JAN

JOURNAL OF ADVANCED NURSING

ORIGINAL RESEARCH

Self-efficacy, self-care behaviours and quality of life of kidney transplant

recipients
Li-Chueh Weng, Yu-Tzu Dai, Hsiu-Li Huang & Yang-Jen Chiang
Accepted for publication 20 November 2009

Correspondence to L.-C. Weng:

e-mail: ax2488@mail.cgu.edu.tw
Li-Chueh Weng PhD RN
Assistant Professor
School of Nursing, Chang Gung University,
Taiwan
Yu-Tzu Dai PhD RN
Professor
School of Nursing, National Taiwan
University, Taiwan
Hsiu-Li Huang PhD RN
Instructor
School of Nursing, Chang Gung University,
Taiwan
Yang-Jen Chiang MD
Clinical Assistant Professor
Division of Urology, Department of Surgery,
Chang Gung Memorial Hospital, Linkou
Medical Center, Taoyuan, Taiwan

W E N G L . - C . , D A I Y . - T . , H U A N G H - L . & C H I A N G Y - J . ( 2 0 1 0 ) Self-efficacy, selfcare behaviours and quality of life of kidney transplant recipients. Journal of
Advanced Nursing 66(4), 828838.
doi: 10.1111/j.1365-2648.2009.05243.x

Abstract
Title. Self-efficacy, self-care behaviours and quality of life of kidney transplant
recipients.
Aim. This paper is a report of an exploration of the effects of self-efficacy and
different dimensions of self-management on quality of life among kidney transplant
recipients.
Background. Self-efficacy is an important factor influencing self-management.
Patients with higher self-efficacy have better self-management and experience better
quality of life. Self-efficacy influences the long-term medication-taking behaviour of
kidney transplant recipients.
Method. A longitudinal, correlational design was used. Data were collected during
20052006 with 150 adult kidney transplant recipients on self-efficacy, self-management and quality of life using a self-efficacy scale, self-management scale and the
Medical Outcomes Scale SF-36 (Chinese), respectively. Relationships among variables were analysed by path analysis.
Results. Participants with higher self-efficacy scored significantly higher on the
problem-solving (b = 051), patientprovider partnership (b = 044) and self-care
behaviour (b = 055) dimensions of self-management. Self-efficacy directly influenced self-care behaviour and indirectly affected the mental health component of
quality of life (total effect = 014). Problem-solving and partnership did not statistically significantly affect quality of life. Neither self-efficacy nor self-management
had any effect on the physical health component of quality of life.
Conclusion. Transplant care teams should incorporate strategies that enhance selfefficacy, as proposed by social cognitive theory, into their care programmes for
kidney transplant recipients. Interventions to maintain and improve patients
self-care behaviour should continue to be emphasized and facilitated. Support to
enhance patients problem-solving skills and the partnership of patients with health
professionals is needed.
Keywords: kidney transplant recipients, nursing, quality of life, self-care
behaviours, self-efficacy, Taiwan

