Application of a theoretical framework
to foster a cardiac-diabetes
self-management programme
C.-J. (Jo) Wu1
RN, DrHlthSc, FACN
& A.M. Chang2
RN, PhD, FRCNA
1 Senior Research Fellow, School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences, Australian Catholic
University, (Brisbane campus), Australia, 2 Professor, School of Nursing, Institute of Health and Biomedical Innovation,
Queensland University of Technology, Brisbane, Queensland, Australia
WU C.-J. (JO) & CHANG A.M. (2014) Application of a theoretical framework to foster a
cardiac-diabetes self-management programme. International Nursing Review 61, 336–343
Aim: This paper analyses and illustrates the application of Bandura’s self-efficacy construct to an innovative
self-management programme for patients with both type 2 diabetes and coronary heart disease.
Background: Using theory as a framework for any health intervention provides a solid and valid foundation
for aspects of planning and delivering such an intervention; however, it is reported that many health behaviour
intervention programmes are not based upon theory and are consequently limited in their applicability to
different populations. The cardiac-diabetes self-management programme has been specifically developed for
patients with dual conditions with the strategies for delivering the programme based upon Bandura’s
self-efficacy theory. This patient group is at greater risk of negative health outcomes than that with a single
chronic condition and therefore requires appropriate intervention programmes with solid theoretical
foundations that can address the complexity of care required.
Sources of Evidence: The cardiac-diabetes self-management programme has been developed incorporating
theory, evidence and practical strategies.
Discussion: This paper provides explicit knowledge of the theoretical basis and components of a
cardiac-diabetes self-management programme. Such detail enhances the ability to replicate or adopt the
intervention in similar or differing populations and/or cultural contexts as it provides in-depth understanding
of each element within the intervention.
Conclusion: Knowledge of the concepts alone is not sufficient to deliver a successful health programme.
Supporting patients to master skills of self-care is essential in order for patients to successfully manage two
complex, chronic illnesses.
Implications for Nursing Practice or Health Policy: Valuable information has been provided to close the
theory-practice gap for more consistent health outcomes, engaging with patients for promoting holistic care
within organizational and cultural contexts.
Keywords: Cardiac-Diabetes Self-Management Programme, Cardiovascular Disease, Coronary Heart Disease,
Diabetes, Intervention Programme, Self-Management, Theoretical Framework, Theory
Correspondence address: Dr Chiung-Jung (Jo) Wu, School of Nursing, Midwifery and Paramedicine, Faculty of Health Sciences Australian Catholic University, 1100 Nudgee
Road, Banyo, Qld 4014, Australia; Tel: +61 7 3623 7889; Fax: +61 7 3623 7105; E-mail: [email protected]; [email protected].
Conflict of interest: The authors declare that they have no competing conflict of interest.
© 2014 International Council of Nurses
336
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Experience from the Field
Theoretical framework for CDSMP
Introduction
Self-management educational programmes are an effective
approach to help patients with chronic diseases manage their
conditions and achieve better health outcomes. However, more
specific detail is needed on the theoretical basis and nature of
such programmes. With the global burden of co-morbidity
increasing, it is essential that further research be conducted on
how self-management can be achieved particularly for patients
with more complex health needs as in those with co-morbidities
(Battersby et al. 2010). Implementing self-management programmes can also be a complex process and literature indicates
that a lack of theoretically based health intervention programmes limits the support for such programmes in practice
(Eccles et al. 2012). A lack of understanding in applying appropriate theory to an intervention has been identified as a possible
reason for inefficiency in translating research findings into practice and subsequent failed interventions (Eccles et al. 2005;
Glasgow et al. 2003; Hrisos et al. 2008; Michie & Abraham 2004;
Michie et al. 2008; Noar et al. 2008). Absence of a theoretical
basis to guide the development and implementation of an intervention can also lead to inconsistent results because of a lack of
justification of how and why an intervention may or may not
work (Hrisos et al. 2008). Consequently, explicitly describing
the theory underpinning health intervention programmes and
the methods of applying such theory is recommended (Helitzer
et al. 2008; Holloway & Watson 2002; Michie & Abraham 2004).
