Scholarly Inquiry for Nursing Practice: An International Journal, Vol. 4, No.

1,1990

The Relationship of Attitude, Subjective

Norm, and Behavioral Intent to the
Documentation Behavior of Nurses
Darlene H. Renfroe, R.N., D.S.N.,
Samford University, Birmingham, Alabama

Patricia S. O'Sullivan, Ed.D.,

Rhode Island Hospital Providence

Gail W. McGee, Ph.D.,

University of Alabama at Birmingham

Ajzen and Fishbein's theory of reasoned action was used to assess the rela-
tionship of nurses' attitude, subjective norm, and behavioral intention to their
documentation behavior. Attitudes, subjective norms, and behavioral inten-
tions toward documantation were elicited from 108 staff nurses. Documen-
tation behavior was based on what should be documented in any hospitalized
patient's chart during a shift.
This exploratory model was analyzed with LISREL VI. The overall fit of
the final model to the data was good, as judged by a chi-square (df—l,p= .845).
The total coefficient of determination for the structural equation was .461.
Attitude toward documentation did not relate significantly to intention to
document optimally. Subjective norm did have a significant effect on behavioral
intent. Attitude and subjective norm accounted for 46.1% of the variance in
behavioral intent. Behavioral intent had a significant effect on documentation
behavior, accounting for 15.2% of the variance.
It appears that subjective norm, which is the influence of others, is what
directs the intention to document and thus relates to subsequent documentation.
Recommendations for practice include the communication of high ideals and
expectations of important others to the staff nurse in order to improve the
quality of documentation.

© 1990 Springer Publishing Company 47

48 Scholarly Inquiry for Nursing Practice

Documentation by nurses is an integral part of patient care. The patient's chart pro-
vides an opportunity for communication among health care professionals. Due to
increasingly shorter hospitalizations, communication is more important today than
ever before (Manion, 1986). Since nurses' notes are usually the only place in the
chart in which care over a 24-hour period is recorded, they provide a critical link for
continuity of patient care. After discharge, the chart is a chronological and histori-
cal record of the quantity and quality of care received by the patient. In malpractice
cases, lack of adequate documentation in nursing records has reflected a failure to
deliver adequate care (Creighton, 1986). Reimbursement has been denied due to
lack of nursing documentation (Deane, McElroy, & Alden, 1986; Neumann &
Taylor, 1985).
The nurses' notes can demonstrate the application of theory in practice, for
example, nursing judgments, evaluations, and decisions as well as actions (Suhayda
& Kim, 1985). Clarification of what nurses should document contributes to the
development of a philosophy of accountable nursing practice (Bartos & Knight,
1978; Romano, McCormick, & McNeely, 1982).
Although proper documentation helps nurses to deliver sound patient care
(Bergerson, 1982; Katz, 1983), the process of documentation is often suboptimal.
The problems associated with documentation have been addressed often in the
nursing literature (Barbiasz, Hunt, & Lowenstein, 1981; Bartos & Knight, 1978;
Bell, 1981; Farrell, 1980; Greenlaw, 1982; Kunkel, 1983; Meade & Kim, 1984;
Rutkowski, 1985; Suhayda & Kim, 1984; Townson, 1985).
Numerous strategies have been advocated to decrease the time for documentation
without compromising its quality. These strategies, however, may be ineffective,
according to the theory of reasoned action (Ajzen & Fishbein, 1980). A change of
beliefs and attitudes about documentation may be necessary before documentation
behavior can be altered. In order to change nurses' beliefs and attitudes about
documentation, the beliefs must be identified and the relationship among belief,
attitude, and behavior must be explored.

