Validation of a self-efficacy instrument
and its relationship to performance of crisis resource
Jennifer L. Plant•Sandrijn M. van Schaik•Diane C. Sliwka•
Christy K. Boscardin•Patricia S. O’Sullivan
Received: 28 September 2010/Accepted: 11 January 2011/Published online: 25 January 2011
? The Author(s) 2011. This article is published with open access at Springerlink.com
influences the development of and access to the associated medical knowledge, procedural
skills and crisis resource management (CRM) skills. Since performance assessment of
CRM skills is challenging, self-efficacy is often used as a measure of competence in this
area. While self-efficacy may influence performance, the true relationship between self-
efficacy and performance in this setting has not been delineated. We developed an
instrument to measure pediatric residents’ self-efficacy in CRM skills and assessed its
content validity, internal structure, and relationship to other variables. After administering
the instrument to 125 pediatric residents, critical care fellows and faculty, we performed an
exploratory factor analysis within a confirmatory factor analysis as well as a known group
comparison. The analyses specified four factors that we defined as: situation awareness,
team management, environment management, and decision making. Pediatric residents
reported lower self-efficacy than fellows and faculty in each factor. We also examined the
correlation between self-efficacy and performance scores for a subset of 30 residents who
led video recorded simulated resuscitations and had their performances rated by three
observers. We found a significant, positive correlation between residents’ self-efficacy
in situation awareness and environment management and their overall performance of
CRM skills. Our findings suggest that in a specific context, self-efficacy as a form of self-
assessment may be informative with regards to performance.
Self-efficacy is thought to be important for resuscitation proficiency in that it
J. L. Plant (&)
Department of Pediatrics, University of California Davis, 2516 Stockton Blvd, Sacramento,
CA 95817, USA
S. M. van Schaik
Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
D. C. Sliwka ? C. K. Boscardin ? P. S. O’Sullivan
Department of Medicine, University of California San Francisco, San Francisco, CA, USA
C. K. Boscardin ? P. S. O’Sullivan
Office of Medical Education, University of California San Francisco, San Francisco, CA, USA
Adv in Health Sci Educ (2011) 16:579–590
Performance assessment ? Self-assessment ? Self-efficacy ? Simulated resuscitations ?
Crisis resource management skills ? Mock codes ? Non-technical skills ?
Self-efficacy is an individual’s confidence in his ability to perform a specific task in a given
domain. It is thought to affect the initiation of behavior, the amount of effort expended and
the persistence of behavior in spite of challenges and negative experiences (Bandura 1977).
It differs from self-confidence in that self-efficacy is context-specific rather than a stable
personality trait and it is therefore thought to have a direct effect on performance in
specific contexts (Bandura 1997). Self-efficacy is believed to be of particular importance in
the context of resuscitation because of its influence on the development of and access to the
associated knowledge and skills (Maibach et al. 1996). These skills include both proce-
dural skills and crisis resource management skills (CRM skills), the generic behavioral
skills needed to safely and effectively manage medical crises such as resuscitations (Gaba
et al. 1994).
Based on this theory, multiple studies have examined the effects of resuscitation
training on self-efficacy and used self-efficacy as a surrogate measure for performance
(Nadel et al. 2000b; Reznek et al. 2003; van Schaik et al. 2008). Competency assessment of
resuscitation skills, especially CRM skills, is challenging. A few validated performance
evaluation instruments have been developed for use by trained observers (Fletcher et al.
2003; Kim et al. 2006), however direct observation of actual resuscitations is nearly
impossible given the rarity of the events in pediatrics (van Schaik et al. 2008) and sim-
ulations can be both time consuming and resource intensive if designed with adequate
fidelity and generalizability (Kane 1992). Measuring self-efficacy appears relatively more
straightforward and is therefore attractive; however, to date, there is limited evidence for a
correlation between self-efficacy and performance. In the context of resuscitation, self-
efficacy in medical knowledge and procedural skills has not correlated with performance in
those areas (Nadel et al. 2000a; Wayne et al. 2006). These findings parallel a larger body of
research highlighting physicians’ general inability to self-assess accurately (Colthart et al.
