Advance Care Planning Self-Efficacy Scale

Abstract

The Advance Care Planning Self-Efficacy Scale (ACP-SES) is a psychometrically validated, 12-item self-report instrument engineered to measure an individual’s situational confidence in executing advance care planning (ACP) behaviors under adverse or demanding conditions. Developed by Alexandra N. Murray, Katie Monahan, Allegra Sacco, Andrea Paiva, Colleen Redding, and Mark Robbins (2024), the scale is conceptually anchored in Albert Bandura’s social cognitive theory of self-efficacy and operationalized through the theoretical architecture of the Transtheoretical Model (TTM) of health behavior change. The ACP-SES captures respondent confidence across critical ACP behavioral domains, including identifying a healthcare proxy, articulating treatment and quality-of-life preferences, completing legal documentation (such as living wills and durable powers of attorney for healthcare), and communicating these wishes to surrogate decision-makers and clinicians. Psychometric evaluation of the instrument was conducted with a diverse sample of community-dwelling adults aged 50 and older across the United States. Following seven iterative rounds of exploratory factor analysis (EFA) that reduced an initial 35-item candidate pool, the scale resolved into an efficient, unidimensional 12-item structure. Confirmatory factor analysis (CFA) demonstrated adequate structural stability. The scale demonstrates exceptional internal consistency (Cronbach’s alpha = .95) and robust construct validity, evidenced by theoretically consistent differentiation across the TTM stages of change (Precontemplation, Contemplation, Preparation, Action, and Maintenance) and expected associations with decisional balance dimensions (pros and cons). The ACP-SES provides clinical gerontologists, palliative care specialists, behavioral researchers, and health psychologists with a standardized diagnostic tool to identify psychological barriers to advance decision-making and evaluate stage-tailored ACP interventions.

Keywords

Advance Care Planning, Self-Efficacy, Transtheoretical Model, Stages of Change, Palliative Care, End-of-Life Decision Making, Living Wills, Healthcare Proxy, Psychometrics, Older Adults, Health Behavior Change, Instrument Validation

Authors

The Advance Care Planning Self-Efficacy Scale was developed and validated through a multi-institutional collaborative investigation led by behavioral scientists and health psychologists specializing in cancer prevention, health behavior change, and palliative medicine:

• Alexandra N. Murray, PhD — Corresponding Author. Digestive Disease & Surgery Institute, Cleveland Clinic Foundation, Cleveland, Ohio, United States. (Email: [email protected]).
• Katie Monahan, MS — Department of Psychology, College of Health Sciences, University of Rhode Island, Kingston, Rhode Island, United States.
• Allegra Sacco, PhD — Department of Psychology, College of Health Sciences, University of Rhode Island, Kingston, Rhode Island, United States.
• Andrea Paiva, PhD — Department of Psychology, Cancer Prevention Research Center, University of Rhode Island, Kingston, Rhode Island, United States.
• Colleen Redding, PhD — Department of Psychology, Cancer Prevention Research Center, University of Rhode Island, Kingston, Rhode Island, United States.
• Mark Robbins, PhD — Department of Psychology, University of Rhode Island, Kingston, Rhode Island, United States.

Purpose

Advance care planning is a multifaceted, dynamic communication and decision-making process through which individuals clarify, articulate, and document their future medical preferences in alignment with personal values, life goals, and cultural beliefs. Despite robust empirical evidence demonstrating that proactive ACP improves end-of-life quality of care, diminishes surrogate caregiver bereavement distress, reduces non-beneficial hospitalizations, and increases hospice utilization, population-level completion rates of advance directives remain stubbornly low—frequently hovering between 30% and 40% among middle-aged and older adults. A primary reason for this persistent implementation deficit is that traditional clinical approaches have historically treated ACP as a transactional, administrative event (i.e., signing a legal form) rather than a complex, emotionally taxing health behavior governed by cognitive, affective, and interpersonal determinants.

