ATTITTUDE FORMATION AND NURSING

“Caring and science were traditionally taught as distinct aspects of nursing practice. While caring, often regarded as the art of nursing, science was look upon as having the rational basis. New understandings of ‘caring science’, re-ignites connections between science, art, values, and ethics” (Watson, 2005).
Health professionals need to understand and change their attitudes and beliefs as it makes a significant contribution in determining whether people will adopt healthy behaviours and how they will respond to illness.
This paper outlines the development of self concept in nurses as individuals, its subsequent relationship in the formation of attitude and behaviours and processes in attitude change.

Identity and self conception

Development of the ‘Self’ is first and foremost linked to our genes or dispositions like moods, personality, etc. But the actual self or the ‘identity of self’ arises out of human interaction. Mead (1934) says, “Self conception comes from seeing ourselves as others see us.”
It is fundamental for every human being to identify the self in the context of the environment because knowing about oneself allows understanding of what one should think and do just as knowing others allows us predict what they think and what they do.
Fiske (2004) adds, “A person not only perceives people has having spatial and physical properties, but also can grasp even such intangibles as their wishes, needs, and emotions by some form of immediate apprehension”. Although people’s perception of themselves and others is immediate, it is in fact filtered through psychological lens or perceiving apparatus. This makes them aware only of the end product, their experience. In other words, the actual reality is much vast than the reality perceived by a human being.
This perceived reality resulting from mediation of psychological lens gives rise to what is called as an attitude.

Social Schema and Attitude

Attitudes can develop through a variety of routes- through direct experience and through indirect experience (through media sources, parents, teacher and peers). Once developed it stabilizes and becomes difficult to change. If it is so then what is the need of attitude?
The fact is as Aronson exclaims, “People do not possess a ‘Gods eye’ view of the world- a perspective that all knowing and free from bias”, that the world is full of information and human mind has limited capacity to analyze each and every situation. Hence, people make use of schemas to make sense of a message dense and decision rich environment. A Schema is a set of interrelated cognitions (e.g. thoughts, beliefs) that allows an individual to quickly make sense of another person, situation, event or a place.
Schemas are cued by easily detected features, such as skin colour, dress or physical appearance. The schema then fills in the missing details. For example, a racist’s schema may easily get cued by looking at the skin colour of an Asian and may conclude him as aggressive.
Accessible schemas, ones that are habitually used or are salient in memory and schemas that have bearing on features that are important to oneself in that context, have a high probability of being invoked. Continuous invoking of these schemas lead to the development of attitude as similar experiences will be perceived in the same manner as before. For example, a nurse who develops an attitude that the patient contributes to his/ her condition (e.g. by not following health advice), may treat unfavorably to them.
Configural model of impression formation, balance theory of person perception and Gestalt psychology agree that all individuals have simplified and holistic templates of cognitive representations which they use for future actions.
These processes are obviously not entirely objective. Their use can often lead to biases and ignoring other information. Apart from idiosyncratic personal constructs, the overall attitude that one develops are dominated by schemas of first impression, stereotype and prejudices.

Forming Impressions of others

The order in which information about a person is received can have a profound effect on subsequent impression. Asch (1946) proposed primacy effect: the trait (information) received first can have disproportionate influence on the final impression, so that the person is evaluated more favourably when positive information is presented first (e.g. intelligent, industrious, etc.,) than when the negative information presented first (e.g. impulsive, critical, etc.,). For example, prior information about the patient’s personality may influence nurses’ subsequent interaction with that individual. Nurses’ prior information about a patient, “she is a lovely woman” can have implications in her/his interactions with that patient. Physical attractiveness may also create ‘halo effect’ so that other characteristics are viewed positively.
A recency effect can also occur when later information has more impact than earlier information. However, primacy effect is more common (Jones, 1972), clearly implying that first impressions is indeed important. For example, non-verbal characteristics touch and nodding of the doctor may influence impressions.

