Nunr Education Tcdq (1991) 11,2OCb206 0 Longman Group UK Ltd 1991

Nursing students attitudes toward AIDS: implications for education S. Gail Synoground

and Dorothy

M. Kellmer- Langan

Increasingly, nursing students will be caring for patients with Acquired Immune Deficiency Syndrome (AIDS), as the disease reaches epidemic proportions. This study examined the attitudes of 87 senior baccalaureate nursing students toward caring for these patients. A 37-item researcher developed Likert scale instrument was administered and addressed five themes: (1) direct care of the AIDS patient, (2) students’ rights, (3) educational preparation, (4) patients’ rights and (5) general beliefs about AIDS. Overall responses were generally positive although 70% of subjects expressed a discomfort in working with patients with AIDS. A large number felt they should have the right to refuse to care for AIDS patients although most indicated they would not refuse such an assignment. Most were very supportive of patients’ rights. Feelings of inadequate preparation to deal with these patient situations were indicated. Significantly more positive responses occurred in all areas among students who had actually cared for patients with AIDS. Findings have implications for development of teaching strategies and curricular approaches to address this health care issue. Data also provide a basis for educational and organisational policy formation.

1987; Bremmer Bowles 1988).

INTRODUCTION The

Acquired

(AIDS) nursing

Immune

epidemic education.

Deficiency

provides Most

Since

Syndrome

a major

challenge

nursing

schools

to are

currently discussing and making critical decisions as to how to adequately prepare students to care

for patients

with

AIDS

(Hodges

8c Poteet

S. Gail Synoground ARNP EdD Assistant Professor, Intercollegiate Center for Nursing Education, W2917 Fort George Wright Drive, Spokane, WA 99204-5277, USA and Dorothy M. Kellmer-Langan RN EdD Dean and Professor, School of Nursing, Pacific Lutheran Universi*/, Tacoma, WA 98447, USA (Requests for offprints to SGS) Manuscript accepted 22 November 1989

200

care

AIDS

is a relatively

professionals

experience

& Brown

have

with it. Steele

Carwein SC

1988;

new disease,

not had a great (1987) notes

health deal of

that AIDS

may be the most critical condition that health care providers will face in this century. With this in mind, she notes that with this ethical dilemmas regarding health

crisis come care. Pro-

viders must face the crisis ‘squarely’ and deal with the accompanying

dilemmas

including

the

looking at one’s attitudes and values about AIDS. Today’s nursing nurses responsible number munity

of

AIDS

agencies,

students will be tomorrow’s for caring for the increasing patients in hospitals, homes and extended

comhealth

NURSE EDUCATION

care facilities. Students have expressed concern and confusion regarding their roles in caring for these patients. This confusion may result from a lack of specific AIDS education or from opinions and attitudes not based on fact. Research in this area is limited; therefore, the purpose of this study was to examine the attitudes of nursing students regarding caring for patients who have been diagnosed with Acquired Immune Deliciency Syndrome. It becomes imperative for nurse educators to assess attitudes and concerns that students may have toward caring for patients with AIDS as a prerequisite to the development of teaching strategies and curricular materials. Additionally, some students have value systems that may not be congruent with caring for clients with AIDS (Steele 1987). Because the nursing profession has a sociai responsibility to make care available, it becomes necessary to determine ways to help students clarify their values and make the changes needed to provide professional care for all patients.

