Advance Care Planning Self-Efficacy Scale

Abstract

The Advance Care Planning Self-Efficacy Scale (ACPSES), developed by Murray et al. (2024), is a 12-item rating instrument designed to quantify an individual’s perceived Self-Efficacy (confidence) in executing specific Advance Care Planning (ACP) behaviors across various situational contexts. Key behaviors assessed include the successful completion of a living will, the designation of a healthcare agent, and the ability to effectively communicate preferences regarding end-of-life quality of life. The development of the ACPSES was conceptually guided by the Transtheoretical Model (TTM) of behavior change. The scale was rigorously validated among a population of older adults (aged 50 and above) in the United States and demonstrated robust psychometric properties through iterative factor analyses.

The final scale, administered electronically, is grounded in strong internal consistency (α = .95) and confirmed construct validity, making it a reliable tool for assessing confidence as a key predictor of engagement in ACP activities.

Keywords

Advance Care Planning, Behavior Change, Confidence, End-of-Life Care, Older Adults, Self-Efficacy, Transtheoretical Model, Psychometrics, Healthcare Agent, Living Will.

Authors

Murray, Alexandra N., Monahan, Katie, Sacco, Allegra, Paiva, Andrea, Redding, Collen, Robbins, Mark.

Purpose

The primary purpose of the Advance Care Planning Self-Efficacy Scale is to provide a quantitative measure of situation-specific self-efficacy directly related to the execution of Advance Care Planning tasks. This evaluation is theoretically grounded in the principles of the Transtheoretical Model (TTM) of behavior change.

By assessing confidence levels, the scale helps researchers and clinicians identify perceived barriers and facilitators to engaging in ACP, thereby informing targeted interventions designed to promote proactive planning for end-of-life care among older populations. The focus is on measuring confidence in specific actions rather than just general attitudes toward death.

Construct

The core psychological construct measured by this instrument is Advance Care Planning Self-Efficacy. This construct refers to an individual’s belief in their own capacity to successfully perform specific actions required for effective ACP, such as initiating difficult conversations, documenting legal preferences (e.g., a living will), and maintaining those plans over time.

Measuring this specific form of self-efficacy is crucial, as confidence is a central driver in the Transtheoretical Model, predicting movement from earlier stages of contemplation and preparation into the active execution of complex health behaviors like ACP.

Validity

The validity of the ACPSES was primarily established through an assessment of its construct validity. Researchers evaluated the hypothesized relationships among self-efficacy scores, the perceived pros (benefits), and the perceived cons (barriers) of ACP across the different stages of change defined by the Transtheoretical Model (TTM).

Specifically, the validation process examined patterns across the five key stages: Precontemplation, Contemplation, Preparation, Action, and Maintenance. The scale successfully demonstrated cross-validation with existing ACP measures that are also based on the TTM framework and indicated that self-efficacy scores varied significantly and predictably according to the participant’s stage of readiness for change, thus supporting the measure’s theoretical grounding.

Reliability

The ACPSES exhibits strong internal consistency, confirming the reliability of the 12-item final measure. Reliability was calculated using Cronbach’s alpha (α), yielding a robust coefficient of α = .95.

This exceptionally high alpha value suggests that all 12 items reliably measure the same underlying construct—namely, confidence in performing Advance Care Planning behaviors—and that the scale provides consistent measurement across the target population.

Factor Analysis

The development process for the ACPSES involved rigorous iterative factor analyses to refine the item set and confirm its dimensional structure. The initial pool of 35 items was systematically reduced through seven sequential exploratory factor analyses (EFA), ultimately resulting in the final 12-item scale.

The Exploratory Factor Analysis strongly supported a clear one-factor solution, suggesting that the scale is unidimensional and measures a single, cohesive construct of ACP self-efficacy. This structure was subsequently tested using Confirmatory Factor Analysis (CFA). The CFA, restricted to a one-factor model, showed acceptable model fit statistics, including: χ² (54) = 182.07, p < .001; Comparative Fit Index (CFI) = .89; and Root Mean Square Error of Approximation (RMSEA) = .13. These results collectively support the scale’s fundamental one-factor structure.

Instrument

Test Type: Original

Format: Participants rated their confidence in performing specific ACP behaviors using a five-point Likert-type scale. The response options ranged from 1 (“Not at all confident”) to 5 (“Completely confident”). The scale is a 12-item rating scale.

Language Available: English (Original development language)

Population Group: Human; Male; Female; Transgender individuals.

Age Group: Adulthood (18+); Middle Age (40-64); Aged (65+); Very Old (85+).

Population Details: The scale was validated specifically with adults aged 50–99 residing in the United States, targeting older adults due to the clinical relevance of Advance Care Planning in this demographic.

Test Methodology: The scale is administered electronically.

Keywords

Psychometrics, Rating Scale, Older Adults, Internal Consistency (α = .95), Construct Validity, Confirmatory Factor Analysis, End-of-Life Care, TTM Stages of Change, Confidence.

Authors

Author ORCID Identifier: Not provided in source content.

Affiliation Email addresses: Murray, Alexandra N. ([email protected]). Key affiliations involved the Digestive Disease & Surgical Institute, Cleveland Clinic Foundation, and the Department of Psychology, College of Health Sciences, University of Rhode Island.

Correspondence Address: Cleveland Clinic, Breast Center, Digestive Disease Institute, 9500 Euclid Avenue, Cleveland, Ohio, United States, 44102.

Permissions & Fee and Test Year

The scale was developed and published in 2024. Information regarding specific permissions and licensing fees for clinical or commercial use of the scale is not detailed in the available source content. No original PDF files or scale documents were listed as available for download by the authors.

Reference’s

Murray, A. N., Monahan, K., Sacco, A., Paiva, A., Redding, C., & Robbins, M. (2024). Development and validation of a measure of self-efficacy for advance care planning. American Journal of Hospice & Palliative Medicine, 41(8), 873–881. DOI: 10.1177/10499091231210504

Items of the Advance Care Planning Self-Efficacy Scale

IMPORTANT: The following scale items must be preserved in their original language and must not be changed in any way.

• You do not like to think about death and dying.

• You would not want to upset your loved ones by sharing your wishes with them.

• Your loved ones do not seem to think you need to do advance care planning yet.

• You do not trust that healthcare providers will respect your wishes at end of life.

• You do not have anybody to talk to about your end of life care wishes.

• Your healthcare providers did not seem to think you needed to do advance care planning.

• You think it is not yet time for you to consider advance care planning.

• You are too busy to complete advance care planning.

• You do not know what kind of medical care you would want at the end of your life.

• Your physician seemed as though they did not have time for the conversations.

• Talking about end of life care makes you uncomfortable.

• You have little experience with death and dying.