Stereotypes and prejudices

Stereotypes are attitudes acquired at an early age and are slow to change. Although they are meant to make sense of particular inter-group relations, they are crude and can become hostile when social tension or conflicts arise.
For example, a nurse may assume that an elderly person possesses certain characteristics simply by being a member of the elderly group.
Stereotypes are widely shared generalisations about members of the huge diversity of the social world. They are often derogatory when applied to out groups and have become central aspects of prejudice and discrimination.
Group Stereotypes and prejudices occur particularly in relation to race and gender. For instance, perception that male is stronger than female. Explanations for prejudices include- favouritism towards in-groups of which one is a member and homogeneity among the out-group i.e. all members of the other group are similar.
Stereotype may be overcome by repeated occurrences of behaviours which do not confirm the stereotype held (Krueger et. al., 1988).
Gannog et. al., (1987) reviewed 38 studies of stereotypes by nurses; they found evidence that nurses hold stereotypes of patients on the basis of age, gender, diagnosis, social class, personality, and family structure.
However, very few studies have studied the effects of these stereotypes. For an illustration, Vicki Chung, a male nurse, explains that during his training he was not allowed to enter the delivery room or have a female patient all because of his gender.
Behaviours are therefore influenced by many characteristics of target person as well as the theories, expectations and stereotypes held by the perceiver. It is important for health care professionals to be aware of the ways in which impressions formed can influence both their behaviour and that of the patient in any given interaction (Messer, 1995).

Relationship between Attitude and Behaviour

Attitude precedes behaviour and guides our choices and decision for action. It is clear that attitude is inevitable. They are meant for people to comprehending and reacting to events, make decisions or make sense of their relationship with other people in everyday life. Each attitude, therefore, is made up of cluster of feelings, likes and dislikes, behavioural intentions. At the same time attitude enables a person to maximize the probability of having positive experiences while minimizing negative ones. Alcoholics, for example are given aversive therapy liked induced nausea or vomiting. After repeated pairing, the alcohol itself causes the aversive response, which decreases the likelihood of relapse.
Attitudes are learned rather than innate; for example direct negative or positive experience with attitude objects. Through repeated association (Classical conditioning), positive consequences verses negative consequences (instrumental conditioning) learning by observations and personal exercise of building connections between more and more elements like beliefs (self perception theory). But contrary to the misconception, attitude may not always predict the behaviour.
LaPiere (1934) studied attitude behaviour issues. Early attempts of LaPeire found no relationship between attitudes and actual behaviour of people. However, later research suggested that attitude and overt behaviour are not related in one-to-one fashion. There are several conditions that prompt or disrupt correspondence between attitude and behaviour. Accessible attitudes are recalled more easily and expressed more quickly like before the promotion of health foods yoghurt was more likely to cue as a dairy product and not a health food. Secondly, certain attitudes cannot be expressed publicly such as responding to a questionnaire. The attitude- behaviour consistency can vary according to the individuals’ low or high identification with the group. Lastly, strong attitudes exert more influence on behaviour. For example, people have strong attitudes for euthanasia or doctor assisted suicide.
However, since attitudes are subjective interpretations of the objective reality and are therefore not without biases and errors.
People use cognitive short cuts to make inferences about the causes of other people’s behaviour. Shortcuts lead to the efficient processing of a great deal of incoming information and are quite satisfactory and adaptive. However, they are not objectively correct all the time: biases are entirely adaptive characteristics of ordinary, everyday social perception (Fiske, 2004).

Biases in Attribution

According to Hogg (2002), there are three main biases

The fundamental attributional error

The fundamental attributional error refers to a tendency for people to make dispositional attributions of others’ behaviour, even when there are clear external/environmental causal contenders. For example, the tendency to attribute road accidents unduly to the drivers rather than to the vehicle or the road conditions is fundamental attributional error.
A number of explanations have been proposed: the actors behaviour attracts more attention than the background, people tend to forget situational causes more readily than dispositional causes; thus producing a dispositional shift over time (Moore, 1979), cultural and developmental factors for example tendency to attribute bad out-group and good in-group behaviour internally and good out-group and bad in-group behaviour externally (Ultimate attribution error).