REVIEW

OF LITERATURE

A number of studies have examined attitudes relating to caring for AIDS patients by practising nurses. Blumenfield et al (1987), found that one-half of the nurses surveyed believed that AIDS could be transmitted to hospital personnel by contact with infected patients despite precautions taken during their care. About one-third of the nurses expressed concern or fear about caring for homosexual men and male prisoners. Additionally, two-thirds indicated that their families and friends were concerned about associating with hospital personnel who cared for AIDS patients. These and other researchers found that many of these health care professionals believed they needed more education about the disease as well as freedom to discuss their fears, concerns, ethics and values surrounding the AIDS issue (Bennett 1987; Blumenfield et al 1987; Flaskerud 1987). The literature revealed limited research concerned with nursing students’ attitudes toward

TODAY

20 1

patients with AIDS. Kagan (1986) surveyed 150 students enrolled in a baccalaureate nursing program in the New York and New Jersey areas. She found that, despite the wide-spread fear of the disease, students expressed general acceptance of AIDS patients. The one risk group that was viewed negatively was the intravenous drug users. In a recent study by Lester and Beard (1988) of 177 baccalaureate students, a number of correlations were found. Students with high fear scores were less willing to care for AIDS patients. High knowledge scores were positively correlated with high fear scores; however, these same students indicated less homophobia. Most felt that AIDS patients are entitled to the same care as other patients but nearly half of the subjects preferred not to care f-or these persons. Additionally, more than one-third felt they should not be given such an assignment. Several authors (Hodges & Poteet 1987; Carwein & Bowles 1988) have discussed the need for educators to address concerns that students have related to caring for patients with AIDS. Issues that must be considered include all aspects of patient care, confidentiality, the right to refuse to give care and risk factors. Information on safety precautions, high risk groups, and incidence and contagion must be included. Clearly, the best weapon against fear and ignorance is education. Hodges and Poteet (1987) contend that the entire curriculum must be examined to clarify how the care of individuals with any infectious disease is addressed. Carwein and Bowles (1988) also found that faculty differed widely in their ideas, views and attitudes. Hodges and Poteet (1987) suggested that both faculty and students must assess their fears and concerns related to AIDS if hysteria is to be avoided. Time is needed by both these groups to work through their own values and beliefs. An issue that arises frequently, and is discussed by Hodges and Poteet (1987), is students’ rights to refuse to care for patients with AIDS. It is imperative, therefore, that nursing schools establish specific written policies and procedures that set forth expectations for both faculty and students.

202

NURSE EDUCATION

TODAY

Instrumentation

RESEARCH QUESTIONS The

following

research

The data collection questions

were

investigated: 1. What are the attitudes and beliefs of baccalaureate nursing students regarding issues involved in the care of patients with AIDS? 2. What are the differences beliefs

of baccalaureate

in attitudes nursing

and

students

regarding issues related to the care of patients with AIDS according to selected variables (sex, basic/RN demographic ‘student,

class, previous

experience

AIDS

education,

in caring for AIDS patients)?

level

II

descriptive

comparative

study

to assess attitudes of

baccalaureate

nursing students

with Acquired

Immune

towards patients

was conducted

at a National League for Nursing

Deficiency

Syndrome.

It

accredited baccalaureate school of nursing in the Pacific Northwest of the United States.

Subjects were 87 senior year students

31 (35.6%) (64.4%) ranged

of whom

were in the first semester

were from

in the 21-43

second

and 56

semester.

Ages

years with a mean

age of

25.4. Nine (10.3%) were male and 78 (89.7%) were female. 78 (89.7%) of the subjects were basic students were

licensed

of whom 5 (6.4%) practical

nurses.

indicated Nine

nurses

working

toward

they

(10.3%)

were diploma or associate degree graduate tered

was a researcher

to measure

subjects’

attitudes regarding issues related to caring for AIDS patients. It was developed following a literature

review and consultation

with nursing

faculty and students. The instrument consisted of 37 Likert scale items to be ranked on a 4-point scale with 4 indicating

strongly

strongly disagree.

agree

and

The l-point

1 indicating

scale, rather than

a 5-point scale, was used to force respondents indicate

either

a positive

Items addressed

or negative

five basic areas:

1) provision

(6 items), 3) perceived

educational

(5 items),

rights

4) patients’

to

attitude. of

rights

preparation

(8 items)

and 5)

general beliefs about AIDS (3 items). Approximately one-half of the statements were worded

involved a survey approach

Subjects

instrument

scale designed

direct patient care (16 items), 2) students’