Foy et al. (2007) highlighted the lack of literature discussing
theories to underpin intervention studies and support the
notion that use of theory will assist in providing a ‘generalisable
framework for predicting and interpreting behaviour, designing
interventions and evaluating potential causal mechanisms’ (p. 2).
This paper describes the theory-based framework from which
the main components were of a self-management intervention
developed to improve health outcomes for cardiac patients with
type 2 diabetes. As these dual conditions are endemic worldwide, it is hoped that a clear and thorough understanding of the
framework from which the intervention was designed will
enable the efficacy of the intervention programme to be tested
in varying cultural contexts in the future. Patients with
co-morbidities of type 2 diabetes and cardiac disease represent a
unique and growing subgroup of the global population, and
although their plan of care is complex, they require specific programmes that take into account needs for managing both of
their chronic diseases.
Background
Coronary heart disease and diabetes remain priority research
areas throughout the world as they have a serious impact on
many aspects of society as well as healthcare budgets. The
© 2014 International Council of Nurses
337
number of people with diabetes is estimated to increase from
171 million in 2000 to 366 million by 2030 (Wild et al. 2004;
World Health Organization 2013a). Concurrently, coronary
heart disease has been reported by the World Health Organization as the most common cause of death worldwide (World
Health Organization 2013b). Patients with both coronary heart
disease and type 2 diabetes have higher morbidity and mortality
rates compared to those without diabetes as well as higher readmissions to acute hospitals (Wu & Chang 2008). Given the finite
supply of healthcare resources, and the increasing economic
costs of these dual conditions, maximizing the effectiveness and
efficiency of self-management intervention programmes for this
specific population is paramount, yet has being notably absent
within health research.
Current literature demonstrates the effectiveness of selfmanagement programmes based upon improving self-efficacy
levels and modifying lifestyles for patients with singular chronic
diseases, such as heart failure (Smeulders et al. 2010) or diabetes
(Deakin et al. 2005). However, many existing healthcare delivery
models for self-management fall short in addressing the
complex needs of patients with two co-morbidities, particularly
when transitioning from hospital setting to home. Thus, developing a self-management programme for cardiac patients with
diabetes, which facilitates and improves transitional care, can
address this gap. Commencing a theory-based cardiac-diabetes
self-management programme while patients are still in the hospital setting would capture these patients’ motivation as they
realize that there is a real need for them to make lifestyle
changes in order to reduce the chance of worsening their conditions and consequent rehospitalization (Heisler 2007; Heisler &
Piette 2005).
The cardiac-diabetes self-management intervention, developed by the authors, has been refined, tested and discussed in
previous papers (Wu & Chang 2008; Wu et al. 2009, 2012). The
results of the initial testing of the programme showed significant improvements in knowledge levels and demonstrated feasibility of the intervention (Wu et al. 2009). However, the aim of
this paper is to explicitly describe the theoretical framework
used as a basis for the Cardiac-Diabetes Self-Management Programme (CDSMP) and, more specifically, the strategies that
were used to individually apply elements of the theory.
Theoretical framework for developing
the programme
Prior to developing the cardiac-diabetes self-management programme, it was essential to understand what the characteristics
and perspectives of patients with both conditions were, in managing their conditions. An earlier qualitative study by the
authors identified four main themes from patients in relation to
338
C-J. (Jo) Wu & A. M. Chang
the management of their conditions: confidence in self, confidence in health professionals, fatigue and feelings of hopelessness (Wu et al. 2007).
Confidence in managing their health was a major theme for
patients, as without confidence they are unlikely to fully adhere
to the ongoing management of their conditions. As Bandura
(2004) confirms, ‘unless people believe they can produce desired
effects by their actions they have little incentive to act or persevere’ (p. 622). Gaining the confidence to perform a task is
imperative to achieving self-efficacy, which can be defined as
mastering of the particular task at hand.
