circumstances and preferences change. As evidence presented in the preceding section indicates, decision-making capacity appears to be less a fixed, unchangeable trait and more a state dependent on a variety of factors. The capacity for decision making should therefore be viewed not as an all-or-nothing state, but as the result of the interplay of multiple functional abilities that can vary according to the context and over time. For example, a person may understand a consent form one day but not the next when he or she is distracted, confused, under duress, in pain, or delirious. Similarly, a person may be impaired in the acute phases of a severe mental illness, such as schizophrenia or bipolar illness, but may return to normal when in remission. The Quality Chasm report also acknowledges that patients vary in their preferences and views about how active they want to be in decision making: some patients desire a very active role, while others may prefer to delegate decision making to their providers or a proxy.

Providing stronger decision support mechanisms for individuals with significantly impaired cognition or diminished self-efficacy beliefs Peer support services and advance directives can be used to assist individuals with significantly impaired cognition or diminished self-efficacy beliefs.

Peer support programs As noted earlier in this chapter, evidence shows that individuals’ belief in their self-efficacy can be increased through four mechanisms: (1) their own success in mastering a task or activity, (2) observation of others’ success in the same area, (3) verbal persuasion and social influences, and (4) individuals’ own physiological and affective states. Vicarious experience is particularly powerful when the observer can identify with some of the characteristics of the person performing the activity. Observing the successes of a model with whom one identifies enhances one’s belief in one’s own capabilities. Empowerment and belief in one’s self-efficacy are also influenced by the verbal encouragement of others (Bandura, 1997b).

The positive effects of seeing or visualizing people similar to oneself successfully perform specific activities are proportionate to the degree of similarity between the person performing the activities and the observer. Modeling that conveys effective coping strategies by individuals who begin timorously, but who gradually overcome their difficulties through persistent efforts can be more helpful than “masterful” models, that is, individuals who perform calmly and faultlessly. Observers are persuaded that if others can do it, they can too (conversely, observing the failures of others similar to themselves decreases the self-efficacy beliefs of observers) (Bandura, 1997b).

Peer support programs involve individuals who serve as models of self-efficacy. These programs provide verbal persuasion and social influences, as well as the opportunity to observe others’ success in facing the same

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