METHODOLOGY This

developed

regis-

a baccalaureate

negatively

to avoid

a response

set and

were

reverse coded for data analysis. Face and content validity were established panel of 4 faculty members

with knowledge

expertise

in the care of AIDS

research

design.

with 10 junior

The

instrument

nursing

comprehensiveness.

patients

students

Reliability

was piloted measures

were not established

administration

the

of

and

and in

for clarity and

internal consistency Cronbach’s collection.

by a

instrument;

for

prior to however,

alpha was conducted following data Obtained alpha coefficients were:

overall instrument 0.89; direct patient care 0.82; students’ rights 0.54; perceived educational preparation

0.7 1; patients’ rights 0.69; and gen-

eral beliefs 0.64.

Data collection One

of

the

researchers

met

with

potential

subects following three lecture classes. The study

degree. 15 (17.2%) of the students had cared for AIDS patients in the past. However, only 13 (14.9%) of the subjects had attended a formal

with an attached letter giving further information including an explanation of rights and

class on AIDS. 10 of these students indicated this content was part of the baccalaureate curriculum and 3 had attended a workshop, with the

assurance of anonymity. The students were informed that their decision regarding participation would not affect their course grades or

number of hours of instruction ranging from l-8 with seven subjects indicating 2 hours,

their relationships with the investigator or other faculty members. A box was provided at the back

was described

and the surveys were distributed

NURSE EDUCATION

of the room following

for placement

completion.

instruments

of the instruments

Returned

constituted

consent

74% indicated

completed

or child with AIDS,

were

analysed

Analysis Program and

using

the

(Walonick

percentages

were

Statpac

Gold

1987). Frequencies tabulated

for

the

responses to each Likert scale statement and then collapsed to indicate positive and negative responses.

Mean scores were obtained

of the five areas addressed attitude

score

two-tailed

were applied

for each

and an overall mean

was calculated

Additionally,

independent

of significance

to demographic was established

t-tests differ-

variables. Level at 0.05.

about resuscitating

question addressed

beliefs

of the

issues related

the overall

nursing

to caring

of drugs. About the same percent would feel differently

students

tices. Over 30% indicated suspect homosexuals officially diagnosed.

subjects right

for patients

(SD

indicated

fairly positive

positive response.

expressed AIDS

patients.

handling they

a general AIDS

were

64%

patients’

comfortable

these same persons. cated

expressed

patient with AIDS.

a

in working with discomfort

in

communicating

The mean of the responses related to educational

with

nursing emphasis

to care for a

curriculum

needed

of AIDS

patients;

touching an AIDS patient (67%), felt they would be able to form a therapeutic relationship with

for such patients. Students were

the patient

rights. The mean response

patient’s family (92%), and would not feel frustrated by the extra care precautions required (68%). However, 75% of the students felt that they would not want to be cared for by a nurse with a positive AIDS

test.

52% did

not feel they had enough knowledge and facts to communicate effectively with the families and friends

to the

to have a greater

on caring for these patients.

cated they were confident

give support

was 2.56 (SD

did not feel well prepatients and felt the

than for other

Most felt comfortable

for the statements

preparation

0.52). Students generally pared to care for AIDS

indi-

Only 19% felt that their care

could

to

their

instructor. 71% agreed with the statement, ‘I would care for a patient with AIDS if hospital

would be of less quality for persons having AIDS

(79%),

from

policy dictates I must care for him/her’. 4 1% did

52% of the students

patients.

with AIDS,

assignment

feel that nurses who are required to care for AIDS patients should be paid more.

bodily fluids although

that they would volunteer

to a patient of

and provi-

70% of the students

discomfort

with

addressing

sion of direct nursing care was 2.62 (SD 0.41), generally

of

most (89%) would not be upset

if assigned

towards patients with AIDS.

