Date of Award


Degree Type


Degree Name

Doctor of Philosophy in Psychology


Clinical Psychology



First Advisor

Mark L. Robbins


A disparity exists between the medical intervention people say they want to receive at end-of-life and the care that is typically delivered. Advance care planning (ACP) involves discussing end-of-life care wishes, including relevant values and cultural beliefs, and documenting these preferences for medical providers and loved ones to minimize unwanted suffering and maximize quality of life. Numerous healthcare institutions have emphasized the importance of doing ACP prior to an imminent medical need, prompting researchers to implement awareness campaigns and interventions in earlier stages of healthcare interactions (e.g., primary care). However, motivation to follow through with ACP varies depending on numerous factors including overall readiness, understanding of the risks and benefits, and how one manages the internal experience of facing one’s own mortality. One intrinsic experience that has been shown to be important for health behavior change is situation specific-confidence, or self-efficacy. This work builds on previous research that approaches ACP intervention from the theoretical framework of the Transtheoretical model (TTM) of behavior change, in which self-efficacy is a core component. Study 1 of this dissertation sought to explore the construct of self-efficacy specific to doing ACP with qualitative work including expert interviews and focus groups with older adults in the community about their experiences. The work presented describes the efforts to understand self-efficacy as a barrier to engagement in end of life care planning. Self-efficacy was associated with interpersonal support, access to structured tools to guide discussions, and tolerance of the unpleasantness of negative emotions. Assessment of themes from focus groups and expert interviews was conducted to write items of a scale of self-efficacy to do ACP. Study 2 of this dissertation describes the development and validation of a scale of ACP self-efficacy using a sequential approach to measure development. Qualitative and quantitative methods were utilized for item development/refinement and scale validation. Split-half validation procedures were conducted, with exploratory and confirmatory factor analyses on randomly selected subsamples. The results of several iterations of exploratory factor analyses supported a final set of 12 items loading on one factor, with high internal consistency. The final 12-item ACP self-efficacy scale was found to have good overall model fit in confirmatory analyses, assessed with χ2 tests of significance and fit indices. Further, the developed scale was validated using previously developed TTM measures of ACP behavior change (Stage of Change, Decisional Balance) and related constructs (General Self-Efficacy, Attitudes Values & Cultural Beliefs). As expected, ACP self-efficacy varied by stage of change, with those in more progressed stages endorsing higher levels of confidence that they could complete ACP behaviors, upholding the relationships hypothesized by the TTM. Together, these two studies address the importance of self-efficacy for engagement in complex behaviors and provide a tool for future use to gain a deeper understanding and increase behavior change in this area.



To view the content in your browser, please download Adobe Reader or, alternately,
you may Download the file to your hard drive.

NOTE: The latest versions of Adobe Reader do not support viewing PDF files within Firefox on Mac OS and if you are using a modern (Intel) Mac, there is no official plugin for viewing PDF files within the browser window.