2008; Davis et al. 2006). Little is known about the relationship between self-efficacy and
performance of CRM skills.
Many of the studies on self-efficacy and self-assessment have been criticized for their
lack of validated instruments (Ward et al. 2002). The development of an instrument is a
rigorous process involving conceptual analysis of the domain of functioning, drafting and
piloting the instrument, and statistical analysis of results including factor analysis and
internal consistency reliability (Shea and Fortna 2002). Throughout this process, the dif-
ferent components of validity such as content, response process, internal structure, rela-
tionship to other variables, and consequences can be examined (Downing 2003). Few
studies measuring self-efficacy have incorporated such rigorous methods.
Given the proposed importance of self-efficacy for resuscitation proficiency, the prac-
tical advantages of using self-efficacy as an adjunct for competency assessment, and the
lack of data on the relationship between self-efficacy and performance of CRM skills, we
believe that the role of self-efficacy in CRM skills merits further investigation. The first
step in advancing our understanding is valid measurement of self-efficacy in this area.
Therefore, the aim of this study was to develop and validate an instrument to measure
580 J. L. Plant et al.
self-efficacy in CRM skills and to examine the correlation between measured self-efficacy
and performance during simulated resuscitations.
We developed an instrument to measure pediatric residents’ self-efficacy in CRM skills
and examined evidence of validity of the resulting scores. We focused on three different
sources of validity: content validity, internal structure, and relationship to other variables
(Downing 2003). Content validity was established and assessed during the instrument
design process, internal structure was investigated using factor analysis and internal
consistency, and relationship to other variables was examined through a correlational, non-
experimental design (Shea and Fortna 2002) (Fig. 1). This approach to instrument
development has been established by others (e.g. Fletcher et al. 2004; Holmes and Shea
1998; Wang et al. 2003; Yudkowsky et al. 2006).
Participants and settings
Participants included a convenience sample of pediatric residents, pediatric critical care
fellows, and pediatric critical care faculty affiliated with residency and fellowship training
programs at two U.S. pediatric teaching hospitals during the 2008 calendar year. The
internal review boards at both institutions approved the study.
Fig. 1 Study methods
Self-efficacy and performance of CRM skills 581
We designed a paper-and-pencil instrument to measure self-efficacy in CRM skills on a
5-point Likert rating scale. As recommended in work describing the construction of self-
efficacy scales with content validity, the design process began with a conceptual analysis of
resource management skills as the generic behavioral skills needed to safely and effectively
manage medical crises such as resuscitations (Gaba et al. 1994). This skill set includes
cognitive skills such as decision-making and situation awareness as well as interpersonal
technical skills to contrast them with technical or procedural skills (Fletcher et al. 2002). We
reviewed prior work defining the construct and published instruments measuring skill per-
who adapted the aviation industry’s principles of crew resource management to develop the
Non-Technical Skills’’ (ANTS) system, an instrument for evaluating anesthesiologists’
performance of non-technical skills (Fletcher et al. 2002, 2003, 2004) that has proven rele-
vance tocritical care medicine (Readeret al.2006) and (3) theapplication of the construct to
critical care medicine in the Ottawa Crisis Resource Management Global Rating Scale
(Ottawa GRS) (Kim et al. 2006). Based on this literature review and personal experience
facilitating simulated resuscitations, two investigators (JP, SvS) developed a comprehensive
list of behaviors associated with CRM skills. We organized our table of specifications using
Fletcher et al.’s (2003) categories of task management, team working, situation awareness,
and decision making with the intent of including at least 4 items from each of category in the
instrument. We wrote a potential item pool of 30 questions. Two other study investigators
(CB, POS) reviewed the items and we rephrased or eliminated problematic items. We then
constructed a 24-item draft instrument. Three physicians with expertise in pediatric critical
care and anesthesia pilot tested the draft and offered comments on content and organization
leading to only minor changes in the instrument.