74%

to take care of a patient

however,

a change

scale was 2.68 (SD 0.34) indicating

for this grouping

Approximately

that they felt they had the

request

with AIDS

of having AIDS even if not

0.42).

enough,

on a 4-point

toward persons

prac-

that they automatically

The mean response

to refuse

AIDS;

mean response

The mean score for the statements

they

a blood transfu-

sexual or drug related

with AIDS as well as to specific aspects of their

attitudes

indicated

toward a patient who had

the disease through

sion than through

roles. The overall attitudes

an AIDS patient if

airway was available.

57% stated that they could accept the lifestyle

was 2.57

and

simi-

of patients who had contracted AIDS through homosexual practices, prostitution, or injection

patients.

The first research regarding

responded

The second group of items addressed students’ rights when assigned to care for AIDS

FINDINGS attitudes

however,

a protective

contracted

for each subject.

to the data to determine

ences according

to either an adult

and 69%

larly regarding resuscitating only a child with the disease. Subjects (84%) did feel positively,

Data analysis Data

that they would not give direct

mouth to mouth resuscitation

to participate.

203

TODAY

(SD 0.41).

They

very

however,

57% indi-

in their ability to care

supportive

of patients’

in this area was 2.94 generally felt that patients

should have the right to confidentiality of their diagnosis (54%), that other patients had no right to know that a patient on the unit had AIDS (87%) and that treatment in a regular health care

204

NURSE EDUCATION

TODAY

Table 1 Means end standard deviations of responses to statements addressing issues related to AIDS with higher meene indicetive of more positive responses

according

Area

X

SD.

nurse

Provision of direct patient care Students’ rights Perceived educational preparation Patients’ rights General beliefs about AIDS Overall

2.62 2.57 2.56 2.94 2.71 2.68

0.41 0.42 0.52 0.41 0.59 0.34

to. selected

Using independent ficant differences female semester

variables. no signi-

were found between male and

students, students

demographic

t-tests (two-tailed), between

basic and registered

or between

first

and

second

senior students.

When subjects were grouped attendance at a class or workshop

according pertaining

AIDS,

some prepar-

students who had received

ation felt significantly

more prepared

than those

who had not (t = 3.23, df = 75, p = 0.001). facility

should

(97%).

They

also agreed

should

have

the right

treatments (98%), for

not be denied

(90%), (65%),

consideration given (60%).

AIDS

to choose

patients patients

unorthodox

but

cost

should

in the type and extent One statement

be a

of care

that elicited

nega-

tive responses by 74% of respondents was in relation to the woman who knew she had AIDS and became pregnant. The fifth area, general included three statements response 0.59.

from

students

deviation indicated

57% felt that available information was correct

even though

of that

about AIDS

the disease

really is, most (63%) felt that their of contracting the disease were small if

they used precautions. Table

1 illustrates

the means

deviations of the responses groups of statements. The

second

differences

Table 2 Comparison

in

research responses

and standard

to each

of these

question by

significantly

different

with the mean

again

(t = 2.02,

an educational

with AIDS

The

also were

df = 75, p =

of those

offering

who had

being higher.

who had actually cared for patients responded

differently

than

those

who had not cared for such patients. In all five areas and in the overall scores, the mean responses

of the group who had cared for such

persons

were

differences

highest

were

(Table

noted

2).

relative

Significant to

attitudes

84, p = 0.003); students’ rights (t = 2.90,df = 84, p = 0.004); patients’ rights (t = 2.38, df = 84, p = 0.01); and in the overall scores (t = 2.78, df = 84, p = 0.006).

was new.