Self-efficacy is the key construct of Bandura’s Social Cognitive Theory (1986), which views human functioning as being
determined by a dynamic interaction of personal, behavioural
and environmental influences. The higher the individual’s efficacy expectation levels are towards a particular behaviour, the
greater her/his success will be in achieving that behaviour
(Bandura 1977, 1986). That is, what people think and feel
influences how they act (Bandura 2001); consequently, people
with high efficacy expectations are more likely to perform challenging tasks. In turn, when perceived efficacy expectations are
low, a person is less likely to take actions to solve a problem.
Thus, a programme that intervenes directly on improving individual’s confidence levels is more likely to successfully change a
person’s behaviour. Consequently, incorporating the constructs
of Bandura’s theory was integral to the formulation of the
intervention.
As discussed by Bandura (2004) and Shortridge-Baggett
(2001), the information sources that assist in attaining selfefficacy include mastery (performance accomplishments),
vicarious experience, verbal persuasion and self-appraisal. These
information sources are advocated to directly promote the
patient’s perception of self-efficacy with the ultimate goal of
adoption of self-management behaviours (Bandura 1977; van
der Bijl & Shortridge-Baggett 2001; Shortridge-Baggett 2001).
Although health professionals’ knowledge of these four strategies can assist them in improving patients’ self-management,
the paucity of papers demonstrating the application of these
strategies necessitates specific examination within the context
of the development of the cardiac-diabetes self-management
programme.
Each of the different information sources were merged within
a teaching programme in the study hospital that commenced
during patients’ admission to a coronary care unit continuing
up to discharge. This programme also incorporated an organized telephone call follow-up; 1–2 weeks after patients were
discharged from hospital. Strategies used for the different information sources ranged from providing patients with a DVD
composed of stories of how people with similar conditions had
© 2014 International Council of Nurses
successfully managed their illnesses (vicarious experience) to
providing positive feedback and encouragement to keep going
or persist with skills acquisition (verbal persuasion). Specific
examples of each information source and its application can be
seen in Tables 1 and 2.
Method for incorporating self-efficacy construct
into intervention programme
Our intervention, which targeted patients with type 2 diabetes
and a cardiac condition, incorporated strategies to improve
patients’ self-efficacy in order to achieve self-management of
their dual conditions. The four information sources of mastery,
vicarious experience, verbal persuasion and self-appraisal form
the framework for Bandura’s self-efficacy theory (Bandura
1977, 2004) and will be discussed further here, in the context of
the intervention.
Mastery is the most influential source of increasing selfefficacy and refers to the actual performance of the behaviour
(Bandura 1977, 1986, 2004). Mastery, within this context,
can be defined as becoming proficient in a set task and is
usually accomplished through practice (van der Bijl &
Shortridge-Baggett 2001). When given the opportunity to be
able to repeat a task, patients are able to progress their attainment of the behaviour through small steps and by building on
previous accomplishments. Through successful repetition,
people will raise their mastery experience and, in turn, improve
their confidence levels (Bandura 1977). After overcoming
impediments and through persistent effort, patients gain a sense
of self-assurance, which further strengthens their self-beliefs of
efficacy (Bandura 1998). Repeated successful experiences will
increase a person’s feeling of self-efficacy to the point where the
occasional failure will not greatly influence their resolve to try
again (van der Bijl & Shortridge-Baggett 2001). Strategies used
to promote this information source within the programme
included providing multiple opportunities to practice skills,
such as measuring blood glucose levels (BGLs), until the
patients were able to master and demonstrate the skill independently. Other basic self-management skills were taught, including how to monitor blood pressure and heart rate as well as how
to perform exercises, which could be increased incrementally
depending upon the patient’s condition.
To achieve mastery in self-management, it was imperative to
assess individual patient’s baseline skill level and build on this
gradually rather than attempt to teach the patients the skills all
in one session. For example, initially when teaching a patient
how to monitor their blood sugar level, we would start with
showing them the equipment; describing how it looked, felt and
worked. After the patient was comfortable with this, we would
then teach them about the finger prick needed to obtain the
Theoretical framework for CDSMP
339
Table 1 An example of applying self-efficacy strategies to information sources within a Cardiac-Diabetes Self-Management Programme in three face-toface sessions
Session
Strategy
Information source to improve self-efficacy levels
1
Introduce Cardiac-Diabetes Self-Management Programme. Make connection between cardiac
diabetes and diabetes.