CONCEPTUAL FRAMEWORK

The purpose of this study was to develop and test an exploratory model that explains
the behavior of documentation by nurses. The theory of reasoned action, a model
designed by Ajzen and Fishbein (1980), was used to related nurses' attitude and sub-
jective norm to the way they intend to behave concerning documentation, which is
the link to how they will actually behave, that is, document. The theory of reasoned
action can perhaps best be presented schematically (see Figure 1). Attitude is made
up of beliefs. Although a person may simultaneously hold many beliefs, salient
beliefs are those beliefs that serve as determinants of one's attitude at any given
moment (Fishbein & Ajzen, 1975). Subjective norm is a person's perception of
social pressures to perform or not perform the behavior. Salient referents are the
referents that are important to an individual and influence the person's subjective
Documentation Behavior of Nurses 49

Figure 1. Causal Model for Explaining Documentation Behavior

norm (Ajzen & Fishbein, 1980). In general, a person will intend to perform a
behavior when it is evaluated as positive and it is perceived that important others
think it should be performed. A person may evaluate a behavior as positive but not
intend to perform the behavior because the motivation to comply with important
others who do not value the behavior predominates.
Although documentation is a mandated activity, the variation in documentation
indicates a behavior that can be evaluated in terms of quality. Behavioral intent
concerning documentation was indicated by responses to questions concerning
intent to document. Indicants of attitude and subjective norm were based on salient
beliefs and salient referents identified from a representative sample.
The effectiveness of a model to represent data can be statistically assessed. For
this statistical strategy, the research hypothesis tested whether the model provided
goodness of fit to the data. A limitation of this research was that as a result of using
three different hospitals to achieve an adequate sample, the effect of hospital and/
or type of delivery of nursing care on documentation behavior could not be assessed.
50 Scholarly Inquiry for Nursing Practice

The items that were used to measure documentation behavior however, are those
that should be documented by all nurses on each shift

REVIEW OF THE LITERATURE

Theory of Reasoned Action in Nursing Literature

The literature concerning the theory of reasoned action is extensive. The review
given here will focus on applications in the nursing literature. Davidhizar (1982)
constructed an instrument following the theory of reasoned action guidelines of
1980, about the attitude of clients with schizophrenia toward their medication. This
instrument was used in 1986 by Davidhizar, Austin, and McBride to support a
relationship between attitude and insight into illness. In 1984, the theory of
reasoned action was used to construct an instrument to study the relationship be-
tween parental attitude and adjustment to childhood epilepsy (Austin, McBride, &
Davis, 1984).
Prestholdt, Lane, and Matthews (1987) used the theory of reasoned action in a
study of turnover among 885 nurses. Consistent with the theory, behavioral in-
tention was the only significant predictor of employment status (behavior of
interest). General attitude, general subjective norm, and moral obligation were the
significant predictors of behavioral intent.
Savage, Cullen, Kirchhoff , Pugh, and Foremen (1987), in a study of 30 RNs from
perinatal units, found attitude and subjective norm significantly related to behavio-
ral intent not to resuscitate in four different situations involving infants. The
questionnaire was consistent with the theory of reasoned action, but measuring the
nurses' actual behavior was not feasible.
There are a number of studies that have used the theory of reasoned action to
organize the study (Bowles, 1986; Chang, Uman, Linn, Ware, & Kane, 1985;
Shamansky, Schilling, & Holbrook, 1985). Other studies, although using the
theory, devised measures or analyses not always consistent with the theory (Ewald
& Roberts, 1985; Miller, Johnson, Garrett, Wickoff, & McMahon, 1982; Miller,
Wickoff, McMahon, Garrett, & Johnson, 1982; Pender & Pender, 1986; Schmidt,
1981). Rarely has the full theory been tested. The present study extended the use
of the theory of reasoned action in nursing. S trengths of the present study included
both the use of specific guidelines to create measures consistent with the theory of
reasoned action, and the use of each of the components of the theory to study the
behavior of nursing documentation.

PROPOSED MODEL OF DOCUMENTATION BEHAVIOR

The proposed model, as shown in Figure 1, is based on the theory of reasoned action,
which explains that nurses' attitudes toward documentation and their subjective
Documentation Behavior of Nurses 51

norm, which is their perception of social pressures, influence their intention related
to documentation. Additionally, the nurses' intentions influence their documentation
behavior.