The primary purpose of the Advance Care Planning Self-Efficacy Scale (ACP-SES) is to operationalize and quantify an individual’s situation-specific confidence in engaging in ACP across challenging, high-friction scenarios. Grounded in the realization that individuals may feel theoretically supportive of advance planning yet feel entirely incapable of executing it when confronted with emotional overwhelm, family conflict, or medical ambiguity, the ACP-SES assesses confidence under specific barriers. These barriers encompass four major domains:

• Managing emotional and affective distress associated with contemplating personal mortality, serious illness, and clinical decline.
• Navigating relational, social, and interpersonal friction, such as fears of upsetting loved ones or handling familial disagreements regarding surrogate appointments.
• Overcoming logistical, technical, and administrative impediments, including deciphering complex medical jargon, executing legal forms, and disseminating paperwork to healthcare systems.
• Addressing cognitive ambivalence, temporal discounting, and clinical uncertainty, such as balancing planning during periods of robust health or managing ambiguity regarding specific interventions.

In clinical environments, the ACP-SES serves as a rapid diagnostic screen to pinpoint the precise psychological vulnerabilities that impede a patient from completing their advance directives. In clinical trials and longitudinal health behavior research, the ACP-SES functions as a responsive outcome measure capable of detecting micro-level changes in self-efficacy induced by digital interventions, stage-matched motivational interviewing, or palliative counseling before overt behavioral completion (e.g., formal legal execution) occurs.

Psychological Construct

The core psychological construct measured by the ACP-SES is advance care planning self-efficacy. Conceptually rooted in Albert Bandura’s social cognitive theory, self-efficacy is defined not as an omnibus personality trait or global expectation of competence, but as a granular, domain-specific judgment of one’s capability to orchestrate and execute designated courses of action to achieve specified performances. In the context of the Transtheoretical Model, self-efficacy represents the situational confidence individuals maintain that they can refrain from relapsing into avoidance or inaction across diverse, high-risk operational contexts.

Advance care planning self-efficacy is fundamentally multifaceted, capturing how self-regulatory efficacy interacts with systemic, interpersonal, and psychological barriers. Although the ACP-SES exhibits a coherent unidimensional latent structure psychometrically, the 12 items systematically sample across four critical experiential domains of ACP behavior:

1. Affective and Existential Self-Efficacy

Contemplating one’s impending physical decline, loss of cognitive agency, and biological death routinely triggers profound existential anxiety, dread, and emotional defense mechanisms (e.g., denial or experiential avoidance). Items measuring affective self-efficacy capture the respondent’s perceived capability to maintain behavioral engagement and deliberate calmly even when flooded with emotional discomfort, stress, or anxiety surrounding end-of-life realities (e.g., Items 1 and 9).

2. Relational and Interpersonal Communication Self-Efficacy

Advance care planning is inherently transactional and social; it requires disclosing vulnerable preferences to family members, designating a solitary surrogate decision-maker among multiple competing relatives, and facilitating difficult clinical conversations with physicians. Interpersonal self-efficacy reflects confidence in navigating surrogate role designation, openly confronting familial discord, managing fears of burdening or upsetting loved ones, and communicating quality-of-life boundaries to healthcare providers (e.g., Items 2, 5, 8, and 10).

3. Administrative and Navigational Self-Efficacy

The completion of advance directives requires administrative literacy, comprehension of medical-legal terminology (e.g., cardiopulmonary resuscitation, mechanical ventilation, artificial nutrition and hydration), and systematic dissemination of completed paperwork across health information exchanges. Navigational self-efficacy addresses an individual’s confidence in demystifying confusing legal documents, allocating time within busy schedules, and distributing documents to appropriate clinicians, proxies, and digital health records (e.g., Items 3, 6, and 11).

4. Cognitive Ambiguity and Temporal Management Self-Efficacy

A prevalent cognitive barrier to ACP is the perception of present invulnerability (temporal discounting)—the conviction that because one is currently asymptomatic or healthy, advance decision-making is premature. Furthermore, individuals frequently struggle with the uncertainty of hypothetical medical states and the awareness that preferences evolve. This facet captures confidence in formulating baseline preferences during periods of wellness and proactively reviewing, updating, and modifying documents as health trajectories change (e.g., Items 4, 7, and 12).