Observer rating instruments
To assess performance of CRM skills, we used both the ANTS system (Fletcher et al. 2003)
and the Ottawa GRS (Kim et al. 2006). The ANTS includes four ‘‘skills categories’’ (task
management, team working, situation awareness, and decision making) with a total of 15
items. Fletcher et al. established the internal consistency of the items that fall under each of
their four scores and demonstrated a best fit for 13 of 15 of these items, but did not report
direct evidence of the scores’ discreteness. The items are rated on a scale of four, although
as others have done recently, we adapted the instrument to a scale of seven to increase the
range of possible scores (Yee et al. 2005). Fletcher et al. reported an inter-rater agreement of
0.56–0.65 at the category level. The Ottawa GRS instrument is divided into five specific
skills (leadership, problem solving, situation awareness, resource utilization, and commu-
nication) and includes an overall performance score. Kim et al. provided a theoretical
justification for their choice of five scores in the Ottawa GRS, but no data to support their
treatment as distinct constructs. Each item is rated on a 7-point scale. In the pilot study to
establish inter-rater reliability, they reported intraclass correlation coefficients for single
measures of 0.24–0.63 for the specific skill scores and 0.59–0.61 for the overall score.
582 J. L. Plant et al.
The self-efficacy instrument was administered to all participants. After completing the
instrument, a subset of residents (the observer-rated group) led simulated resuscitations as
part of the residency program curriculum. Only second and third year residents were
eligible to lead simulated resuscitations and participate in this part of the study. The
simulation sessions followed a structured format. One faculty instructor (SvS) wrote all
case scenarios. Scenarios differed per session, but were constructed in a standardized
manner with three learning objectives per scenario specific to its medical content. Each
session included interprofessional teams, occurred in situ, and demanded a similar level of
CRM skills. They utilized medium fidelity mannequins (ALS Baby Trainer with Heartsim
200 and MegaCode Kid VitalSim, Laerdal Medical, Wappingers Falls, NY) and were
video recorded. Three independent, trained observers (JP, DS, SvS) viewed the videos and
scored the residents’ performance of CRM skills on both the ANTS and Ottawa GRS
The statistical analysis included examination of: (1) instrument internal structure and (2)
instrument relationship to other variables including known group comparison and com-
parison to performance.
Instrument internal structure
Since this was an explorative study, we initially performed an exploratory factor analysis
(EFA) to determine optimal representation of the data. We included approximately 5
subjects per item in order to ensure stability of the factor analysis (Streiner 1994). Using
principal axis factoring, we determined the number of factors observed based on sampling
adequacy as assessed with the KMO statistic and on the eigenvalues greater than 1. We
eliminated items with loadings\0.4 (Stevens 2002). To determine the goodness of fit and
the strength of the parameter estimates and to consider the prior work in crisis resource
management that suggested a two factor model (cognitive and interpersonal skills Fletcher
et al. 2002), we conducted an EFA within the confirmatory factor analysis (CFA)
framework. This method of EFA within CFA has been described elsewhere in the literature
(Brown 2006). The subsequent evaluation of the factor analytic models was based on
relevant fit indices including: Chi square test/df\2, Root Mean Square Error of
Approximation\0.08, as well as Tucker Lewis Nonnormed Fit Index and Comparative Fit
Index both[0.85 (Hu and Bentler 1999). We examined the average inter-item correlation
by calculating Cronbach’s alpha for each factor derived from the factor analysis. A value
[0.70 was considered adequate internal consistency (Nunnally 1978).
We calculated mean scores for each participant for each factor on the self-efficacy
instrument for subsequent validity analyses.
Instrument relationship to other variables: known group comparison
With analysis of variance, we compared the self-efficacy factor scores reported by pediatric
residents with those of the pediatric critical care fellows and faculty. This analysis was
based on the assumption that pediatric residents have less experience with pediatric
emergencies and therefore lower self-efficacy in CRM skills than pediatric critical care
Self-efficacy and performance of CRM skills583
fellows and faculty. We did not evaluate the second and third year residents as separate
groups due to the small numbers in each group. In addition, the study took place during the
transition between academic years, therefore a separation between second and third year
residents would not truly reflect a year difference in experience for all participants.