Case study in DVD – of patients that the population can identify with, followed by discussion
with patient, comparing and contrasting patient with person on DVD
Assist patient to identify body and emotional responses as they endeavour to undertake
self-management of their conditions
Demonstrate basic skills of self-management including monitoring their heart rate, blood
glucose levels, exercise, diet, medication and foot care
Provide exercises where patient can be successful in incremental steps to self-management
Provide feedback and encouragement to patients of their success in basic self-management skills
Encourage patients to discuss his or her own BGL
To look at patient’s own basic skills
Opportunity to have questions answered:
Self-monitoring BGL and keeping a record
Review self-monitoring results
To review the case study
Encourage patients to discuss their own self-monitoring results
Opportunity to have questions answered
Verbal persuasion
1
1
1
1
1
2
3
3
Vicarious experience
Self-appraisal of physiological and emotional
responses
Vicarious experience
Mastery
Verbal persuasion
Vicarious experience
Verbal persuasion
Mastery
Self-appraisal
Mastery, self-appraisal
Vicarious experience, Verbal persuasion
Vicarious experience
Verbal persuasion
Mastery, self-appraisal
Table 2 An example of applying self-efficacy information sources to strategies within a Cardiac-Diabetes Self-Management Programme in telephone
follow-up
Information sources
Strategy
Telephone prompt conversations
Mastery
Reinforce techniques (provide support)
Assessment of basic skills of self-management including
monitoring their heart rate, blood glucose levels, exercise,
diet, medication and foot care: e.g. check daily, if not done,
attempt to find reason why it is not done
Interpretation of self-monitoring results
Provide support
Tell me your experience of managing your conditions at home
after hospital admission. Are you managing at home all
right?
Have you been continuing to check your blood glucose levels?
What have the levels been like?
What are you planning to you about it? (goal setting)
Tell me your experience of managing your conditions at home
after I saw you 2 weeks ago. Any concerns or difficulties
about managing your conditions at home? If yes, please give
details – how did you find out this concern or difficulty
(identify problem)
How did you go about it? (take own action)
To be combined with vicarious experience
To be combined with performance accomplishment
How do you feel? What do you feel after you have done it?
(self-evaluation)
Vicarious experience
Verbal persuasion
Self-appraisal
Get them to reflect on reasons for self- monitoring activities
Physical, emotional status will affect patient’s self-appraisal
about the task
blood sample. Once the patient had achieved this task, we
would then show them how to insert the test strip with the
blood sample into the machine and how the results were
obtained. The final step in this process was to discuss with the
© 2014 International Council of Nurses
patient how, where and when to record each reading. Patients
were offered multiple opportunities to practice any or all of the
steps and family involvement was also encouraged, at the
consent of the patient.
340
C-J. (Jo) Wu & A. M. Chang
Vicarious experience is the second source of information
used to build self-efficacy and can be accomplished through
providing social models (Bandura 1998). People persuade
themselves that if others like themselves can do it, then they
should be able to also perform that behaviour to some degree
(Bandura 1977). To apply this information source within the
intervention programme, two main strategies were undertaken.
Firstly, patients observed the researcher performing BGL monitoring before they performed the action themselves. Additionally, patients were provided with a DVD portraying three cases
of how other people with the same conditions have succeeded
in the tasks required to manage their cardiac condition and
type 2 diabetes. The DVD provided a tangible resource which
patients could view at any time to obtain perspectives on how
other people, similar to them, were successful in managing their
conditions. Although the participants may not have personally
known the actors in the DVD, the DVD cases provided the
social models, described in Bandura’s theory, who participants
felt they could relate to. Consequently, the actors (a middle-age
working man, a 68-year-old woman and an indigenous
woman) became positive role models for the patients and
assisted in reinforcing the changes being undertaken, in a positive manner.
The third information source of verbal persuasion is used to
enable people to achieve what they wish to achieve (Bandura
1986). People who are verbally persuaded in a positive manner
are more likely to activate and maintain their efforts, and incorporate their abilities to master a given activity (Bandura 1986).