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Introduction
Kidney transplantation (KT) is indicated in end-stage renal
disease (ESRD). Almost 50,000 kidney transplantations are
performed annually in the world (WHO 2003). In 2005,
17,429 patients with ESRD underwent kidney transplantation in the United States of America (National Kidney and
Urologic Disease Information Clearinghouse 2005). A total
2536 patients received a kidney transplant (or combined
kidney and pancreas transplant) between April 2008 and
March 2009 in the United Kingdom (organdonation.nhs.uk
2009), while in Taiwan, from 1997 to 2006, 1837 patients
underwent the procedure (Bureau of National Health Insurance 2007). The survival rates of grafts and patients have
dramatically increased during the past decade (Pirsch 2003).
Thus, improving the quality of life (QOL) of patients with KT
has become an important issue for transplantation teams
(Habwe 2006). Quality of life is demonstrated through the
physical, psychological and social domains of health and
appears to be influenced by a persons experiences, beliefs,
expectations and perceptions (Burra et al. 2007).
The KT recipients continue to live with a chronic condition
because they run the risk of chronic rejection, infection or
graft function failure (Pirsch 2003). Thus, these patients need
to take responsibility for their own care after KT. Selfmanagement has been recognized on a worldwide basis as an
important aspect of successful health care (Bodenheimer
et al. 2002, Linnell 2005). Self-management involves several
dimensions: problem-solving, decision-making, resource utilization, patientclinician partnership, self-care behaviours
and active participation in care (Lorig & Holman 2003,
Curtin et al. 2005). Self-management has been shown to
improve health function, decrease readmission rates and
promote QOL (Lorig et al. 2001, Glasgow et al. 2007).
Self-efficacy is a psychological construct defining a persons
confidence in performing a particular behaviour and in
overcoming barriers to that behaviour (Bandura 1994).
Patients with greater self-efficacy have been shown to practise
more self-management behaviours, leading to better disease
control, better physical function and better QOL (Gaines
et al. 2002, Tsay & Halstead 2002). Among KT recipients,
only a few studies have explored the relationship between
self-efficacy and medication-taking behaviour, showing that
KT recipients with higher self-efficacy adhered better to
medication-taking behaviours (De Geest et al. 1995, Christensen et al. 2000, Baines et al. 2002).
According to social cognitive theory, greater self-efficacy
may improve outcomes through specific behaviours (Bandura
1994). To determine whether one variable (explanatory)
can influence another variable (outcome), the explanatory
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Self-efficacy, self-care behaviours and quality of life

variable must occur before the dependent (outcome) variable.

Thus, self-efficacy should be measured before self-management to explain and describe its effect. Therefore, we
conducted the present study to understand better the
relationship between self-efficacy and self-management
among KT recipients and the effects on their QOL.

Background
Quality of life among patients with kidney transplant
Cross-sectional research suggests that overall QOL improves
after KT (Chen et al. 2007, Smith et al. 2008) and is better
than that of patients receiving other renal replacement
therapy (Niu & Li 2005, Liem et al. 2007). However, the
long-term QOL of KT recipients has been reported not to be
equal to that of healthy controls in the general population
(Karam et al. 2003, Neipp et al. 2006). The QOL of KT
recipients has been shown to be affected by symptom distress
(De Geest & Moons 2000, Matas et al. 2002, Chen et al.
2007), anxiety and depression (Perez-San-Gregorio et al.
2006), and rejection and infection (Rebollo et al. 2000, Griva
et al. 2002). Moreover, personal and psychosocial environmental factors that influence QOL need to be specified more
clearly in kidney transplantation (Dew 1998).

Self-management and quality of life after kidney

transplantation
After kidney transplantation, patients need to receive treatment and clinical follow-up continually because they live
with the risk of organ rejection and infection. Thus, they have
to monitor any signs and symptoms and respond as soon as
possible to manage complications. A mutually respectful
partnership between patient and nurse/physician is a key
aspect of promoting patients health (Bodenheimer et al.
2002, Nagelkerk et al. 2006). Some experts have stated that
KT recipients need to participate more in their care and selfmanagement than do those with other chronic conditions
(Curtin et al. 2005). The gold standard of postsurgical care
for kidney transplantation recipients is to empower them to
work with healthcare providers and to report any symptoms
and signs correctly and immediately. Although this proposition has not yet been supported by research, mutual respect
and a collaborative relationship between patient and nurse/
physician has been suggested as a critical element of
successful self-management (Thomas-Hawkins & Zazworsky
2005).
Problem-solving is a core aspect of effective self-management (Glasgow et al. 2007). KT recipients who more actively
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L.-C. Weng et al.

seek information to solve problems have been shown to

experience fewer depressive symptoms (Christensen et al.
2000), and those with better long-term adherence to taking
medication have shown better problem-solving ability (De
Geest et al. 1995). The effect of problem-solving skill or
ability on QOL in the KT population, however, has not been
investigated.
Treatment-related behaviours of KT recipients such as
regular clinic visits and medication-taking behaviour after
transplantation are positively correlated with quality of life
(De Geest et al. 1995). Additionally, KT recipients with
better dietary control (Lin et al. 2002) and more healthpromoting behaviours (Houle et al. 2002) have reported
better QOL. However, when other factors such as symptom
distress and social support were included in a multiple
regression analysis, treatment-related behaviours had no
effect on QOL (Lin et al. 2002). Thus, no conclusive effect
of treatment-related behaviours on QOL has been found.