Instrument relationship to other variables: comparison to performance
We calculated mean observer scores for the four category scores on the ANTS instrument
and each score on the Ottawa GRS instrument and found high inter-item correlations for
both. For the purposes of our analysis, we therefore calculated composite observer scores
for these two instruments by averaging the mean observer scores for the four category
scores on the ANTS instrument and averaging the mean observer scores for the five
specific scores (excluding the overall score) on the Ottawa GRS instrument. In the process,
we eliminated the item ‘‘Decision Making: Balancing risks and selecting options’’ from the
ANTS instrument due to a consistent inability to rate this item in our simulations. We
assessed inter-rater reliability by calculating type III intraclass correlation coefficients for
average measures and considered[0.8 to be good inter-rater reliability (Landis and Kock
1977). In order to evaluate the relationship between self-efficacy and performance of CRM
skills, we calculated Pearson’s correlation coefficients for self-efficacy factor scores with
composite observer scores for those residents completing the simulations.
We used SPSS Version 16.0 for all statistical calculations other than the factor analysis
that we performed with Mplus Version 4.1. A p value\0.05 was considered significant
for all calculations except the Pearson’s correlations. For these correlations between self-
efficacy and observer scores, we performed a Bonferroni correction, setting p = 0.025 to
maintain the familywise error rate at the 0.1 level.
A total of 125 study participants completed the self-efficacy instrument: 31 first year
pediatric residents (PGY-1), 34 PGY-2’s, 35 PGY-3’s, 3 pediatric chief residents, as well
as 13 fellows and 9 faculty members in pediatric critical care. Thirty pediatric residents (14
PGY-2’s, 16 PGY-3’s) from one institution participated in video recorded simulated
resuscitations (observer-rated group).
Instrument internal structure
The EFA specified a four factor model based on sampling adequacy (KMO = 0.88) and
eigenvalues exceeding 1. In this model, four items were deleted from the final analysis due
to low correlations with all other items in the data. The CFA of the remaining 20 items
supported the four factor model solution. Each of the model fit indices indicated acceptable
fit: v2test = 1.85, RSMEA = 0.08, TLI = 0.89, and CFI = 0.91. The factor loadings
were all significant with no negative residual variances. We defined these factors based on
past models of CRM skills and our understanding of the construct as: situation awareness,
team management, environment management, and decision making. Table 1 contains the
items, item loadings, communalities, eigenvalues, and reliability coefficient for each
584J. L. Plant et al.
Instrument relationship to other variables: known group comparison
As expected, pediatric residents reported significantly lower mean self-efficacy scores for
all four factors measured on our self-efficacy instrument than pediatric critical care fellows
and faculty (Table 2).
Instrument relationship to other variables: comparison to performance
The mean self-efficacy scores for the observer-rated group (n = 30) and the mean com-
posite observer scores are shown in Table 3. The intraclass correlation for the three
observers was 0.86 for the composite ANTS score and 0.85 for the composite Ottawa GRS
The correlations between residents’ self-efficacy scores and composite observer scores
are listed in Table 4. Significant moderate positive correlations were observed between
Table 1 Factor analysis of the self-efficacy instrument
Factor Defined asItemsItem
0.49 0.4410.06 (45.7) 0.82
Delegate tasks0.690.662.08 (9.4)0.88
Coordinate team members 0.820.78
Identify and utilize skills
Instruct and correct team
Communicate plan to team 0.560.51
0.400.391.16 (5.3) 0.77
interventions taken place
Provide reassurance and
Take charge0.560.751.00 (4.5)0.91
See big picture0.480.58
Decide on most
Re-evaluate and change
plan as needed
Self-efficacy and performance of CRM skills585
residents’ self-efficacy in situation awareness and environment management and the
composite ANTS score (0.52 and 0.44 respectively, p\0.025) as well as between these
two self-efficacy scores and the composite Ottawa GRS score (0.54 and 0.42, p\0.025).
We developed an instrument to measure pediatric residents’ self-efficacy in CRM skills
and found validity evidence for the scores from our instrument through content validity,
internal structure, and relationship to other variables including known group comparison
and comparison with performance of CRM skills. We will review our findings in light of
other work on CRM skills, self-efficacy and performance, consider possible reasons why
only two of our self-efficacy factors significantly correlated with performance, and reflect
on where our work fits within the research on self-assessment.
