Attitudes of nurses towards AIDS Patients
AEJNE Volume 4 - No.2 March, 1999.
The World Health Organisation (WHO) (1993, p.1) estimates that by the year 2000, 'more than 40 million people will be infected with Human Immunodeficiency virus (HIV)'; while the National Centre in HIV Epidemiology and Clinical Research (1997, p.1) states that during a three month period in Australia, a total of '218 diagnoses of HIV and 70 AIDS related deaths were reported'. These two facts signify the need for improved health care for patients suffering from HIV due to the predictable strain which will occur in coming years on services. Nurses are at the forefront of caring for all patients, and HIV patients present complex challenges for health care professionals. An important issue that has emerged is how nurses adapt to these challenges and care for HIV patients. Inadequate care will not only affect the patient, but it has the capacity to adversely affect the nursing profession. This literature review will examine the nursesí attitudes towards caring for patients with AIDS as well as the factors which influence these attitudes. The literature suggests that there are differing points of view as to how nurses care for HIV patients. Studies by Dubbert & Kemppainen (1994), Sherman (1996) and Kemppainer et al (1992) demonstrate clearly that nurses have a `fearí of caring for HIV patients. How to alleviate this fear and improve quality of care is the basis for many other studies and is also an issue examined in this literature review.
Dubbert and Kemppainen (1994) sought to examine what they considered to be the greatest challenge facing health care providers in this decade, the care of AIDS patients. A short vignette (370 word) describing a male AIDS patient with the diagnosis of pneumocystis pneumonia was given to twenty nurses. After reading the vignette, the nurses had to complete a Nurse Willingness Questionnaire (NWQ) specifically designed to measure nursesí resistance or willingness to carry our a variety of nursing activities on a HIV patient. The NWQ is a 13 item self report instrument using a Likert scale. The nurses were also asked to complete a Fear of AIDS Schedule (FAIDSS). This examined the association between responses on the NWQ and the fear of contracting AIDS associated with high risk sexual behaviour and through nonsexual contact and medical procedures. The results showed no correlation between the FAIDSS and contracting AIDS via high risk sexual behaviour, but did correlate a fear of contracting AIDS via nonsexual interpersonal exposure and medical procedures. The four items of highest correlation were the changing of dressings and commencing intravenous fluid or a blood transfusion. This study had a coefficient alpha of .97 representing high internal consistency reliability. The vignette and NWQ gave the self report research style credibility with a minimum possibility for researcher bias. Despite the sample size of twenty, this study indicated that nursesí had a fear of contracting AIDS. What is not known however, is whether this affects their nursing practice or factors which influence the nursesí attitudes.
Sherman (1996) performed a study aimed at examining the relationships between perceived social support for nurses, death anxiety and the nursesí willingness to care for AIDS patients. The descriptive correlation design concluded that there was a positive relationship between perceived social support and nurses' willingness to care. The study also found that the greater the nursesí death anxiety, the less willing they were to care for an AIDS patient. The sample used in this study of 220, were all female Registered Nursesí (RN) with between a five and fifty percent rate of caring for a AIDS patient on a daily basis. By studying only females, the results may have been skewed. Sherman did not discuss the reasoning behind the convenience sample selection of female RNís, other than saying that the literature suggests females and males differ in death and anxiety. It could therefore be argued, that this study is not a true representation of the RN population as the objectives stated in the study suggest. From the results of this study, indicating a relationship between anxiety and willingness to care, procedures to reduce nursesí anxiety may need to be further examined and implemented in hospitals or other studies. A study by Kemmpainen et al (1992) examines the attitudes of nursesí in different areas of AIDS prevalence, to determine if a relationship exists between AIDS prevalence and nursesí attiitudes or willingess to care for an AIDS patient.
Kemmpainen et alís (1992) study was a similar study to his study in 1994 (Dubbert & Kemppainen, 1994). However, this study used a 500 word vignette, containing an almost identical study to Dubbert & Kemmpainen (1994). This survey was sent to five hospitals, each containing varying numbers of AIDS admissions. Dubbert & Kemmpainen (1994) study involved twenty nurses, while Kemmpainen (1992) earlier study involved 571 nurses, also using the NWS. The number of participants who responded from the high, medium and low prevalence of AIDS patient hospitals were approximately equal. Using the 13 items on the NSW as the dependent measure and the prevalence of AIDS patients as the variables, the results of Kemmpainen et al(1992) study revealed an exceedingly clear and consistent pattern. Nurses in hospitals with low and moderate AIDS prevalence were consistently more willing to provide care for the portrayed AIDS patient than nurses employed in a high prevalence hospital. This study has been used as the basis of further research because of its reliability, validity and results. Why nursesí in low prevalence areas have more positive attitudes was not explored in the study and should be the basis for further research. Steele & Melby (1995) also performed a study examining attitudes of nurses in the community, hospital and hospice settings.