Self-efficacy and quality of life after kidney

transplantation
Self-efficacy has been strongly and positively associated with
several health indicators: better diabetes control and lower
HbA1c levels (Ikeda et al. 2003), better functional performance (Gaines et al. 2002, Siela 2003), fewer depressive
symptoms (Weng et al. 2008), better quality of life (Tsay &
Healstead 2000, Mancuso et al. 2001) and lower healthcare
utilization (Lorig et al. 2001). Some studies have shown that
KT recipients with higher self-efficacy for medication-taking
behaviour were more likely to show long-term adherence to
prescribed medication (De Geest et al. 1995, Baines et al.
2002). However, the association between self-efficacy and
QOL has not yet been investigated in the KT population.
In summary, QOL has been deemed a good outcome
indicator of KT. However, limited research has explored the
effect of self-efficacy on QOL in KT recipients, and the
dimensions of self-management, in this context, have not yet
been thoroughly investigated.

related to quality of life and (iii) self-management is positively

and significantly related to quality of life.

Design
A panel design was used to collect data from adult KT
recipients at two points in time: at the time of the first crosssectional data collection (beginning in September 2005) and
6 months after the first collection.

Participants
Patients who had received kidney transplants were recruited
from the outpatient clinic of a 3,000-bed tertiary private
hospital in northern Taiwan. To be included in the study,
they had to (i) have received a KT at least 6 months and no
longer than 10 years prior (we thought that acute phase and
long-term survivors might have different stressors and receive
different treatment protocols, which could affect the results);
(ii) be at least 18 years old; (iii) be in a stable medical
condition; and (iv) agree to participate. Taking into consideration access to participants and the need for certain
statistics, we used PASS (power analysis and sample size)
software to estimate the number of participants needed.
Setting the a level at 005 and the power at 080, we
determined that we needed to include 120 patients as well as
allowing for a 10% attrition rate. Thus, the sample size was
set at 132.
The data were collected over a 15-month period in 2005
2006. Of the 186 patients who met the inclusion criteria, 31
refused to participate. Thus, the sample for the first data
collection included 155 patients (155/186, 833%). For the
second data collection (6 months later), four patients did not
complete the questionnaire after two telephone reminders,
and another was lost to follow-up. Thus, the final sample
included 150 KT recipients (150/155, 968%). Examination
of age, sex, time after transplantation (years) and renal graft
function showed no statistically significant differences among
patients who refused to participate or who did not complete
the second questionnaire and the final sample.

The study
Data collection
Aim
The aim of the study was to explore the effects of self-efficacy
and different dimensions of self-management on quality of
life among KT recipients.
Three hypotheses were addressed: (i) self-efficacy is
positively and significantly related to each dimension of selfmanagement, (ii) self-efficacy is positively and significantly
830

