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Nurses' attitudes to the nursing process at a public hospital: a descriptive study


Leticia Bottcher DiasI, Erika Christiane Marocco DuranII

I Student of the Undergraduate Nursing Course. College of Nursing, State University of Campinas (Unicamp). Campinas, Brazil. Email:
II Nurse. PhD. PhD Professor. College of Nursing, State University of Campinas (Unicamp). Campinas, Brazil. Email:





Objectives: to describe nurses' attitudes to the nursing process (NP) at a public hospital. Method: in this descriptive study, 35 nurses participated and four instruments were used to characterize the participants, their perceptions of the NP, and their knowledge of and contact with the NP. Data were collected in the first half of 2016, and analyzed using descriptive statistics. Results: the adjective least chosen by the nurses was the dual term "routine-creative", while the most chosen was "negative-positive". The nurses were also found to have little contact with the NP after graduating, but considered their knowledge to be good. Conclusion: the nurses' contact with the NP needs to be expanded so that clinical practice can be improved.

Descriptors: Nursing process, nurse's role, attitude of health personnel, hospital administration.




The nursing process (NP) is a methodological instrument that supports the nursing knowledge body, directing its reasoning, basing its actions on technical-scientific knowledge and covering the nurses' historical-cultural values. It is a systematic instrument that guides professional care, considering the data collected, the judgment about human responses (nursing diagnoses), nursing planning and interventions, as well as results and evolution1.

The term Nursing Process has been used since 1955, and it is considered a structure for the care to be provided2. Even being long established, the articles found concerning nurses' use and perception are scarce, divergent, and mostly with more than five years of publication3.

Associated with this fact, the implantation of the NP in hospitals encounters obstacles that become a great difficulty. Studies point out that the implementation of the NP refers to the legal and managerial imposition, which requires only the documentation and not the effective use of this methodology4-6. In the surgical context, difficulties are also described, such as the lack of capacity of the team, the lack of mastery of the physical examination and the scarcity of human resources1.

The willingness and perception nurses have for the NP reflect in personal attitudes of approach or withdrawal, which influences their behavior4,5. Such attitudes can be favorable or unfavorable characterizing a difficulty in implanting, maintaining and becoming involved in the NP5. A transcultural instrument was developed to evaluate the attitudes of nurses facing the nursing diagnoses and validated for the concept of the nursing process. A study with the purpose of describing the disposition about the NP found that the nursing prescription is little valued and is seen as routine, but warns that it should not be performed in a mechanized way and without reflection5.

Routine use and lack of knowledge about the methodology makes it difficult for professionals to use it in an incomplete, inaccurate way and they do not have the knowledge for it3,7. It should be emphasized that nurses' attitudes towards the NP influence their implementation and maintenance. Personal factors that influence the positioning before the NP are described as the experience in clinical practice, the formal education and the professionals' expectations about themselves1.

Nurses' attitudes also have major implications for the hospital accreditation process. Accreditation promotes the qualification of health services, focusing on patient safety and the rational use of tools to support care, an aspect closely related to the nursing process8,9.

In view of the need to use NP for the scientificity of the profession and the importance of nurses' positioning for the consolidation of this scientific action, this study aimed to describe the attitudes of nurses related to NP and the degree of knowledge and contact of these with the NP in an accredited hospital.



A descriptive, cross-sectional study developed at a Public Teaching Hospital of a city in the interior of São Paulo, certified by the National Accreditation Organization (NAO) with level three, which presents an excellent management, reason for choosing this institution.

The institution has 260 beds and performs consultations, hospitalizations, exams and surgeries of its region. Maintaining the quality standard is one of the hospital's most enhanced features.

During the data collection, in the first half of 2016, 78 nurses worked in the institution and all were invited to participate in the study, but there were 35 of them (44.87%). They were used as research instruments:

- Characterization of the population: personal and work data

- Degree of knowledge about the Nursing Process - the participant chose between no, little, moderate or very much in relation to his/her knowledge about the NP and its phases1.

- Degree of contact with the Nursing Process - the participant chose between no, little, moderate or very much in relation to his/her contact with the NP through reading, participation in classes/courses, participation in events, use in clinical practice and research1.

- Positions on the Nursing Process (PNP) - composed of 20 pairs of adjectives that are separated by a scale of seven equidistant points and the subject is invited to indicate the proximity that they have with the adjective in relation to the Nursing Process1,5.

The Positions on the Nursing Process instrument evaluated nurses' attitudes towards the NP. The favorable disposition and the unfavorable disposition were separated by a semantic scale of 1 to 7 and for each adjective the higher the number, the more favorable the attitude. To present the results, the means of the responses were performed and the adjectives that were inverted in the instrument were corrected for analysis1,5.

Data was analyzed using statistical software SAS version 9.4 and described in the tables below.



In the sample, 85.71% (n = 30) were female, the age ranged from 26 to 49 years, on average 35.4 (SD ± 6.2). Of the total number of nurses, 51.43% reported having a specialization (Latu sensu), 2,86% masters ( Stricto sensu) and 45.71% reported not having completed postgraduate studies. The average working time in the institution is five years and 11 months, with a minimum of one month and a maximum of 14 years and nine months. As for the training time, the average is ten years and one month, with a minimum of five years and a maximum of 28 years.