The aim was to discover the fears and knowledge that nursesí posses with regards to AIDS, and compare them to the different health care settings; hospital, community and hospice. Although the sample size was not high, the technique of a simple random selection with no indication of researcher bias, and a high response rate gave the study credibility. The study revealed that the respondents gained most of their information on AIDS/HIV through the media, press and by reading journal articles. Although their knowledge came from a variety of sources, it was interesting to note that almost 50% incorrectly believed that being exposed to vomitus by a HIV patient put them at risk of contracting HIV. Hospital nurses indicated a higher rate of oral hygiene practice and a much lower rate for body hygiene practice compared to the community and hospice settings. Thirty-eight percent of respondents felt that nursing an AIDS patient put them at a great risk of HIV contraction. This result is supported by Berryís (1990) study. An interesting result from this study suggests that 21.4% of the nursing sample indicated that they had all the information needed about AIDS/HIV. Almost half the respondents felt they had a right to refuse nursing a HIV patient and felt they should be aware if their client has HIV/AIDS. The most significant result of this study was the lack of knowledge which the sample nursesí possessed with regards to AIDS. Having nurses with a general lack of knowledge in AIDS, may inhibit the building a successful nurse-patient relationship. If the patient does not trust or believe the nurse, then the effectiveness of the treatment and the professionalism of nursing could also be jeopardized. The suggestion of whether or not knowledge or education is a factor in nursesí attitudes is debatable and was the purpose of Lachinger & Goldenberg (1993) study.
This qualitative correlational study by Laschinger & Goldenberg (1993) suggests that their sample of practicing nurses had positive attitudes towards caring for HIV patients but had concerns about the occupational risk of contracting AIDS. Laschinger & Goldenberg (1993) also found that educational level was significantly related to attitudes, indicating that nurses with higher levels of education had more positive attitudes. The study had a very low response rate, which Laschinger & Goldenberg (1993) defended by stating that the sample appeared to be representative of the expected demographics, but did not discuss why this is the case. The representation of the study to all areas of nursing must also be questioned, considering the sample used were all employed in one urban hospital. If the results of this study are taken at face value, then further education is needed to change nursesí attitudes. Tesssaro & Highriter (1994) investigated the intentions of public health nursesí attitudes towards HIV patients in an effort to establish any other factors which may influence nursesí attitudes.
The data collected in this study was based on a cross-sectional survey in three different area of HIV prevalence, similar to Kemmpainen et al ës (1992). The sample size was large with a high participate rate, reliability coefficient and alpha reliability coefficient. The results of the study indicated that nursesí who persononally knew someone with AIDS, had stronger intentions to care for patients with AIDS. Using the Theory of Reasoned Action, this study found that attitudes and subjective norms did not fully explain the nursesí intention to work with a HIV infected patients. Nurses from low prevalence areas had stronger intentions with work with HIV infected patients if they had cared for someone with the infection or AIDS. These findings are consistent with Kemmpainen et al (1992) but cannot be generalised to all public nurses because areas with medium level prevalence of AIDS were not sampled. Tessaro & Highriterís (1994) findings also contributed to the belief that many factors influence nursesí attitudes
A Further study by Baylor & McDaniel (1996) also examined the attitudes and factors that influence attitudes of nurses towards AIDS patients. The cross-sectional design investigated 138 RNís using an instrument developed by Scherer & Haughey (1989). Baylor & McDaniel (1996) concluded that knowledge alone does not decrease the fear of nursing a patients with AIDS. Unlike Laschinger & Goldenberg (1993), Baylor & McDaniel (1996) concluded that educational background is not related to nurses attitudes, and nurses with experience in caring for HIV patients have more positive attitudes and that nurses are knowledgeable concerning AIDS. These results are not consistent with Laschinger & Goldenberg (1993). Whether this is a correct causal effect or a result of a self-sectional study process cannot be inferred from this cross-sectional study. This study was also limited to a midwestern American State and therefore cannot be generalised beyond this geographic area. This study did not measure the nursesí attitudes towards towards groups at high risk of contracting AIDS other than homosexuals, whereas a study by Jemmott et al (1992) discovered that homosexuality is a factor which influences care given by the nurse to a HIV patient. From the basis of these studies, the factors which influence nursesí attitudes cannot easily be defined or agreed upon.