METHOD
Sample and Procedure
The study was approved both at the university and hospital levels to ensure the rights
and welfare of all subjects, including confidentiality and anonymity. In general the
strategy was that, first, units where data could be collected were identified from a
list of patient care units. Then contact was made with the head nurse on each unit
to explain the study, elicit cooperation, and schedule a day for data collection. Prior
to shift report in the location where shift report occurred, each nurse choosing to
participate completed the questionnaire in approximately 15 minutes. The primary
researcher distributed the questionnaires, explained the study, and remained on the
unit to collect the forms when the questionnarie was completed. After the shift, the
researcher returned to the unit to score the documentation for one patient assigned
to each nurse that shift. The chart was randomly selected, and the researcher was
blind to the nurse's responses. If achartof apatientadmittedon that shift or apatient
with discharge orders was chosen, another patient's record was selected. A
convenience sample of all staff nurses on all units within three hospitals in the
southeast was used. Units excluded from the sample were the emergency room,
operating room, labor and delivery, and psychiatric units. The hospitals had an
average size of 488 beds.
The research questionnaire was handed to 138 nurses in the three hospitals across
all shifts on 27 units over a period of 10 days. Twenty questionnaires were not com-
pleted and 10 were discarded since either the nurse did not document that day or no
identifier existed to match the questionnaire with a given nurse's documentation.
There were 108 (78%) useable questionnaires with accompanying documentation
data.
Respondents were generally full-time employed (93%) females (95%) working
in intensive care (66%) and holding a B.S.N. (44%). The sample was evenly dis-
tributed across shifts and the three hospitals. The mean age was 33.3 years (SD =
9.5) with a mean of 5.4 years of experience (SD = 7.7). On average, the nurses
documented on 7.2 patients per shift (SD = 5.4).

Measures
To test the theoretical model shown in Figure 1, measures were developed by the
primary researcher to represent each component in the model. Specific Ajzen-
Fishbein (1980) format was used so as to conform as closely as possible to their
theory as well as to provide face valid measures. The content validity of the
52 Scholarly Inquiry for Nursing Practice

questionnaire was assessed by two experts in the theory of reasoned action. Specific
measures developed are discussed in what follows.
Attitude. Both general and specific attitude were assessed. General attitude
refers to an overall assessment about documentation calculated from summing re-
sponses to three semantic differential items concerning the nurse's feelings about
documentation. Specific attitude is an evaluation of a set of beliefs about docu-
mentation. Based on a prior sample of staff nurses, eight salient beliefs (e.g.,
"...contributes to continuity of care for my patients") were identified. Specific
attitude toward documentation was obtained by having the nurses rate the strength
of their beliefs for each salient belief and then multiplying this score by an eval-
uation of the belief. For example, concerning documentation, the nurse rated the
statement "Places me at risk legally" from likely to unlikely and then rerated the
statement to evaluate whether this was a good or bad outcome from documentation.
Using Ajzen and Fishbein (1980) guidelines, these two scores were multiplied
together; this was repeated for each belief and summed for the eight to constitute
specific attitude.
Subjective Norm. Similarly, subjective norm has a general component assessing
social pressure to document well. A single item assessed the general subjective
norm: the nurse's perception of what those people most important think should be
done regarding documentation. Specific subjective norm is the evaluation of the
importance referents attached to an individual's documentation. Six salient refer-
ents (e.g., "Lawyers") were identified in the prior study identifying salient beliefs.
The specific subjective norm was obtained from evaluation of each salient referent
and assessment of the motivation to comply with that referent. For example, the
nurse rated the statement, "Physicians think I (from definitely should to definitely
should not) document the very best that I know how on all my assigned patients
today" and in another part of the questionnaire, rated that statement, "I want to do
what the physician wants me to do." The two scores were multiplied together. This
was repeated and then summed for the six referents. The variables, specific attitude
and specific subjective norm, were derived by a process of multiplication and
summation and were not amenable to internal consistency reliability measures
(Bagozzi, 198 la).
Behavioral Intent. Generally, in the theory of reasoned action, behavioral intent
is assessed by a single item such as asking how likely it is that the nurse would docu-
ment on the patients today. This question is not meaningful when documentation
is required. Two strategies were employed. First, the nurse rated on a 7-point scale
the likelihood of documenting optimally on all assigned patients. Second, the nurse
gave a percentage estimate of the likelihood of documenting optimally on all
assigned patients.
Documentation Behavior. Documentation behavior was based on what should
be documented in any hospitalized patient's chart in an a 8-hour shift. Three areas
Documentation Behavior of Nurses 53