Although 22% felt the government was not telling the whole truth about how contagious the disease chances

two groups

toward caring for these patients (t = 3.04, df =

beliefs about AIDS, and elicited a mean

of 2.71 with a standard

Responses

of these

0.04),

Students

possible should be done that

scores

attended

the right to die with dignity

that everything

them

to AIDS

that

overall

to to

Analysis of the data obtained in this survey of the attitudes and beliefs of baccalaureate nursing students

regarding

persons

with

issues related

AIDS

reveals

to the care of

some

interesting

perspectives. Overall attitudes towards the elements of these situations were positive, a

addressed

study

DISCUSSION

subjects

finding consistent

with that of Kagan (1986) who

of responses of subjects who had and had not cared for AIDS patients

Area

Cared n

X

SD

Not Cared n X

SD

t

P

Direct patient care Students’ rights Educational preparation Patients’ rights General beliefs Overall

15 15 15 15 15 15

2.90 2.85 2.69 3.16 2.89 2.90

0.33 0.43 0.57 0.50 0.66 0.38

71 71 71 71 71 71

0.40 0.40 0.51 0.38 0.57 0.32

3.04 2.90 1.05 2.38 1.21 2.78

0.003 0.004 n.s. 0.01

2.57 2.52 2.54 2.88 2.69 2.64

k&6

NURSE EDUCATION

concluded

that students

generally

felt positive

Subjects

had

mixed

about caring for patients with AIDS.

issue of confidentiality

A number of more specific findings bear Students generally expressed consideration. discomfort in working with these patients, par-

discussion

feelings

positive

Again,

the this

due to the debates and

of this issue feelings

regarding

of diagnosis.

probably is to be expected

205

TODAY

were

in all circles. evidenced

for

Strong patients

ticularly in the physical aspects of care including

rights of access to health care, the right to death

the handling

most did

with dignity

required

possible

not

feel

of bodily fluids, although

that

the

extra

precautions

and the right

to have everything

done in their treatment

as well as the

would be overly burdensome. Greater comfort was described in the areas of communication,

right to seek unorthodox treatments These last findings, however, are

touching

tempered

and giving of emotional

support.

Inter-

estingly, over half of the students indicated would volunteer Although

they

to care for AIDS patients.

in light of concerns generally

transmissibility

be noted

whether the government information accurately.

these behaviours.

43% could

not accept

38% of the students

that they automatically

suspect

indicated

homosexuals

of

having AIDS even if not officially diagnosed. large number differently ted

the

rather

also noted

that they would feel

towards someone disease

than

through

through

A

who had contrac-

a blood

other

modes

transfusion of

trans-

mission.

indicated,

however,

Differences

that

variables

research

The question

means is hard to determine.

arises as to the impact that lack of

one-fourth

were

not

according

to selected

were addressed Significant

in two areas.

First,

in the differstudents

who had taken classes that dealt with AIDS more prepared

sure

always was reporting

question.

ences were noted

the disease and its About

they

in responses

demographic second

was factual.

to deal with related

those who had received

What ‘differently’

felt that information

they were receiving regarding

could accept lifestyles that involved homosexual practices, prostitution and drug abuse, it should that the other

somewhat expressed regard-

ing the cost of care. Respondents

57% of the subjects stated that they

if desired.

felt

issues than

no classroom

prepar-

ation. This one factor may have influenced

the

overall mean scores which also were significantly

acceptance of lifestyle has on quality of nursing care given to these individuals. Because homo-

higher

phobia

the scores of those who had received this type of

has been documented

to be an area of

in this group,

although,

noted that, in all areas addressed

be

concern among many members of society, it is of no surprise that it is to be found among nursing

structured

students. It clearly presents challenges to nursing educators, many of whom may not have

determining attitudes and beliefs may be the experience of actually caring for individuals who

resolved

the underlying

issues for themselves.

Quite a few of the students have

the

right

to refuse

patients;

however,

request

a change

instructor

felt they should

to care

for

AIDS

most would not be upset or of

if assigned

assignment

from

to such a patient.

their Inter-

estingly, 4 1% believed they should be paid more for providing

this care.

Students generally did not feel well prepared to care for AIDS patients, although some of them had information

attended workshops or received about the disease as part of their

regular classes. Overall, the need was felt for greater emphasis on all aspects of this health problem within the nursing curriculum.

information

it should

in the survey,

were higher.