Potential participants were identified by the researchers

(LCW and two clinical nurse specialists in kidney transplantation care) during clinic visits from September 2005 to
January 2006. If patients met the inclusion criteria and
agreed to participate in the study, their written consent was
obtained. They then completed a self-administered questionnaire, which was returned immediately. Clinical data were
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JAN: ORIGINAL RESEARCH

retrieved from participants medical records with their and

the study sites permission. The second data collection started
in February 2006 and was completed in November 2006.
After data collection, all participants received US $15 as
thanks for their participation.
Health-related quality of life
Health-related quality of life (QOL) was measured by the
Medical Outcomes Scale, Short Form (SF-36), Taiwan version,
which was developed to measure physical and mental health as
well as general well-being (Lu et al. 2003, Ware & Kosinki
2005). The 36-item SF-36 consists of eight aggregate scales:
physical functioning (PF), role-physical (RP), bodily pain (BP),
vitality (VT), general health (GH), social functioning (SF),
role-emotion (RE) and mental health (MH). The possible range
of scores for each subscale is 0100. The eight scales can be
categorized into two constructs: the physical component
summary scale (PCS) and mental component summary scale
(MCS) (Ware & Kosinki 2005). This scale has mainly been
used to assess the QOL of patients having kidney transplant
(Butt et al. 2008). Higher scores indicate better health-related
QOL. In our study, the PCS and MCS were used as the
dependent (outcome) variables. Cronbachs a for internal
consistency reliability was 059085 for the eight subscales.
We also followed the method of Tseng et al. (2003), who used
age to test criteria validity. The data revealed that younger
patients (30 years and younger) had statistically significant
better PF and BP than older patients (55 years and older).
Self-management
Self-management was measured by the Kidney Transplantation Self-Management Scale, which was developed by the first
author based on literature review (Weng 2008), consultation
with experts in kidney transplantation care (one physician
and three Registered Nurses), and interviews with three KT
recipients (Weng 2008). The scale was developed and its
reliability and validity tested by item analysis and confirmatory factor analysis (Joreskog & Sorbom 2001, Chiu 2003).
This 27-item scale has three dimensions: problem-solving,
patientprovider partnership and self-care behaviour.
The problem-solving dimension has ten items that measure
patients problem solution action while facing transplant-related problems. Sample items are I will find some
information to solve the problem and I record my laboratory data and continually check it with my doctor. The
patientprovider partnership dimension contains four items
that measure the interaction between patients and their
healthcare providers. Sample items are I discuss with my
doctor about any question regarding treatment regimens and
I feel comfortable and satisfied when I talk with doctor and
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Self-efficacy, self-care behaviours and quality of life

nurses. The self-care behaviour dimension contains 13 items

that measure the frequency of transplant-related behaviours,
e.g. taking medication, measuring the amount of urine and
palpating the transplant site. Responses to all subscales are
rated on a 5-point Likert-type scale, ranging from 0 (never do
it this way) to 4 (always do it this way). The range of possible
scores for problem solving is 040, for patientprovider
partnership is 016 and for self-care behaviour is 052.
Internal consistency reliabilities (Cronbachs a) for the
problem-solving, patientprovider partnership and self-care
behaviour subscales were 080, 070, 081 respectively.
Self-efficacy
Self-efficacy for self-management was measured by the Kidney Transplantation Self-Care Self-Efficacy Scale, which was
developed by the first author based on clinical experience and
the literature (Weng 2008). This 13-item scale assesses
patients confidence in their ability to follow prescribed diet,
exercise and medication regimes (three items), to monitor
early signs of rejection and infection (five items); to monitor
blood pressure and other physical parameters (three items),
and to monitor emotional distress (two items). Responses are
rated on a 5-point Likert-type scale ranging from 0 (no
confidence at all) to 4 (very confident). Scores range from 0 to
52, with higher scores indicating higher self-efficacy for selfmanagement. Internal consistency reliability (Cronbachs a)
for the present study was 090.
Psycho-physical stress
We analysed physical stress and psychological stress as control
variables and included three measures: physical stress, symptom distress and depressive symptoms. The first two scales
were developed by the first author to test the content validity as
determined by nine experts (five MDs and four RNs).
The physical stress scale includes six situations that
concern whether a patient was ever readmitted for treatment
of infection, graft rejection, co-morbidity or complications.
Responses to the items are rated as 0 (did not happen) or 1
(did happen). Scores for this subscale range from 0 to 6. The
content validity index (CVI) for the present study was 090.
Symptom distress was measured by a 23-item scale, which
included uncomfortable symptoms related to medication and
treatment such as gum swelling, overgrowth of hair and
headaches, with responses rated on a 4-point Likert-type
scale, ranging from 0 (no distress) to 3 (severe distress). CVI
for this study was 095 and Cronbachs a was 090.
Depressive symptoms were measured by the 21-item
Chinese version of the Beck Depression Inventory. Responses
are rated on a 4-point Likert-type scale ranging from 0 (rarely
or none of the time) to 3 (most or all of the time). Patients
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L.-C. Weng et al.