of content were evaluated: nursing assessment, interventions, and evaluation.

Additionally, the mechanics of documentation were evaluated. This area included
noting date and time, correct spelling, use of approved abbreviations, frequency
according to institutional standards, and so on. The instrument consisted of a check-
list and accompanying guidelines. Each item was scored as either present or absent.
Content validity was established based on literature and review of the instrument
by an expert panel consisting of a quality assurance monitor, staff nurse, head nurse,
nurse researcher, and nurse educator. The instrument was tested with 75 samples
of nurses' documentation, and an internal consistency value (KR-20) of .76 was
obtained for 24 items. The Kuder-Richardson-20 was appropriate to estimate relia-
bility for the dichotomously scored measure. In the study, reliability analysis led
to revising the documentation instrument to 20 items (KR-20 = .71). Interrater
reliability of scoring documentation from the patient chart was assessed, resulting
in an intraclass correlation coefficient of .84 for a single rater.

Pilot Study
Prior to implementation of the study, a pilot study was conducted in a 282-bed
private hospital. The sample included 25 nurses. Data were collected on each shift
on each of three units. The methodology and instructions on the instruments were
modified slightly based on the pilot study.

Analytic Techniques
The theoretical model was analyzed with LISREL VI (Joreskog & Sorbom, 1984).
Analysis of linear structural relations (LISREL) is a technique based on maximum-
likelihood analysis of a structural equation system that is used to examine the
plausibility, or fit, of a proposed model. LISREL allows the inclusion of multiple
measures of one construct, such as the two measures of attitudes, subjective norm,
and behavioral intent in Figure 1. Additionally, LISREL simultaneously estimates
sets of equations that prevent erroneous specification of an underidentified model,
more likely to occur with use of multiple regression and path analysis (Aaronson,
Frey, & Boyd, 1988).
The LISREL VI model includes two components, the measurement model and
the structural model. The measurement model assesses the relationship of observed
(indicator) variables to their respective latent constructs, while the structural model
provides estimates of the strength and direction of hypothesized relationships be-
tween latent constructs in the model. LISREL VI provides indicators of the overall
fit of the hypothesized model to the data (X2, degrees of freedom, and probability),
the quality of measurement (X estimates and corresponding t -values), structural
relationships hypothesized within the model (B and y estimates and t -values), and
of possible misspecifications in the model (modification indices and normalized re-
siduals). LISREL VI also provides estimates of the error variance for the observed
independent variables (08), the observed dependent variables (0£), and each structural
54 Scholarly Inquiry for Nursing Practice

TABLE 1. Correlation Matrix for Observced Six Variables Used in

LISREL Analysis (N = 101)
1 2 3 4 5 6
1. Behavioral Intent—Likert 1.00
2. Behavioral Intent—% .658 1.00
3. Documentation Score .218 .312 1.00
4. General Attitude .244 .246 .066 1.00
5. Specific Attitude .332 .305 .157 .332 1.00
6. Specific Subjective Norm .482 .447 .185 .205 .435 1.00

equation (y). In addition, coefficients of determination are given that reflect the
explained variance for each structural equation. (See Joreskog & Sorbom, 1982,
1984 for a full discussion of these various indicators).
LISREL is appropriate for both confirmatory and exploratory analyses and may
be used to guide exploratory model development The theory of reasoned action has
often been assessed with LISREL (Bagozzi, 198 Ib; Bentler & Speckart, 1981;
Bumkrant & Page, 1982; Ryan, 1982). The correlation matrix used in the LISREL
analysis was based on 101 cases for whom there were no missing data (see Table
1). Descriptive statistics for the seven observed variables in the model for this study
are displayed in Table 2.

