable effect. And physiological states, such as anxiety, breathlessness or pain, are interpreted as signs of vulnerability and lower efficacy when they are strong (Bandura, 1977).
Why the Theory Fits
The problem of low mobility in hospitalized older adults is not mainly one of knowledge or motivation. Most patients know that walking is good for them and want to go home. The gap lies in their confidence that they can walk safely in an unfamiliar environment while ill, often after being told to call for help before getting up. Observational research found that older men on medical units spent 83% of their measured stay lying in bed even though most could walk independently at admission (Brown et al., 2009). Self-efficacy theory explains that pattern: the hospital removes opportunities for performance accomplishments, offers few models, provides conflicting persuasion and heightens the physiological cues of illness, all of which lower efficacy.
The theory also explains why well-meant messages can backfire. When a nurse tells a patient to call before getting up and then takes 15 minutes to answer the call light, the patient learns that walking depends on others and that trying alone is risky. Each such episode lowers efficacy further, while each successful walk with a nurse nearby raises it.
Translating the Constructs Into Nursing Actions
Each source of efficacy suggests nursing actions. For performance accomplishments, nurses can build a graded sequence of successes: dangling the legs over the bedside, then rising to stand, then walking to the chair, then to the door and into the hallway, with each success noted and praised. For vicarious experience, units can show patients others walking, through photographs or videos of older patients walking on the unit, or by encouraging patients to walk together. For verbal persuasion, nurses and physicians can deliver a consistent message that walking is expected and safe with the right support, replacing the message that patients should stay in bed. For physiological states, nurses can treat pain before walking, time activity after bronchodilators, reinterpret mild breathlessness as normal exertion, and reduce anxiety by staying close during early attempts.
Outcome expectations also need attention. Nurses can link walking to what the patient values, such as going home or climbing the stairs to a bedroom, so that the behavior has personal meaning.
Documentation can reinforce these actions. Recording each walk, with distance and the level of assistance, gives the patient visible evidence of progress, which is itself a performance accomplishment, and gives the team information for setting the next day's goal.
Evidence From Function-Focused Care
Function-focused care is a rehabilitative philosophy in which nurses help patients engage in daily activities and physical activity to prevent avoidable decline. It was developed with social cognitive theory as a foundation, so its strategies map closely onto the sources of efficacy. In an observational study of older adults on medical-surgical units, patients lost physical function during hospitalization, but those who received more function-focused care declined less (Boltz et al., 2011). In a comparative trial, a family-centered version, which involved environmental changes, staff education and partnership with family caregivers in care planning, was associated with better performance of daily activities and walking and with less severe and shorter delirium than education alone, and family caregivers reported feeling more prepared (Boltz et al., 2014). Family members are a natural source of verbal persuasion and support for performance, which may explain part of the effect.
Limits of Borrowing
Self-efficacy theory was developed to explain behavior change in people who can choose to act. In hospital, patients' choices are constrained by lines, alarms, staffing and rules. A theory focused on the individual's beliefs can distract from these structural barriers, and a nursing application must address them directly rather than treating low mobility as a patient's lack of confidence. Delirium and dementia also limit the theory's reach, since efficacy beliefs require the capacity to reflect on one's abilities. For such patients, family involvement and environmental changes may matter more than persuasion.
A further limit is cultural. Beliefs about rest, illness and the proper role of patients and nurses vary, and some patients expect to be cared for rather than encouraged to do things themselves. Nurses applying the theory need to ask what walking means to each patient and family rather than assuming that confidence is the only barrier.
Conclusion
Self-efficacy theory, borrowed from psychology, fits the problem of low mobility among hospitalized older adults because it explains why capable patients do not walk and identifies four sources of confidence that nurses can influence. Function-focused care, which draws on the same theoretical foundation, offers evidence that nursing actions built on these principles can reduce functional decline. Borrowing responsibly means adapting the theory to the hospital, adding attention to structural barriers and cognitive impairment that the theory does not address.
References
Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191-215. https://doi.org/10.1037/0033-295X.84.2.191
Boltz, M., Resnick, B., Capezuti, E., Shabbat, N., & Secic, M. (2011). Function-focused care and changes in physical function in Chinese American and non-Chinese American hospitalized older adults. Rehabilitation Nursing, 36(6), 233-240. https://doi.org/10.1002/j.2048-7940.2011.tb00088.x
Boltz, M., Resnick, B., Chippendale, T., & Galvin, J. (2014). Testing a family-centered intervention to promote functional and cognitive recovery in hospitalized older adults. Journal of the American Geriatrics Society, 62(12), 2398-2407. https://doi.org/10.1111/jgs.13139
Brown, C. J., Redden, D. T., Flood, K. L., & Allman, R. M. (2009). The underrecognized epidemic of low mobility during hospitalization of older adults. Journal of the American Geriatrics Society, 57(9), 1660-1665. https://doi.org/10.1111/j.1532-5415.2009.02393.x
How this DNP 800 Module 3 example is structured
Aspen does not publish DNP 800 module prompts, so check your classroom for the exact instructions. This example states the practice problem, summarizes the borrowed theory, argues its fit, translates each construct into nursing actions, reviews evidence from a nursing approach built on it, and names the limits of borrowing.
DNP 800 Module 3 questions, answered
What does DNP 800 Module 3 usually ask for?
Aspen's DNP 800 description includes psychosocial sciences among the foundations of nursing, so applying a theory from another discipline to a practice problem is a typical assignment. Check your classroom for the prompt.
What is a borrowed theory?
A theory developed in another discipline, such as psychology or sociology, and applied to nursing problems. It should be adapted to the nursing context and its fit justified.
What are the four sources of self-efficacy?
Performance accomplishments, vicarious experience, verbal persuasion and physiological states, with performance accomplishments the most powerful.
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