chose the response for each item that best matched their
situation over the past 2 weeks. Total scores range from 0 to
63, with higher scores representing more depressive symptoms. To examine validity, we used exploratory factor
analysis and principal component analysis, followed by a
varimax rotation. A two-factor structure for the 21 items of
the Beck Depression Inventory was identified. The percentage
of variance explained was 403%. We used the sum of the
scores of the scales for analysis, and Cronbachs a for this
study was 089.

earlier (SD = 27) (Table 1). The number of men and women
was nearly equal. The majority had religious beliefs (667%),
were married (678%), and were employed (687%). The
largest proportion had completed high school (374%). The
majority (513%) of patients had over three mismatches in
HLA typing, and most (853%) received a cadaver kidney.
Among the 22 recipients from a live donor, most received the
new kidney from a sibling.

Demographic data and renal graft function

Data were collected on age, sex, current immunosuppressive
drug regimen, human leucocyte antigen (HLA) typing and
source of donor kidney. Kidney graft function was measured
as calculated glomerular filtration rate (cGFR) using the
Cockcroft-Gault formula (Franklin 2002): cGFR = [(140
age)/serum creatinine level] [body weight/72]. The higher
the cGFR level, the better the kidney graft function.

Among the mean scores for the eight SF-36 subscales, the
highest was for bodily pain, followed by physical function,
social function, role-emotional, mental health, role-physical
and vitality (Table 2). The lowest subscale score was for
general health. The mean MCS score was 459 (SD = 102)
and PCS was 509 (SD = 72). Average scores for the selfmanagement dimensions of problem-solving, patientprovider partnership and self-care behaviours were 304, 119
and 393 respectively. The average score for self-efficacy was
423, depressive symptoms was 83, symptom distress was
137, the physical stress index was 17 and the cGFR was 545
(Table 2).

Ethical considerations
The study was approved by the research ethics committee of
the study site.

Data analysis
Data were primarily analysed by path analysis. Hypothesized
relationships among variables were examined by multiple
linear regression analysis (Frankfort-Nachmias & Nachmias
2000, Chiu 2003). Variables were entered into each regression model by forced entry. The causeeffect relationship
between self-efficacy and self-management was analysed as
the time-interval effects between these variables. Thus, the
measurement of self-efficacy was based on the data collected
at the first point in time, while the measurement of selfmanagement and QOL was based on data collected at the
second point. Other data, which served as control variables,
were used for the first-time data in the regression model.
Before path analysis, the assumptions of normal distribution, homoscedasticity, multicollinearity for dependent (outcome) variables and the normality of residuals (Loether &
McTavish 1980) were examined and assured (Weng 2008).

Results
Participant characteristics
Participants had a mean age of 418 years old (SD = 104) and
had received their kidney transplant a mean of 46 years
832

Descriptive analysis of study variables

Effect of self-efficacy and self-management on physical

and mental health of QOL
Self-efficacy was found statistically significantly (P < 001),
positively, and directly to influence the self-management
dimensions of problem-solving, patientprovider partnership

Table 1 Participants demographic and selected clinical characteristics (N = 150)

Variable

Mean

Age (years)
418
Time since kidney
46
transplant (years)
Gender
Male
Female
Tissue typing
2 mismatches
3 mismatches
Immunosuppressant regimen
Neoral-based
FK 506-based
Other
Source of kidney transplant
Cadaveric
Living relative