Verbal persuasion alone may be limited in increasing selfefficacy, but when combined with any or all of the other
sources, it can contribute to successful performance of specific
tasks (Bandura 1986). Therefore, in applying this strategy in
the intervention, patients were verbally encouraged by the
researcher and given positive feedback, such as telling patients,
‘You can do it’ and ‘You are doing really well’, in order to assist
their performance. Specific verbal persuasion statements used in
the telephone follow-up are shown in Table 2.
Self-appraisal is the fourth information source identified in
Bandura’s theory and also influences people’s self-efficacy as it
assists to remove self-doubt (Bandura 2004). While attempting
to learn new behaviours, people may reflect on their own physical and emotional states in judging their abilities (Bandura
1998, 2001); however, they may interpret their stress reactions
and tension in the early stages as signs of incompetence.
People’s self-beliefs of efficacy can be improved if they are able
to ‘read’ their own cues. If people are aware of their thoughts or
emotional states or cues such as anxiety, stress, fatigue and
mood when they face a certain task, they can alter their own
thinking and thus reduce fear about their ability to perform the
© 2014 International Council of Nurses
task (Bandura 2004; O’Sullivan & Strauser 2009). For the
cardiac-diabetes self-management programme, participants
were asked questions about how they felt with each new action
and encouraged to recognize their feelings and emotions. If at
any time they became aware of feelings of stress or self doubt,
they were given further strategies to undertake, such as stopping
the activity, taking a deep breath, watching the DVD again or
calling a friend or other support person. When they felt ready,
they were encouraged to attempt the task again and would often
be heard to say things such as ‘I did it!’ or ‘I can do it!’ These
were seen as successful self-appraisal statements.
Each of the information sources were able to be directly
incorporated into the intervention using strategies that supported the patient’s self-care behaviour and initial positive
results support the manner in which the programme is being
implemented (Wu et al. 2009, 2011). Now that the theoretical
foundation for the programme has been extensively explored, it
is hoped that the programme can be tested in differing cultural
contexts. If proven to have a significant effect on selfmanagement behaviours within different contexts, the programme will have international value to the cohort of patients
with cardiac disease and diabetes and consequent potential benefits to global health.
Discussion
The social-cognitive self-efficacy model (Bandura 2004)
emerged and evolved as a result of attempts to understand how
people can change their behaviours. Changing behaviours, particularly in regard to health habits, is a process that requires
deep understanding of the principles of such a theory as just
telling someone to change their behaviour is insufficient and
ineffective. Elements of Bandura’s theory have been utilized in
other health programmes such as in the appropriate disclosure
of a dementia diagnosis (Foy et al. 2007) and previous studies
measuring specific self-efficacy levels in other clinical populations have produced improvement in self-management behaviours (Haas 2000; Moon & Backer 2000). A systematic review
conducted in 2010 demonstrated the effectiveness of interventions that incorporated the self-efficacy construct with strategies
to increase physical activity (Ashford et al. 2010). However,
without a substantive framework to guide the self-efficacy strategies within any programme or thorough explanation of the
elements of such a programme, it is difficult to fully comprehend how some self-management programmes actually assist
patients to change their self-management behaviours. Explicit
understanding of the application of such a framework, as outlined in this paper, enables further development of the intervention with the potential to apply it across differing cultures and
Theoretical framework for CDSMP
contexts, as there is clear direction and reasoning on strategies
utilized and expected outcomes.
Applying theory-based interventions across differing cultural
contexts requires more than just translation of tools to be used.
Knowledge and appreciation of ethnic cultural sensitivities and
understanding of the ethics associated with applying interventions across cultures is an integral part of the process. The
dynamic nature and variations within different cultures pose
challenges to the application and transfer of any intervention
across such diverse settings. However, through increasing
globalization, cultural influences are more recognizable, that is
what happens in one country more often now impacts other
countries (Bandura 2002); globalization is changing the nature
and delivery of health care and nursing in general (Schroth &
Khawaja 2007).