Theoretical Framework

The ACP-SES is anchored in two foundational behavioral science theories: Albert Bandura’s Social Cognitive Theory and James O. Prochaska, Carlo C. DiClemente, and Wayne F. Velicer’s Transtheoretical Model (TTM) of Behavior Change.

Social Cognitive Foundations of Self-Efficacy

Bandura posited that perceived self-efficacy dictates behavioral choice, expenditure of effort, persistence during adverse experiences, and physiological stress responses. Individuals with low self-efficacy in a specific behavioral arena perceive challenges as insurmountable obstacles, leading to behavioral avoidance. Conversely, individuals possessing elevated self-efficacy approach demanding tasks as challenges to be mastered. Bandura identified four principal informational sources that inform self-efficacy judgments: enactive mastery experiences, vicarious experiences, verbal persuasion, and physiological/affective states. The ACP-SES specifically samples across situations where somatic anxiety, interpersonal resistance, or procedural ambiguity threaten to undermine behavioral enactment.

The Transtheoretical Model Architecture

The TTM conceptualizes health behavior modification not as an isolated, all-or-nothing event, but as an incremental progression through five distinct Stages of Change:

• Precontemplation: The individual has no intention of taking action within the foreseeable future (typically defined as within the next 6 months) and is frequently uninformed or defensive regarding the need for ACP.
• Contemplation: The individual acknowledges the utility of ACP and intends to initiate planning within the next 6 months, but remains caught in profound decisional ambivalence.
• Preparation: The individual intends to execute advance care plans in the immediate future (typically within the next 30 days) and has begun taking preliminary behavioral steps (e.g., obtaining forms, identifying a proxy candidate).
• Action: The individual has explicitly altered their behavior within the past 6 months by formalizing legal documents, engaging in structured family conferences, and submitting documentation to health systems.
• Maintenance: The individual sustains their planning behaviors over time (more than 6 months), periodically auditing, revising, and re-disseminating their preferences as clinical or life circumstances shift.

Within the TTM matrix, self-efficacy operates as a critical mediating variable that changes systematically as an individual transitions through the stages. In Precontemplation, self-efficacy is characteristically at its lowest point, while perceived barriers (Cons) dominate. As individuals advance through Contemplation and Preparation, self-efficacy rises monotonically. In Action and Maintenance, self-efficacy reaches its peak, allowing the individual to sustain behaviors despite situational stressors. The ACP-SES was constructed to empirically mirror this theoretical gradient, providing a psychometric index that reflects stage progression in adult populations.

Validity

The validity of the ACP-SES was established through a series of rigorous empirical evaluations detailing its construct, convergent, criterion-related, and structural validity characteristics (Murray et al., 2024).

Construct and Criterion-Related Validity Across TTM Stages

Construct validity was validated by examining relationships between the ACP-SES and the established stages of change for advance care planning. In accordance with theoretical postulates of the Transtheoretical Model, cross-sectional analyses demonstrated a pronounced, statistically significant ascending gradient across stages. Individuals situated in the Precontemplation stage demonstrated the lowest ACP self-efficacy scores, reflecting pervasive vulnerability to emotional avoidance and procedural confusion. Mean self-efficacy scores exhibited linear increases across Contemplation and Preparation, achieving zenith levels among respondents in the Action and Maintenance stages. One-way analyses of variance (ANOVA) revealed substantial between-group variance across stages, confirming that the scale differentiates individuals based on readiness to plan.

Decisional Balance Relationships

Construct validity was further corroborated by assessing the relationship between the ACP-SES and the Decisional Balance inventory (pros and cons of ACP). The empirical patterns aligned with theoretical expectations: self-efficacy correlated negatively with the perceived Cons of advance planning (e.g., burdening family, acknowledging mortality) and correlated positively with the perceived Pros (e.g., peace of mind, autonomy protection). Furthermore, as self-efficacy scores crossed above the population median, the ratio of Pros to Cons shifted in favor of action, illustrating the classic TTM crossover phenomenon.