SD

104
27

73
77

487
513

73
77

487
513

66
77
7

440
513
47

128
22

853
147

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Self-efficacy, self-care behaviours and quality of life

and self-care behaviour (b = 051, 044 and 055 respectively)

(Table 3). No statistically significant direct effect was found
for self-efficacy on physical and mental health.
However, self-efficacy was found indirectly to affect
mental health through self-care behaviour. The effect was

Table 2 Descriptive statistics for study variables (N = 150)

Variable
Quality of life
Physical function
Role-physical
Bodily pain
General health
Vitality
Social function
Role-emotional
Mental health
Physical health (PCS)
Mental health (MCS)
Self-management
Problem-solving
Patientprovider partnership
Self-care behaviour
Self-efficacy
Depressive symptoms
Symptom distress
Physical stress index
Renal graft function (cGFR)

Mean

SD

825
622
849
593
602
782
707
674
509
459

175
392
187
204
183
189
370
180
72
102

305
119
393
423
83
137
17
545

64
32
72
69
76
98
10
204

cGFR, calculated glomerular flow rate.

Range

15100
0100
10100
0100
5100
0100
0100
8100
286663
141661
1240
016
1552
1752
041
145
06
891223

014 (055 self-efficacy 025 self-care behaviour). No statistically significant, indirect effect of self-efficacy on physical
health was found, however. Among the three dimensions of
self-management, only self-care behaviour had a direct,
positive and statistically significant effect (b = 025,
P < 005) on mental health (Table 3). The simple relationships among self-efficacy, self-management, and mental and
physical health are shown in Figure 1.

Discussion
Study limitations
This study had several limitations. First, the generalization of
results may have been compromised by recruiting patients
from only one study site, although having one site ensured
homogeneity of the study sample as treatment protocols may
differ among medical centres. Further research should
balance generalization and homogeneity by including patients
from different transplantation centres.
Another limitation was that patients were included only if
they had received KT at least 6 months earlier. Thus, our
results do not reflect the situation of patients during the first
6 months after transplantation. In addition, the interval
between first data collection and follow-up was only
6 months, which might have been too short of a time for
study variables to react.

Table 3 Effects of self-efficacy and

self-management on quality of life

PS
Self-efficacy
Self-management
Patientprovider partnership (PPP)
Self-care behaviour (SC)
Problem-solving (PS)
Physical stress
Symptom distress
Depressive symptoms
Age
Time since kidney transplant
Gender
Organ source (1 = cadaveric)
Tissue typing
cGFR
R2
Adj. R2
F
P

PPP

SC

PCS

MCS

051**

044**

055**

006

010

002
018
003
008
008
001
005
005
003
026
021
496
000**

012
010
003
015
002
002
006
-001
007
027
021
503
000**

003
005
011
021*
017*
004
003
004
001
044
040
170
000**

001
011
003
005
012
017
025*
017
022*
006
010
010
021
013
278
0002*

006
025*
002
003
022*
030**
007
006
003
001
005
009
036
029
578
000**

cGFR, calculated glomerular flow rate.

*P < 005, **P < 001.

Reference group is 3 mismatches.
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L.-C. Weng et al.

006
Problem-solving
051**
Self-efficacy

003
PCS

011
055**

Self-care
behaviour

001

044**
Patient-provider
partnership

025**

002

006
MCS
010
Time 1

Time 2

Thus, although we did not find a statistically significant

effect of problem-solving and patientprovider partnership
on QOL, our findings are not conclusive and need more
investigation, particularly because there is a lack of research
by which to compare the findings of the present study.

Quality of life
Our results show that kidney transplant recipients had an
overall average QOL. They did not suffer from functional
limitation or distress related to pain, reflecting our inclusion
criterion of a stable medical condition (good renal graft
function). Perception of general health was the poorest
among the eight SF-36 subscales, consistent with previous
studies (Griva et al. 2002, Houle et al. 2002, Ekberg et al.
2007). After receiving KT, patients experience fewer uncomfortable symptoms and less pain, as well as no longer needing
to be attached to a machine. However, the need for long-term
medication, frequency of medical follow-ups, laboratory
examinations, and threat of rejection or infection made some
participants feel that their health status was not good enough.