As mentioned earlier, patients with dual diagnoses such as
type 2 diabetes and a cardiac condition are becoming a rapidly
growing subgroup globally, with needs that are more specific,
yet more complex, than those of a patient with a singular diagnosis. Patients may experience a form of ‘culture shock’ when
diagnosed with these conditions (Munoz & Luckman 2005);
therefore, it is essential that any intervention or programme
developed to assist patients to manage their co-morbidities has
a strong foundation, which will enhance awareness and understanding of their conditions and provide guidance for successful
management (Ray 2010). Furthermore, relationships between
nurses and patients using technology to promote adherence to
management regimens presents challenges to patient care
(Martin et al. 2005). As health professionals, it is crucial to
ensure that the technological aspects of providing care do not
predominate the essential human dignity of patients. A selfefficacy approach to promoting self-management does attend to
human dignity by being patient rather than health professional
focused in a social context, for example, by assessing patients’
needs and goals for care and by providing models, similar to
themselves, who demonstrate progression to successful selfmanagement. However, greater attention to human dignity
would be enhanced if the self-efficacy-based intervention
for promoting self-management was also guided by more
complex theoretical models such as Watson’s transpersonal
caring theory (Watson 2008, p. 243). This may be explored in
future studies.
Our intervention addresses the self-management needs for a
group of patients with dual diagnoses within a caring and
empowering framework, based upon theory, through using the
strategies outlined. The construct of self-efficacy as it applies in
this intervention may transcend cultural and ethnic boundaries
as many patients, regardless of ethnicity, desire to modify their
behaviour for positive health outcomes.
© 2014 International Council of Nurses
341
Limitations
There is no one size fits all for nursing staff in providing a
complex intervention such as self-management for patients with
dual diagnoses. However, this paper illustrates practical principles to develop and implement an evidence-based theoretical
intervention.
Implications for nursing or health policy
There is an increase in the practice and knowledge gap when
implementing an evidence-based intervention. It is reported
health interventions for cardiac patients are often ‘underused’,
yet for other conditions may be ‘overused’ (e.g. screening for
prostate cancer), or ‘misused’ for other programmes (Walshe &
Rundall 2001). This paper has provided valuable information by
explicating the application of theory-based intervention to close
the theory-practice gap to achieve more consistent health outcomes, and for making future health policy in effectively health
services delivery.
Conclusion
Bandura’s self-efficacy theory has provided a solid platform for
the cardiac-diabetes self-management programme; however,
knowledge of the concepts alone is not sufficient to deliver a
successful health programme. Delivering interventions based
upon components of the theory in ways that support the patient
to master skills of self-care was the primary goal of this intervention and this paper. Methods of applying Bandura’s four
information sources of mastery, vicarious experience, verbal
persuasion and self-appraisal for delivering the programme
have also been discussed in the context of assisting patients to
promote self-efficacy in self-management of two complex,
chronic illnesses. Approaches for incorporating Bandura’s four
information sources for enhancing self-efficacy include promoting mastery towards attainable goals, providing models of
successful self-management by way of people with similar conditions, giving encouragement and feedback as well as assisting
patients to become aware of their emotional and physical
responses to attempting self-management. Our work has contributed to the literature on theory-based interventions. Useful
and practical information provided in this paper is highly relevant for the international nursing community. Such an intervention will be more likely to lead to improvement in delivery
of patient education and therefore achieve more sustainable
outcomes.
Acknowledgements
The authors would like to express their sincere gratitude for
research grants at various stage of the development of this
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C-J. (Jo) Wu & A. M. Chang
cardiac-diabetes self-management programme. The initial programme was supported by the John P Kelly Research Fund,
Mater Health Services in 2005. The revised programme, incorporating text-messaging, was funded by a Queensland University of Technology (QUT) Early Career Researcher research
grant in 2008. The later development of a DVD and incorporation of peer supporters was funded by the Department of
Health and Ageing through the ‘Sharing Health Initiative’
Research Grant in Australia.
Author contributions
C-JW contributed to idea conception, principal drafting of this
manuscript, as well as appraisal, editing and drafting the final
draft. AC contributed to idea conception, appraisal and editing
of the manuscript. Both authors have read and approved the
final manuscript.
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