Convergent and Discriminant Validity

Convergent validity was established through high, positive intercorrelations between the ACP-SES and external measures of general health self-efficacy, patient activation, and prior palliative discussion history. Individuals with higher ACP-SES scores were significantly more likely to have designated a formal healthcare power of attorney, held explicit end-of-life discussions with their primary care physicians, and completed statutory living wills. Discriminant validity was supported by weak to non-significant associations with general trait anxiety and unrelated demographic indices, verifying that the ACP-SES captures situation-specific self-efficacy rather than generalized affective distress or socio-economic advantage.

Reliability

The psychometric reliability of the Advance Care Planning Self-Efficacy Scale has been demonstrated through empirical evaluations of internal consistency and scale precision:

Internal Consistency

In the primary validation cohort comprising community-dwelling adults aged 50 and older across the United States (Murray et al., 2024), the final 12-item ACP-SES demonstrated exceptional internal consistency reliability, yielding a Cronbach’s alpha coefficient of α = .95. This high alpha value confirms strong inter-item covariance and indicates that the 12 items reliably capture the overarching latent construct of advance care planning self-efficacy. Corrected item-total correlations across all 12 items remained consistently high, ranging from approximately .68 to .85, demonstrating that each individual item contributes meaningfully to the total score without introducing extraneous measurement noise.

Measurement Precision and Standard Error

The scale’s high internal consistency is paired with a low Standard Error of Measurement (SEM), indicating precision across the score continuum. This degree of reliability minimizes attenuation bias during multivariate modeling and ensures that observed variances in longitudinal or experimental studies reflect actual shifts in patient confidence rather than measurement error.

Factor Analysis

The internal latent structure of the ACP-SES was established through a psychometric design combining iterative Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) (Murray et al., 2024).

Exploratory Factor Analysis (EFA)

The instrument development began with an initial candidate pool of 35 items developed by palliative care clinicians, health psychologists, and TTM psychometricians. This candidate pool was administered to a national sample of adults aged 50 to 99. The dataset was subjected to seven iterative exploratory factor analyses utilizing principal axis factoring and oblique rotation methods (such as Promax and Oblimin) to evaluate factor structures while allowing situational facets to correlate.

Item reduction was conducted using standardized psychometric retention criteria:

• Primary factor loadings exceeding .50 on the target construct.
• Absence of substantial cross-loadings (items exhibiting secondary loadings greater than .30 were removed).
• Adequate item-total correlation (minimum cutoff of .40).
• Preservation of clinical content representation across emotional, interpersonal, logistical, and cognitive domains.

Through this iterative reduction process, 23 items were systematically removed due to redundancy, inadequate communalities, or psychometric instability across sub-demographics. The resulting 12-item instrument demonstrated parsimony while preserving broad domain coverage.

Confirmatory Factor Analysis (CFA)

The final 12-item configuration was subsequently evaluated via Confirmatory Factor Analysis to test the hypothesized single-factor latent model. Maximum likelihood estimation was utilized to assess structural model fit. The CFA yielded the following goodness-of-fit indices:

• Chi-Square Goodness-of-Fit: χ² (54) = 182.07, p < .001. While the statistically significant chi-square statistic is standard in large sample sizes, fit evaluation relied on descriptive fit indices.
• Comparative Fit Index (CFI): .89. The CFI approaches the standard .90 benchmark for acceptable model fit, confirming that the single-factor specification captures the vast majority of sample covariation.
• Root Mean Square Error of Approximation (RMSEA): .13 (90% CI [.11, .15]). The elevated RMSEA reflects residual localized covariances among items measuring related situational contexts (e.g., paperwork-specific items sharing unique procedural variance).

All standardized factor loadings for the 12 items loaded significantly on the primary self-efficacy latent factor, with standardized parameters ranging between .70 and .88 (all p < .001). These structural findings confirm that the ACP-SES is best conceptualized and operationalized as an omnibus unidimensional measure reflecting global advance care planning self-efficacy across diverse situations.