Self-efficacy and self-management

The mean self-efficacy score for our sample of KT recipients
indicated that they were highly confident about their behaviours related to post-transplant care. The self-care behaviour
most frequently reported was I frequently check if I have any
of the following symptoms: fever, weakness, cough and
tenderness at the transplant site. This result indicates that
self-monitoring behaviour was the most frequent behaviour
834

Time 2

Figure 1 Effects of self-efficacy and selfmanagement on quality of life (simple).

PCS, physical component summary; MCS,
mental component summary. *P < 005,
**P < 001.

undertaken after kidney transplantation, consistent with the

goal of organ transplant care (McPake & Burnapp 2009).
Our results indicate that kidney transplant patients had
good overall self-management, as indicated by mean scores
over 70% of the possible score in all three dimensions.
Problem-solving and self-care behaviours, which are essential
aspects of self-management, were carried out well. Our
results also indicate that patients maintained collaborative
relationships with nurses and physicians. For successful selfmanagement, patients must work as experts themselves and
perceive mutual respect between healthcare providers and
themselves (Lorig 2002, Thomas-Hawkins & Zazworsky
2005).

Relationships among self-efficacy, self management and

quality of life
Self-efficacy was positively and statistically significantly
correlated with three dimensions of self-management,
supporting our first hypothesis. These results are in keeping
with previous reports on KT recipients (De Geest et al. 1995,
Baines et al. 2002, Curtin et al. 2005). This finding echoes
previous reports that self-efficacy can motivate and increase
self-management (Shoor & Lorig 2002), as well as influencing the long-term medication-taking behaviour of kidney
transplant recipients (De Geest et al. 1995, Baines et al.
2002, Russell et al. 2003).
Self-efficacy had no direct effect on QOL, and therefore
our second hypothesis was not supported. However, there
was no indication that self-efficacy had no effect on QOL. As
noted above, self-efficacy can help patients to maintain
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JAN: ORIGINAL RESEARCH

What is already known about this topic

Self-efficacy is an important factor influencing selfmanagement.
Patients with higher self-efficacy have better selfmanagement and experience better quality of life.
Self-efficacy influences the long-term medication-taking
behaviour of kidney transplant recipients.

What this paper adds

Self-efficacy has positive effects on the problem solving,
patientprovider partnership and self-care behaviour
dimensions of self-management.
The self-care behaviour dimension of self-management
directly, positively and statistically significantly affects
the mental health component of quality of life.
Self-efficacy had indirect positive effects on the mental
health component of quality of life.

Implications for practice and/or policy

Transplant care teams should incorporate strategies that
enhance self-efficacy, as proposed by social cognitive
theory, into care programmes for kidney transplant
recipients.
Intervention to maintain and improve patients self-care
behaviour should continue to be emphasized and facilitated.
Support to enhance patients problem-solving skills and
the partnership of patients with health professionals is
needed.

confidence in their self-care behaviour. Efficacy beliefs

contribute strongly to the level of motivation and behavioural
performance (Bandura & Locke 2003). In a previous study,
we found that self-care behaviour was a partial mediator of
self-efficacy and depressive symptoms (Weng et al. 2008).
Self-efficacy might be needed to initiate the behaviour, which
then affects the outcome (e.g. health status, QOL).
Only the self-care behaviour dimension of self-management directly and statistically significantly affected the
psychological health aspect of QOL, in partial support of
our third hypothesis and in agreement with previous research.
Self-care behaviour related to disease management and health
promotion was found to be the essential element for
maintaining physical and psychological health by Sousa et al.
(2005). Similarly, health-promotion behaviours of 70 patients after KT were positively correlated with quality of life
 2010 Blackwell Publishing Ltd