The distribution of nurses according to their functions shows that most of the nurses did not hold a managerial position (80%) and had as their main activity the planning of care (48.57%), followed by administrative activities (25.71%) and direct care (22.86%). They were nurses who worked in their preference unit (74.29%); were fully satisfied with their work (57.14%) and were satisfied with their professional choice (68.57%). Nurses from all work shifts were contemplated - morning, afternoon, daytime, night shift.

Table 1 presents the results of the instrument of degree of contact and degree of knowledge with the NP.

Table 1: Degree of knowledge and contact with the NP. Sumaré, São Paulo, 2016.

Regarding the degree of knowledge of the NP, 62.68% (n = 22) of nurses reported knowing moderately the NP in general and 37.14% (n = 13) reported knowing a lot. The degree of contact was classified, for the most part, as moderate, but little and no responses were significant when compared to the degree of knowledge.

The results of the instrument Positions on the Nursing Process are described in table 2.

Table 2: Statistic of the scores of the PNP items. Sumaré, São Paulo, 2016.

The higher the average, the more favorable the nurse was in relation to the pair of adjectives. The lowest mean scores for PNP items were for the pairs routine/creative (4.4) and difficult/easy (4.60) and the highest for negative/positive (6.57) and unimportant/important(6.51).



Keeping the picture found in the studies in the area, the majority of the nurses population is female and about half have some type of postgraduate degree, which aligns the current needs of the country with professional practice5,8. The training of professionals took place, on average, ten years ago. It can be considered that practically all of them already had in their basic training the introduction of the NP study, which increases the degree of knowledge before the NP9,10. Studies show that most of the knowledge, skills and competences of the professional profile are constituted from the undergraduate training, which is consistent with the data found10,11.

The majority of the nurses presented professional improvement with the conclusion of Strictu sensu and Latu sensu courses. It should be emphasized that post-graduation give impulse to science, technology and innovation, particularly in this study, in the context of nursing. This fact increases the scientific practice of Brazilian nursing, which translates into efficient and effective care for the individual, family and community, and quality health education12.

It is argued that for care with excellence, the nurses' involvement with direct care is part of the necessary skills, being close to the hospitalization process, contrary to what was found in the study that, even though it is an accredited hospital, only 22.86% (n = 8) of the nurses responded that they give direct care to the patient most of the time, even though 80% of the sample did not hold a managerial position13.

The degree of knowledge of the NP is more related to the interview and physical examination, practical part, than the theoretical part of diagnosis, prescription and evolution. Both parties had high knowledge scores, which means that nurses perform NP with clinical background, but recognize the need for theoretical support. It is emphasized that nurses know the NP, however, they have little contact with this methodological tool. In this way, it is necessary to deepen their studies, either through courses, training or continuing education, in a way to subsidize nurses to perform the NP in a reflective and deep way, which offers quality to care 3,5.

The number of little and no answers in the contact-grade instrument confirmed what was found in other studies that relates NP activities in most cases to graduation and hardly after training. It is known that post-graduation increases the level of care provided, so it is necessary that the specialization programs, masters and doctorates approach the NP and improve such clinical practice5,10.

Regarding the average score in PNP items, the lowest average was that of routine / creative adjectives (4.4). It is indicated by the literature to analyze items with scores ≥5.5 as strongly favorable; and those with a mean score ≤4.5 as the most unfavorable14.

In front of the scenario, it is inferred that the realization of the daily NP is configured with a task that does not instigate critical thinking and reflection or does not enable them, and it is necessary to develop tools, forms and technologies that make its execution easier and more enjoyable which aims at better quality of care5.

The most punctuated adjectives in the PNP instrument were insignificant / significant, unimportant / important and negative/positive with an average above 6.5. This result demonstrates a favorable position of the nurses in the maintenance and improvement of the NP, which facilitates its execution and development. This attitude is also exemplified in studies that identify perceptions, pointing out that nurses consider that NP benefits the patient and gives conditions for scientificity1,5,7,15.

A study with the objective of knowing the challenges faced by nurses for the implementation of the NP and possible strategies found that the factors established as impediments to the implantation are the values of the nurses, the dynamics of work, the lack of support of the institution, the lack of nurses and lack of experience with the method16. It was found in the study that nurses have favorable attitudes, therefore, it is necessary for hospitals to be supported by strategies such as management support, promotion of pedagogical practices and consideration of the NP for adequate sizing16,17. An institutional reorganization is encouraged which should align this need with continued education in hospitals5,7.

Experiences of implantation and involvement of nurses have been described successfully from meetings for training of the NP, semiology and laboratory exams and adoption of referentials for the service18.

It is imperative that nurses acknowledge their limitations as regards knowledge of the praxis of the NP by identifying the difficulties presented during clinical reasoning or the process of diagnosing and recording the steps of this methodological tool so that the implementation of quality and documented care is feasible.



The NP is undergoing improvement in Brazil, especially in this study, in an accredited hospital with a level of excellence. It is important for institutions to be concerned with its implementation, not only by the legal aspect, but also to increase and improve the quality of care and, consequently, the patient's quality of life.

The professionals present a positive attitude towards the NP, however, they need an incentive to keep their practices beyond the training period, stimuli to improve the clinical reasoning and documentation involved in the NP and be valued in relation to this practice, believing and visualizing the change that its accurate use provides. Hospitals should create study and improvement groups that, together with the favorable attitude, will raise the level of the NP, bringing quality and visibility to nursing. New research should be carried out with the objective of sharing successful experiences in the services' interventions and professional qualification.



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