Instrument / Measurement Tool

The ACP-SES is a structured, 12-item self-report rating scale designed for rapid administration across research and clinical environments. Below are the structural specifications, administration modalities, and scoring mechanics:

• Test Type: Original psychometric rating scale / self-report questionnaire.
• Construct Assessed: Advance Care Planning Self-Efficacy (situational confidence in overcoming barriers to advance care planning).
• Item Count: 12 standardized items.
• Administration Method: Electronic (computer-assisted self-interviewing, clinical patient portals, tablets) or traditional pencil-and-paper administration.
• Target Population: Adults across the lifespan, validated specifically in community-dwelling adults aged 50 to 99, including diverse genders and clinical settings.
• Completion Time: Approximately 3 to 5 minutes.
• Prompt Instructions: Respondents are presented with the stem: “Please indicate how confident you are that you can engage in advance care planning in each of the following situations:”
• Response Scale: 5-point Likert-type scale with the following anchors:
  • 1 = Not at all confident
  • 2 = Slightly confident
  • 3 = Moderately confident
  • 4 = Very confident
  • 5 = Extremely confident
• Scoring Protocol:
  • Item Directionality: All 12 items are phrased positively with respect to confidence; there are no reverse-scored items.
  • Total Score Calculation: Items can be summed to generate an omnibus continuous score ranging from 12 to 60, or averaged across the 12 items to produce a mean composite score ranging from 1.0 to 5.0.
  • Score Interpretation: Higher numerical scores denote greater self-efficacy and resilience when confronting emotional, relational, logistical, and temporal barriers to ACP. In clinical applications, mean scores below 3.0 (“Moderately confident”) identify individuals with substantial vulnerability to avoidance who may require targeted counseling, educational scaffolding, or motivational interviewing.
  • Subscale Profiles: Although psychometrically unidimensional, clinicians may examine item clusters qualitatively to diagnose domain-specific vulnerabilities: Affective Stress (Items 1, 9), Interpersonal Conflict (Items 2, 5, 8, 10), Logistical Friction (Items 3, 6, 11), and Ambiguity/Readiness (Items 4, 7, 12).

Permissions & Fee and Test Year

The Advance Care Planning Self-Efficacy Scale was published in 2024. The instrument is protected by academic copyright held by the authors and the publishing entity, SAGE Publications. The scale was developed under institutional support from the Cleveland Clinic Foundation and the University of Rhode Island.

For non-commercial research, academic investigations, and direct clinical practice applications, the ACP-SES is generally available for scientific use under standard fair-use academic guidelines. Clinicians and research teams seeking to integrate the scale into digital electronic health record (EHR) platforms, funded multi-site clinical trials, or commercial software solutions are advised to contact the corresponding author to obtain formal authorization and coordinate data-sharing arrangements:

Alexandra N. Murray, PhD
Digestive Disease & Surgery Institute, Cleveland Clinic Foundation
9500 Euclid Avenue, Cleveland, Ohio, 44102, United States
Email: [email protected]

References

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• 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. https://doi.org/10.1177/10499091231210504
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• Prochaska, J. O., & Velicer, W. F. (1997). The transtheoretical model of health behavior change. American Journal of Health Promotion, 12(1), 38–48. https://doi.org/10.4278/0890-1171-12.1.38
• Sudore, R. L., Heyland, D. K., Lum, H. D., Rietjens, J. A., Korfage, I. J., Ritchie, C. S., Hanson, L. C., Meier, D. E., Pantilat, S. Z., Lorenz, K., Howard, M., Green, M. J., Simon, J., Feuz, M. A., & You, J. J. (2017). Defining advance care planning for adults: A consensus definition from a multidisciplinary Delphi panel. Journal of Pain and Symptom Management, 53(5), 821–832. https://doi.org/10.1016/j.jpainsymman.2016.12.331
• Velicer, W. F., Rossi, J. S., Diclemente, C. C., & Prochaska, J. O. (1996). A criterion measurement model for health behavior change. Addictive Behaviors, 21(5), 555–584. https://doi.org/10.1016/0306-4603(95)00083-6

Items of the Scale