Self-efficacy, self-care behaviours and quality of life

in a study by Houle et al. (2002). Self-care behaviour was not

limited to taking medication and measuring the amount of
urine but also included self-monitoring strategies, preventing
side effects, help-seeking behaviours and mental adjustment.
These behaviours could help patients to become aware of the
risk signs early, to decrease uncomfortable symptoms and
anxiety, to get appropriate help, and to decrease perceptions
of helplessness. Thus, self-care behaviour improves the
quality of life, especially the mental component of health.
Surprisingly, we did not find any statistically significant
effect of problem-solving on mental or physical well-being.
This may be due, however, to how we measured problemsolving. Our findings showed, however, that participants had
good problem-solving ability, even if the problems may not
have been solved. Previous researchers also have argued that
problem-solving might not positively affect health outcomes.
If patients try to solve an unsolvable problem (e.g. chronic
pain), they could become frustrated (Lui et al. 2005, De
Vlieger et al. 2006). If we were to examine first the
relationship between patient problem-solving ability and the
problems (specific), then this might make the relationship
between problem-solving and QOL more explicit.
We also found no statistically significant effect of patient
provider partnership on QOL. This is not consistent with the
claim of some scholars that a partnership between patient
and healthcare professional is the most important element of
self-management and that a good partnership will benefit
patients health (Lorig 2002, Curtin et al. 2005). However,
our results might not truly demonstrate the effect of a
patientprovider partnership, which was measured by a
questionnaire, possibly oversimplifying the complicated
interaction between patients and clinicians.
Further, we found no statistically significant effect of selfmanagement on physical health. The recovery process and
potential risk of complications after KT might need more
direct medical treatment, possibly explaining why we found
no statistically significant effect. However, there is insufficient research on this relationship with which to compare our
findings.

Conclusion
Self-efficacy can improve self-management and will benefit
QOL indirectly for patients with KT. Their self-efficacy can be
promoted by four strategies: mastery, modelling, persuasion
and learning. Transplantation nurses can help patients experience mastery by guiding them to set goals and develop action
plans to restore physical activity, adhere to a medication
regimen, and re-engage in social interaction. The second
strategy, modelling, could be achieved by introducing a
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patient with KT to someone who has had a successful selfmanagement experience. In the third strategy, persuasion,
nurses can encourage and support patients to adopt healthy
behaviours by explaining to them that they have the ability
take care of themselves. The last strategy, learning, involves
thoroughly explaining the bodys responses to patients.
Transplantation nurses could help patients to learn about
the effects of KT treatment and how the body responds. Thus,
they will learn to more efficiently manage their symptoms,
which will result in a sense of confidence and well-being.
Self-care behaviour was found to be positively and directly
associated with QOL. We should realize that the scope of
self-care behaviour goes beyond taking medication and
regularly visiting a clinic. Educating and coaching patients
after KT should include the full range of self-monitoring
strategies, prevention of side effects, help-seeking behaviours
and mental adjustment. Further, nurses should discuss with
patients any difficulties that they might have in applying selfcare behaviours in daily life, and suggest strategies to help
resolve these difficulties. The goal is to familiarize patients
with these behaviours, encourage them to participate in their
care, give them confidence, and help them to realize their
responsibility in post-KT care.

Funding
This study was supported in part by a grant from the National
Council of Science in Taiwan (NSC95-2314-B-182-051).

Conflict of interest
No conflict of interest has been declared by the authors.

Author contributions
WLC and DYT were responsible for the study conception
and design. WLC and HHL performed the data collection.
WLC performed the data analysis. WLC, DYT, HHL and
CYJ were responsible for the drafting of the manuscript.
WLC, DYT, HHL and CYJ made critical revisions to the
paper for important intellectual content. WLC, DYT and
HHL provided statistical expertise. WLC obtained funding.
DYT and CYJ provided administrative, technical or material
support. WLC and DYT supervised the study.

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