Letter to the Editor

Is Attitude Toward Nursing Diagnosis aDeterminant of Its Use?

There are many factors that may influence the use of thenursing diagnosis; however, we would like to specificallyhighlight the impact of attitudes on nursing diagnosis. Howpeople feel about a certain concept has an important role inhow they behave regarding said concept (Fishbein, 1967).Therefore, nurses’ attitudes toward the nursing diagnosisare most likely a predictor of its use and, consequently, ofthe utilization of the nursing process (Guedes, Turrini,Sousa, Baltar, & Cruz, 2012).

A large number of theories have been created to explainthe relationship between attitude and behavior. One of themost influential is the Theory of Reasoned Action (TRA)proposed by Ajzen and Fishbein (Ajzen & Fishbein, 1980;Fishbein & Ajzen, 1975). According to this model, a person’sintention to perform a behavior is essential for it to occur.The intention is modulated by an attitudinal component,called “attitude toward the behavior,” and a normativecomponent, called “subjective norm.” The attitudinal com-ponent refers to the subject’s belief that a performance ofa certain behavior will lead to certain consequences and theextent to which it evaluates those consequences as positiveor negative. The normative component is constituted by thesubject’s beliefs about the possibility that the behavior is oris not acceptable for others that are considered as signifi-cant. That is, people perform a behavior when they evaluateits consequences as positive and believe that others thinkthey should perform it (Ajzen & Fishbein, 1980).

In a study recently published in the Journal of ClinicalNursing, we, together with our colleagues, explored therelationship between the characteristics of nurses and theirattitude toward nursing diagnosis (Romero-Sánchez et al.,2013). Based on cluster analysis, three groups with differentattitude profiles were obtained from an opportunisticsample of 548 Spanish nurses to assess the differentialcharacteristics among professionals who belonged to eachof them. The study found that there were no intergroupdifferences in the sociodemographic and professional vari-ables studied except in the field of work. It was determinedthat nurses who were involved in management had a betterattitude than those working in other areas. In addition,highly remarkable differences between groups regardingthe degree of contact with the nursing diagnosis werefound, demonstrating that those who showed a more posi-tive attitude had more interaction with the nursing diagno-sis in five assessed activities: use in practice, training andreading on the subject, and research and attendance toscientific meetings.

It can be observed that the results of the previousstudy are quite consistent and have theoretical plausibilityas per the above-mentioned model described by Ajzen andFishbein. The use of the nursing diagnosis would matchwith the behavior in this case. This was significantly asso-ciated with a positive attitude, the attitudinal dimension ofthe TAR, which is composed of the expectations andresults of behavior, as stated previously. Both attributesmay have been positively influenced by training andreading on the subject. The learning acquired by nurses inthese activities could have facilitated the understanding ofthe benefits of using the nursing diagnosis, both for them-selves and for the patient, which could have had a positiveimpact on the expectations. Likewise, training would havefacilitated the acquisition of skills in the diagnostic pro-cess, which would lead to better implementation andbetter outcomes.

However, we should have assessed the perceivedsupport to the use of the nursing diagnosis by institutionsand coworkers in order to assess the consistency of theresults with the full model. In this case, the perceivedsupport would make up the subjective norm. Although wedid not formally assess this aspect, the fact that a betterattitude was found in nurses with management roles maybe indicative of the consistency of the study with the modelalso in this respect. Spanish nurses involved in managementwere in charge of promoting the implementation of thenursing process at multiple institutions (Romero-Sánchezet al., 2013).

Nevertheless, there is another aspect to consider. Thedesign we used in the study made it possible to find anassociation between attitude and behavior but not a clearcause–effect relationship. This refers to another classic dis-cussion point in the study of attitudes: Do attitudes deter-mine behavior or the opposite? It is often assumed that theattitudes come first and influence the behavior. It cannot bedismissed that external factors, such as an institution’s poli-cies to promote the use of the nursing process and others,have influenced the nurses’ use of the nursing diagnosisand its contribution to the formation of a positive attitude.

Whether the attitude or behavior comes first, the rela-tionship found between attitude toward the nursing diagno-sis and contact with it suggests that the implementation ofprograms that aim to familiarize nurses with the nursingdiagnosis in practice, training, and research could providean attitudinal change that could lead to an increase of itsuse (Romero-Sánchez et al., 2013).

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71© 2013 NANDA International, Inc.International Journal of Nursing Knowledge Volume 25, No. 2, June 2014

Therefore, in this commentary, we want to emphasizethe need of taking the attitudes into consideration as apossible determinant of the use of the nursing diagnosis infuture research. New evidence needs to be found that,along with verifying the findings we presented in othersettings, determines the causality between attitude andbehavior, and formally evaluates the influence of nursingenvironments on attitudes toward the nursing diagnosis. Adeeper understanding of the determinants of use of thenursing diagnosis would be useful to design specific pro-grams to maximize its implementation.

José Manuel Romero-Sánchez, RN, MScN, PhDcResearch Group under the Andalusian Research,

Development and Innovation Scheme CTS-391, Universityof Cádiz, Cádiz, Spain

Olga Paloma-Castro, RN, MSc, PhDcNursing Department, Nursing School, University of Cádiz,

Cádiz, Spain

References

Ajzen, I., & Fishbein, M. (1980). Understanding attitudes and predicting socialbehaviour. Englewood Cliffs, NJ: Prentice-Hall.

Fishbein, M. (1967). Readings in attitude theory and measurement. New York:Wiley.

Fishbein, M., & Ajzen, I. (1975). Belief, attitude, intention, and behavior: Anintroduction to theory and research. Reading, MA: Addison-Wesley.

Guedes, E. S., Turrini, R. N. T., Sousa, R. M. C., Baltar, V. T., & Cruz, D. A. L. M.(2012). Attitudes of nursing staff related to the nursing process. Revistada Escola de Enfermagem da USP, 46(spe), 130–137. doi:10.1590/S0080-62342012000700019

Romero-Sánchez, J. M., Paloma-Castro, O., Dueñas-Rodríguez, M.,Paramio-Cuevas, J. C., Pastor-Montero, S. M., Frandsen, A. J., . . .Castro-Yuste, C. (2013). The relationship between characteristics ofnurses and their attitude towards nursing diagnosis: A cluster analysis.Journal of Clinical Nursing. Advance online publication. doi:10.1111/jocn.12325

Letter to the Editor J. M. Romero-Sánchez and O. Paloma-Castro

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