The actor-observer effect

The actor observer effect is really an extension of fundamental attribution error. It refers to the tendency of people to attribute others’ behaviour internally to dispositional factors and their own behaviour externally to environmental factors (Jones, 1972). People also tend to consider others behaviour to be more stable and predictable than their own.
There two main explanations for the actor observer effect: the actor quite literally has different perspectives on behaviour than the observer and so explains it differently. Actor has a wealth of information and behaves in very different ways in different contexts but the observer simply see the actor in particular context/s.
Conversely, people tend to see their behaviour as typical and assume that under similar circumstances others would behave in the same way (false consensus effect). It is so because attitudes tend to be so salient that it may displace consideration of alternatives. At other times, people seek company of similar others- thus experiencing inflated consensus (Aronson, 2004).
This suggests the important possibility that false consensus is the mechanism of maintaining a stable perception of reality. External threats, positive qualities, perceived similarities of others and minority group status all also inflate perceptions of consensus (Sanders, 1983).

Self serving bias

Self Serving Biases enhance or protect self evaluation. “People tend to attribute internally and take credit of their successes, or attribute externally and deny responsibility of their failures. Self serving bias is clearly ego-serving” (Hogg, 2002).
The belief in a just world (Hogg, 2002), can result in a general pattern of attribution in which victims are deemed responsible for their misfortune- poverty, oppression, tragedy, and injustice, all happens because victims deserve it. e.g. unemployed are held responsible for being out of work, rape victims are responsible for the violence against them.

Attitude change

Accumulating evidence of attributional biases and errors, people are viewed as naïve scientist and are thought as cognitive misers.
The fact that humans are cognitive misers does not mean they are doomed to distort. Indeed, once people know some of the limitations and common biases they can think better and make smarter decision.

Persuasive communication

Persuasive communication considers large number of variables that can determine what will do the trick in changing another person’s mind. Hogg (2002) says, some obvious areas of applications are: political propaganda and advertising and active participation of the person (cognitive dissonance).
Context of persuasion: the communicator (attractiveness, likeability, similarties), the message (repetition, fear arousing message, for example health workers visiting local schools to talk about danger of smoking) and the audience (self esteem sex individual difference, age) determines the extent of persuasion. For example, ability of the nurse to help her patients remember and act on her instructions like giving medication.
The theory of planned behaviour links success of an outcome to people’s beliefs that they can control their behaviour. The promotion of health practice uses persuasive communication through distribution leaflets, advertisements, free campaigns, etc.

Dual process model

Dual process model is based on the assumption that people employ two modes of thinking. When people are alert and active, they apply ‘systematic’ mode and the other is called the ‘heuristic’ mode. Heuristics are most likely to be used when people do not have time to think carefully, are overloaded with information/ unimportant information, have little knowledge or apply whatever comes quickly to mind (Heuristic systematic model- Chaiken, 1993).
The dual process model may abstract, but it has everyday life practical implications. For example, knowing that change in attitude can be brought about by thinking systematically, the nurse can observe such behaviours as alertness, thoughtfulness, attentiveness in the patient and talk about behaviour change at that moment.

Conclusion

Given that humans have limited capacity to process information, they attempt to adopt strategy that simplifies complex problems. People develop attitudes and behaviours to ignore information and reduce cognitive overload or overuse information at other times to keep from having to search more. For this people are often willing to accept less than perfect alternative. Similarly, attitude is energy saving behaviour as people do not have to figure out from the scratch how they should relate to the object or situation in question.
The strategies of the cognitive misers make fairly good use of the limited cognitive capacity to process near infinite world of information-but can lead to serious errors, biases and attitudes. Any attempts to make changes in the biases or attitudes do not necessarily change the behaviours. For example, people may have positive attitude towards condom use but yet not used themselves. Many smokers are well aware of the health risks of smoking yet do not change their behaviour.
Thus research on attitude provides set of issues to be considered when making attempts to change behaviour. But it needs to be remembered that if attitude and behaviour change were easy, then people would have very different social world with very different problems.