It would appear that the most crucial factor in

have the disease of AIDS. Consistently, were more indicated

positive among

attitudes

those students

who

that they had had this opportunity.

must be noted that this group comprised of 87 subjects,

probably

It

only 15

a result of the limited

number of persons diagnosed with the disease being treated in health care facilities in the local community prior to and at the time of this investigation. Certainly, further study needs to be done of this factor and its impact; however,

it

seems clear that fears and concerns can best be overcome through actual experiences with and confrontation of situations. Other implications from evident.

Assessing

attitudes

this

research

of students

are

related

206

NURSE EDUCATION

TODAY

to nursing care of patients is an important

part of

AIDS

should

be

placed

in

the

the educational process, a factor which is particularly true with regard to persons who have

Should it be taught as a separate

AIDS.

materials dealing with infectious

Knowledge

the disease,

is the best protection

and nursing

students

against

need

to be

presented with specific accurate guidelines, both to enhance their care and to protect themselves. Based on assessment educators

of these attitudes,

need to carefully

cula for adequacy

the content

be integrated

with other curricular diseases? Either

approach may be appropriate but should determined only after thorough assessment both the organisation,

the curriculum

In the future,

analyse their curri-

will contact frequency.

patients with AIDS with increasing It is imperative that these pro-

needed

skills,

fessionals

be well prepared

health care providers

to address

ations which they will be required

of content presented also is warranted. The AIDS epidemic clearly is a major

disease is the first step.

profession questions.

Assessing chal-

nursing

students and faculty. It helps students to develop a self-awareness of their beliefs and feelings and openness

in their

their fears and personal faculty, knowledge in designing facilitating

ability

to discuss

value systems. Among

of student attitudes can help

appropriate

curricular

discussions

and,

and organisation-related

attitudes

and perceptions

the situ-

to confront. about

the

and has created Assessing

students’ attitudes toward this disease and the persons affected by it is beneficial for both

facilitates

and the

community.

both in the psychomotor and psychosocial areas. Additional research relative to appropriateness

many unanswered

be of

nursing

in addressing

lenge to the nursing

curriculum.

unit or should

materials,

developing

References Bennett J 1987 Nurses talk about the challenge of AIDS. American Journal of Nursing 87: 11561155 Blumenfield M, Smith P, Milazzo J, Seropian S, Wormser G 1987 Survev of attitudes of nurses working with AIDS patients. General Hospital Psychiatry 9: 58-63 Bremmer M, Brown L 1986 Learning to care for clients with AIDS: The practicum controversy. Nursing and

Health Care 7: 25 l-253 Carwein V, Bowles C 1988 AIDS policy and guidelines development. Nurse Educator 13(6): 14-16 Flaskerud 1 1987 Nurses call auf for AIDS information.

student

policies.

Nursing-and Health Care 8: 557-562 Hodges L, Poteet G 1987 The tragedy of AIDS: A new trial for nursing education. Nursing and Health Care 8: 565-568 Kaean K 1986 Baccalaureate nursine v students’ attitudes

CONCLUSION

0

In

conclusion,

determine students’ disease

nursing

the

most

fears which

its scope. students

negative

is relatively

They to obtain

the provision discussion

and

educators

effective

also

need

to

way to deal attitudes

with

toward

new and uncertain

will need

the knowledge

to assist

these

necessary

of safe quality nursing

that arises is where

a in for

care. One

the content

on

toward patients with Acquired Immunodeficiency Syndrome (AIDS). Dissertation Abstracts International 47(06B): 2372 Lester L, Beard B 1988 Nursing studenrs’ attitudes toward AIDS. Journal of Nursing Education 27: 339404 Steele S 1987 AIDS: Clarifying values to close in on ethical questions. Nursing and Health Care 7: 247248 Walonick D 1987 Statpac Gold Statistical Analysis Package. Walonick Associates, Minneapolis