TABLE 2. Componential Analysis of Violent Patient Categories

Negative Negative
Positive Reinforcement Reinforcement Consequences
Source=Staff Source=Patient Source=Staff
Positive Negative
Categories Attention Attention
The User High Low High Low
The Outlaw Moderate High Moderate Low
Rebel Without a Moderate High Low Low
Cause
Little Big Man Moderate High Moderate Low
The Child High Low High Low
The Vamp Low High Low Low
Documentation Behavior of Nurses 55

FINDINGS

Initial Estimation

Because this was an exploratory analysis, model revisions that did not conflict with
the theory of reasoned action and that were based on indicators of model mis-
specification were admissible. In the firstLISREL analysis, there were unreasonable
values, indicating that general subjective norm and specific subjective norm did not
load well together on the latent construct of subjective norm. Since general sub-
jective norm was the weaker variable, it was deleted from the model.
With this deletion, the latent independent construct, subjective norm, and the
latent dependent construct, documentation behavior, have only one indicator
variable each. To take error into consideration when there is only one indicator
variable, Joreskog and Sorbom (1982) recommended the use of internal consistency
reliabilities to determine appropriate parameter estimates. The reliability estimate
of .71 was used for the documentation score. Because the specific subjective norm
was a multiplicative score, there was no internal consistency reliability measure
available. Based on the belief that it is more logical to assume some error of
measurement than to assume perfection (Joreskog & Sorbom, 1982), a reliability
estimate of .75 was chosen to estimate the parameter.

Final Model Estimation

The only difference between the proposed model in Figure 1 and the final model was
the deletion of X4, general subjective norm. In the final model, all the measures
appeared to be adequate, and the overall fit to the data was good (x2 = 3.41; df= 7;
p = .845). The LISREL estimates for the final model are presented in Table 3. No
significant path was found from attitude to behavioral intention (t = 1.02). The path
from subjective norm to behavioral intention was significant (t = 2.80). Also, as
postulated, the path from behavioral intention to documentation behavior was
significant (t=2.98). The coefficient of determination (R2) for behavioral intention
was .461; for documentation behavior, .152.
Figure 1 represents the theoretical model posed by Ajzen and Fishbein (1980).
Finding a model that fits does not rule out other plausible models. The theoretical
model, however, is rational and is based on the theory of reasoned action, which
provided guidance for the variables included in the model. It is possible that there
are other variables that should be studied, but a goal of this study was to be as
consistent with the theory of reasoned action as possible. There was no indication
that paths not included in the model, such as that indicating a direct effect of attitude
on behavior, needed to be included. The study did result in a model that fits the data
well and that provides useful information.
56 Scholarly Inquiry for Nursing Practice

TABLE 3. LISREL Estimates for the Measurement

and Structural Model Component of the Final
Model
Maximum
likelihood
Parameter estimate t value**
Xxn .435 3.595
Xx 21 .763 4.890
Xx32 .866 10.607
Xy H * 1.000 —
Xy 21 1.000 6.291
Xy32* 1.000 —
88i .811 6.150
682 .418 2.004
683* .250 -
0 el .342 3.436
0e2 .342 3.426
6e3* .290 —
p2i -405 2.980
•Yn .164 1.022
•y12 .431 2.802
$21 .642 4.652
i|in .355 3.384
if>22 .602 4.645
*Parameter value set.
**t > 2.0 considered significant.

