Page 123 - JSOM Winter 2024

of a physician, as they are more qualified than other special- stronger the self-efficacy, the longer the engagement and the
ties and disciplines that have a narrower educational focus more intense the effort will be toward completing the action,
or patient age range limitations. 9,11,12 However, evidence has behavior, setting, or choice. Those who persevere to succeed
demonstrated that additional training is needed for APNs will reinforce their self-efficacy and eventually eliminate their
to successfully increase tactical self-efficacy and successfully fear or avoidance behavior. However, those who prematurely
function in the tactical environment. 2,9,11–20 give up and cease their efforts to succeed will retain their fears
and avoidance behavior. 2
Purpose
This project aimed to show that, with increased tactical self- Efficacy expectations vary along three dimensions: magnitude,
2
efficacy, FNPs could become the ideal advanced-level pro- generality, and strength. Magnitude refers to the tasks’ diffi-
viders to deliver operational care and training for the SWAT culty level; those with high self-efficacy can complete complex
team. 2,9,12 To increase their self-efficacy, the FNPs completed tasks, and those with low self-efficacy can only complete easy
the Tactical Combat Casualty Care (TC3) course, which is rec- tasks. Generality suggests that mastery expectations can be
ognized as a national standard for tactical training. 17,21–33 The circumscribed or extended into a generalized sense of efficacy
FNPs completed a general self-efficacy scale (GSES) to mea- stretching well beyond the action, behavior, setting, or choice.
sure pre- and post-course self-efficacy. 2,34 Additionally, their Finally, strength indicates that expectations can be either weak
tactical knowledge was measured using course-embedded pre- and easily extinguished or strong; strong expectations lead to
and post-tests, and their ability to perform their clinical skills perseverance in one’s self-efficacy coping efforts. 2
while working within a tactical setting was measured after the
TC3 course via a tactical clinical scenario. Efficacy expectations are based on four sources of informa-
tion. The first source is performance accomplishments through
2
The population, intervention, comparison, and outcomes personal mastery experiences or exercises. The second source is
(PICO) clinical question that was formulated for this proj- vicarious experiences like watching others and emulating their
ect was, “In the nontactical civilian FNPs, does receiving ed- behavior. The third source is verbal persuasion and the power
ucation through the Tactical Combat Casualty Care course of verbal suggestion. The fourth source is physiological states. 2
increase their tactical self-efficacy to perform their role in a
tactical environment with a local metropolitan SWAT team?” The TC3 course was developed to minimize torso and extrem-
The population for this project was the non-tactical civilian ity hemorrhage, which is the leading cause of preventable death
FNPs described in the clinical question above. The interven- among combat casualties, according to data obtained from the
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tion was providing education through the TC3 course to in- Vietnam conflict. TC3 interventions focus on procedures that
crease tactical self-efficacy. A comparison is not needed for an could eliminate or significantly reduce the leading causes of
evidence-based practice (EBP) project. As such, a comparison preventable death—hemorrhage control, airway management,
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was not included. The outcome of the intervention was an in- and relief of tension pneumothorax. EBP guidelines from a
crease in FNPs’ self-efficacy to perform their role in a tactical military systematic review were drafted into the original TC3
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environment with a local metropolitan SWAT team. curriculum. These guidelines were published in the Journal of
Special Operations Medicine in 1996. From this process, the
Self-efficacy is one’s cognitive belief in one’s ability to arrange, Department of Defense established a trauma registry to ensure
order, and execute courses of action successfully. 2,35 Bandura battlefield trauma care practices are documented, and contin-
2
based his self-efficacy theory on the principal assumption that uous learning processes can continue for years. 21
psychological events create and strengthen self-efficacy, leading
to two differentiated outcomes: response-outcome expectations APNs are trained to work and perform roles traditionally re-
and efficacy expectations. Response-outcome expectations are served for physicians due to shortages of physicians and pop-
defined as a person’s belief that a specific behavior will lead to ulation healthcare needs that have gone unmet. 2,4,12,13,16 APNs
a specific outcome. An efficacy expectation is the conviction are underutilized in the prehospital environment. Still, current
2
that one can successfully execute a specific behavior to produce evidence supports the use of the APN, either alone or as part
a specific outcome. 2 of a team, in the prehospital or tactical environment. 13–15,18,19,36
APNs continue to gain experience, grow in number, and ex-
These two outcomes are different because an individual can pand the settings and manners in which they practice. 4
believe that a specific action or behavior will produce a partic-
ular outcome but doubt whether they can perform the specific Methods
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action or behavior. The expectation of personal mastery of an
action or behavior affects the initiation of the action or behav- This EBP project used a quasi-experimental approach. Concur-
ior and the persistent coping of the action or behavior. It is the rent with the pilot project, the FNPs completed the TC3 cur-
strength of one’s conviction in their effectiveness that drives riculum, which included taking the TC3 exam. Although this
their decision as to whether they will even try to cope with exam was not part of the pilot project, it measured the tactical
the outcomes related to the initiation of the action or behavior knowledge and skills the FNPs gained from the course. 37,38 As
in the first place. Therefore, self-efficacy influences behavior, part of the pilot project, the FNPs completed a pre- and post-
choices, and settings. As fear and avoidance of a choice, ac- course GSES. 34
tion, behavior, or setting increases, self-efficacy decreases, and
as fear and avoidance of a choice, action, behavior, or setting The measurable outcome was the FNPs’ change in tactical
decreases, self-efficacy increases. 2 self-efficacy after the course. To measure the self-efficacy of
the FNPs, the 10-question GSES, a validated self-efficacy scale
Efficacy expectations also influence effort and how long one used to measure self-efficacy in a broad range of situations,
will engage in a choice, behavior, action, or setting. The was used. 34,39 General self-efficacy is an individual’s ability to
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