Table 2 Comparison of mean self-efficacy scores for residents versus fellows/faculty
Factor Residents (n = 103)
Mean ± SD
Fellows/faculty (n = 22)
Mean ± SD
Situation awareness 3.75 ± 0.514.48 ± 0.38
Team management3.23 ± 0.643.99 ± 0.59
3.54 ± 0.53 4.36 ± 0.49
Decision making3.18 ± 0.574.31 ± 0.54
Table 3 Resident scores on the self-efficacy, anaesthetists’ non-technical skills, and Ottawa global rating
InstrumentScore ScaleMean ± SD (n = 30)
Self-efficacy instrumentSituation awareness 1–53.78 ± 0.51
Team management 1–53.33 ± 0.56
Environment management 1–53.49 ± 0.42
Decision making1–5 3.33 ± 0.60
ANTS instrument Composite score 1–75.18 ± 0.99
Ottawa GRS instrumentComposite score 1–75.12 ± 1.00
Table 4 Correlation between residents’ self-efficacy scores and observed performance scores
Self-efficacy scoreANTS score Ottawa GRS score
Team management0.25 0.1850.280.133
586J. L. Plant et al.
We drew heavily from previous work in the field of crisis resource management and
personal experience of the principal investigators and other experts when developing our
instrument. In spite of this attempt to ensure content validity, two of our items, ‘‘follow
Pediatric Advanced Life Support algorithm’’ and ‘‘consider a variety of explanations for
the symptoms’’, were eliminated during factor analysis likely because they refer more to
medical knowledge than CRM skills. The reasons for the poor performance of the other
two eliminated items, ‘‘stay calm yourself’’ and ‘‘elicit suggestions from other team
members’’, are less clear however in a subsequent study by our group, residents were found
to be particularly unable to self-assess their level of calmness and their degree of inter-
action with the team while leading simulated resuscitations (Plant et al. 2010). Our resi-
dents may lack insight into their ability and performance of these two specific skills. Factor
analysis in this study indicated the remaining 20 items fell with good internal consistency
reliability into four distinct areas of CRM skills: situation awareness, team management,
environment management, and decision making. In spite of the fact that we referenced both
the ANTS (Fletcher et al. 2003) and Ottawa GRS (Kim et al. 2006) instruments when
developing ours, two of our factors (team management and environment management) are
not shared with either of these instruments. This discrepancy is likely because of the
complexity of the construct of CRM skills and possibly because our methods and target
audiences differ from those of Fletcher et al. and Kim et al. Interestingly, in our study, the
inter-item correlations for observers’ scores on the ANTS and Ottawa GRS instruments
were so high that we created composite observer scores for each. It is unclear whether our
high degree of inter-item correlations was a function of the instruments or the ‘‘halo effect’’
We found significant positive correlations between two factors from our self-efficacy
instrument and performance as measured by the composite observer scores on the ANTS
and Ottawa GRS instruments. Since published guidelines suggest that correlations with an
absolute value between 0.3 and 0.5 are considered moderate (Cohen et al. 2003), our
findings give some support the assertion that self-efficacy is related to performance of the
associated skills, at least in the context of resuscitation (Bandura 1977; Maibach et al.
1996). Maibach et al. (1996, p. 95) have discussed the theoretical importance of self-
efficacy in resuscitation training, stating, ‘‘it is likely to influence the development of and
real-time access to other cognitive, affective, psychomotor, and social aspects of resus-
citation proficiency’’. Studies have provided conflicting evidence regarding this hypothesis.
In a study of internal medicine residents’ ability to follow ACLS algorithms during sim-
ulated resuscitations, there was no correlation between self-efficacy and performance
(Wayne et al. 2006). In another study, a large majority of pediatric residents expressed
confidence in technical skills such as endotracheal intubation, whereas only a minority
performed those skills properly (Nadel et al. 2000a). A more recent study found positive
correlations between self-efficacy in technical skills and the initiation, but not the suc-
cessful performance, of those behaviors during simulated resuscitations. This same study
showed a moderate correlation (r = 0.48) between self-efficacy in general resuscitation
skills and observers’ assessment of their global performance (Turner et al. 2009). While
their study provides the first positive evidence for a link between self-efficacy and per-
formance during resuscitations, the study did not allow for the demonstration and mea-
surement of CRM skills, since the simulated resuscitations were not performed in a team
context. Our study is unique in that we examined the relationship between self-efficacy and
performance of CRM skills during interdisciplinary simulated resuscitations.