DISCUSSION

Do nurses know what to document? In this study, nursing actions were documented
in only 85% of the charts. Suhayda and Kim (1984) found that only 81 % of nurses'
notes in a critical care unit contained a reference to nursing interventions. Emotional/
psychological status should be documented on each patient each shift; yet, only 13 %
of the charts in this study made reference to patients' emotional status. For example,
no assessment of emotional status was given for a patient with cancer of the brain
receiving radiation, an alert patient recently made "do not resuscitate," an awake
amputee on the night after surgery, and a patient with acquired immune deficiency
syndrome. Either nurses are not assessing this area, or they are not aware of the need
to document the information.
Documentation scores were lower than anticipated. Only 65% of what was iden-
tified as minimal documentation was present in the evaluated charts. The majority
Documentation Behavior of Nurses 57

of the nurses in the study worked in the intensive care units, where most registered
staff nurses were employed and where documentation tends to be done more
frequently than in other settings, thereby increasing efficiency (Breu & Gawlinski,
1981). Nurses assigned to fewer patients tend to spend more time documenting care
(Deane et al., 1986). Documentation scores may have been even lower without the
number of intensive care unit nurses in this sample.
The level of nursing documentation found in this study can be explained by the
model used here. The way nurses intended to document accounted for 15.2% of the
variance in their actual documentation. The results of this study give specific
direction as to how to affect intention. Based on the model, 46.1% of the variance
in the way nurses intend to document can be accouted for by the nurse's attitude and
subjective norm — primarily the latter. Subjective norm is very much under the
influence of nursing administration, since it reflects the social pressure to perform
or not perform a behavior. If nursing administration clearly emphasized nursing
documentation and collaborated with physicians and other health professionals in
this effort, it is likely that nurses would perceive this importance and comply.
Nursing administration could foster a group cohesiveness among nurses, physi-
cians, and other health professionals, as a way to strengthen the link between
subjective norm and behavioral intent (Fredericks & Dossett, 1983). These efforts
couldresultin a higher subjective norm relating to ahigher intentand, subsequently,
to better documentation.
Intent to document is a measure of documentation behavior. Knowledge of a
nurse's intent to document is useful in the prediction of the quality of documentation.
Strategies designed to identify the nurse's intent to document, as well as strategies
to affect intention, could improve documentation. Expressing behavioral intention
to others has been found to increase efforts to make behavior consistent with
intention (Sherman, 1980). Staff meetings in which nurses state their intention to
improve their documentation may lead to better quality charting. In this study, the
linkage between the nurse's attitude toward documentation and the intent to docu-
ment was not significant. Perhaps nurses intend to document optimally, without
consideration of their attitude toward documentation. This interpretation would be
consistent with a previous study that found that people intended to do what they
thought was morally responsible even though it was identified as being unpleasant
(Gorsuch & Ortberg, 1983).
In this study there was a possible measurement problem for specific attitude.
Directions for evaluation of belief were identified during the pilot study as con-
fusing. Despite editing, this was the only section of the questionnaire eleciting
written and verbal comments concerning a lack of clarity. The notion of evaluating
beliefs was difficult to communicate for a required behavior. At this point, the lack
of relationship between attitude and behavioral intent can be both defended and
questioned. Based on the study, the researchers advocate a focus on subjective norm
instead of attitude to improve documentation. When important others have high
ideals and expectations related to doumentation, and these ideals and expectations
58 Scholarly Inquiry for Nursing Practice

are communicated to the nurse, the quality of documentation will increase. Admin-
istrative expectations may be communicated via the forms used for charting. For
example, when a form provides space and prompts for specific information, that
information is more likely to be included in the record (Thoma & Pittman, 1972).
There are other variables, not accounted for by the theory of reasoned action,
which probably affect documentation behavior of nurses, for example, the nurse's
workload and unforeseen events that impinge on the day's documentation. Future
research should devise methods to study these variables. Including these measures
could improve the ability of the theory of reasoned action to explain the documentation
behavior of nurses. Additionally, the model should be tested in different hospitals
and/or with different deli very systems to assess the effect of these variables.
Overall, the theory of reasoned action has provided insight into the documentation
behavior of nurses. Presently, it appears that the influence of others is what directs
the intention to document, and thus related to subsequent .documentation. The
construct of attitude needs to be explored further as to the variables that intervene
between intent and behavior.

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