We found correlation with performance for self-efficacy in situation awareness and
environment management, but not for team management and decision making. A possible
Self-efficacy and performance of CRM skills587
explanation for this finding is that level of experience may affect ability to predict skill
level. ‘‘Personal performance mastery experiences’’ are thought to be among the most
direct and powerful factors affecting self-efficacy (Bandura 1997). It is assumed that
successful practice of skills increases self-efficacy whereas unsuccessful practice decreases
self-efficacy. A lack of experience with skills may, therefore, limit an individual’s ability
to accurately assess self-efficacy, a concept called the ‘‘dual burden’’ by Kruger and
Dunning (1999). In addition, there is some evidence that exposure to benchmarking
examples and feedback improves an individual’s ability to self-assess accurately (Lane and
Gottlieb 2004; Martin et al. 1998). Pediatric residents have considerable experience with
patient assessment and resource acquisition, activities corresponding to situation awareness
and environment management. While engaged in these patient care activities, they are
exposed to benchmarks as they observe their peers and attending physicians demonstrate
the related skills, receive feedback regarding their own performance and are likely to
reflect on their performance in light of this feedback. Accordingly, due to their experiences
requiring situation awareness and environment management skills, residents in this study
may have been better able to assess their abilities. In contrast, pediatric residents have less
experience, especially early in their training, with independent decision-making and team
management, the other two factors on our self-efficacy instrument and, as a result, may be
unable to accurately assess these abilities.
Our results support that there is a role for assessment of self-efficacy in crisis resource
management training. In light of our findings and the fact that self-efficacy is a form of
self-assessment, the conclusion that ‘‘physicians are inaccurate self-assessors’’ may be
premature and an oversimplification. Many of the studies on which this conclusion is based
have been criticized for their suboptimal quality (Colthart et al. 2008; Davis et al. 2006). In
this study, we specifically addressed the issue of measurement and used psychometrically
robust approaches to measuring both self-efficacy and performance. We were able to find
some correlation between self-efficacy and performance suggesting that the ability to self-
assess may be task and context specific.
Our study has several limitations. First, since this study was incorporated into a resident
resuscitation curriculum and a variety of scenarios were used to maximize the educational
experience, the scenarios were not identical for all residents. The complexity and therefore
difficulty of scenarios may have varied, however, the residents were not evaluated on their
medical knowledge or technical skills and should have been able to demonstrate the same
level of CRM skills in each scenario. Second, we were unable to find a validated rating
instrument for CRM skill performance that was developed specifically for use in pediatrics.
Since CRM skills are generic behavioral skills, generalizable across fields of medicine and
we were able to achieve good inter-rater reliability with instruments developed for adult
practitioners, the ANTS and Ottawa GRS seem to have been appropriate for our setting.
Finally, our study through its quantitative nature was not designed to elucidate the
underlying reasons for our pattern of findings. Self-assessment is a qualitative process and
qualitative inquiry into an individual’s approach to self-assessment may shed further light
on the factors that determine its accuracy (Colliver et al. 2005; Colthart et al. 2008; Ward
et al. 2002).
With this study, we add to the evidence that self-efficacy correlates with performance of
resuscitation skills, at least in the domains of situation awareness and environment
588 J. L. Plant et al.
management. Our findings highlight the need for more in-depth research into the deter-
minants of self-assessment. When applied to specific domains and in a well-defined context
with adequate feedback and benchmarks, self-assessment may accurately inform self-
directed learning and evaluation.
Datar, and Maurice Zwass for their review of the self-efficacy instrument. This study was supported in part
by a UCSF Faculty Education Research Grant. Dr. Plant was supported by a NICHD Institutional Training
Grant for Pediatric Critical Care T32HD049303-03.
The authors of this article would like to thank Drs. Natalie Cvijanovich, Sanjeev
mercial License which permits any noncommercial use, distribution, and reproduction in any medium,
provided the original author(s) and source are credited.
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