A number of studies previously mentioned suggest that negative attitudes towards caring for AIDS patients exist. How to modify these attitudes must be explored in an effort to improve patient care. Kemppainen et al (1996) performed a study in which two groups of nurses received different instructions on AIDS and AIDS care. In the first group, correct knowledge was reinforced and negative attitudes challenged in the context of peer group discussion. The second group worked individually with a nurse trainer to accomplish the same goals as they provide in direct care to hospitalised patients. Participants worked in all areas of the hospital setting including medicine, surgery, intensive care, psychiatry and geriatric. A randomized study found that none of the interventions had a significant impact on the nursesí attitude, either post-intervention or during a six month follow-up. This is not the first intervention study which has failed to detect change in attitudes among direct patient care providers. Feit et al (1990) also found that 86% of the participants reported no change in willingness to care for patients with AIDS. Upon further analyses Kemppainen et al (1996) discovered that attitudes towards homesexual AIDS patients was a strong predictor of nursing willingness to care for the patient. This is consistent with previous research by Bennett et al (1993) who found homophobia significantly affected attitudes among a randomly selected survey. Cole & Slocumb (1993), Jemmott et al (1992) found that homoexuality affects attitudes of nurses when caring for AIDS patients, and Meisenhelder (1994) found that homphobia, lack of knowledge, lack of emotional involvement and fear accounted for 57% of the fear of contagion among the participants. Using a convenience sample, Cole & Slocumb (1993), found that nurses had a more positive attitude towards caring for a person AIDS if the patient acquired AIDS via a blood transfusion, while having more negative attitudes towards drug users. Wallack (1991) also found strong negative attitudes towards intravenous drug users.
From the research conducted, it appears as if nurses may experience a difficulty of establishing a therapeutic relationship with AIDS patients. The effects of a `non-therapeutic relationshipí is an issue of great depth. Knowledge alone does not appear to decrease nursesí fear or change attitudes of nursesí towards caring for AIDS patients, although some research disputes that statement. Longitudinal studies need to be conducted to determine whether interaction with AIDS patients changes nursesí attitudes. After a decade of research in this area, no definitive answer can explain the reasons for differences in nurses attitudes towards caring for AIDS patients. Further, published research must also be conducted in many countries around the world to determine trends or other factors that may influence attitudes. Reliable sources of information must be made readily available for nursesí caring for AIDS patients with support session to elicit individual feeling and concerns about AIDS care.
List of References
Baylor, R., McDaniel. 1996, `Nursesí Attitudes Toward Caring for Patients With Acquired Immunodeficiency Syndromeí, Journal of Professional Nursing, vol.12, no.2, p.99-105.
Bennett, J., DeMayo,M., Saint Germain, M. 1993, `Caring in the time of AIDS: the importance of empathyí, Journal of Advanced Nursing, vol.15, p.638-45.
Berry, S. 1990, Nursesí attitudes to patients with AIDS, Nursing Times, vol.86, p54-55.
Cole, F., Slocumb,E. 1993, `Nursesí Attitudes Towards Patients With AIDS', Journal of Advanced Nursing,vol.18, p.1112-1117.
Dubbert, M., Kemppainen, J., White-Taylor, T. 1994, `Development of a measure of Willingness Provide Nursing Care to AIDS Patients, Nursing Administration Quarterly, vol.18, no.2, p.16-21.
Feit, L., Melzer, S., Vermund, S., Schelov, S. 1990, `Concern about AIDS among hospital physicians, nurses, and social workers', Social Science and Medicine, vol.33, p.239-48.
Jemmot, J, J., Freleicher, J., Jemmott, L. 1992, `Nurses' Intentions Regarding AIDS patients', Research in Nursing and Health, vol.15, p.295-301.
Kemppainen, J., St.Lawrence, J., Irizarry, A., Weidema, D., Benne, C., Fredricks, D., Wilson, M. 1992, `Nursesí Willingness to Perform AIDS Patient Care, Journal of Continuing Education in Nursing, vol.23, no.3, p.111-116.
Kemppainen, J., Dubbert, P., McWilliams, P. 1996, `Effect of group dicussion and guided patient care experience on nursesí attitudes towards care of patients with AIDS, Journal of Advanced Nursing, vol.24, p.296-302.
Laschinger, H., Goldenberg, D. 1993, `Attitudes of Practicing Nurses as Predictors of Intended Care Behaviour with Person Who Are HIV Positive: Testing the Ajzen-Fishbein Theory of Reasoned Action', Research in Nursing and Health, vol.16, p.441-450.
Meisenhelder, J. 1994, `Contributing Factors to Fear of HIV Contagion in Registered Nurses, IMAGE, vol.16, p.65-69.
National Centre in HIV Epidemiology and Clinical Research, `Australian HIV Surveillance Update . Diagnoses in the third quarter 1 July , 30 September 1996', National Centre in HIV Epidemiology and Clinical Research, vol.13, no.1, p.1.
Scherer, Y., Haughey, B. 1989, Knowledge and Attitudes about Acquired Immunodeficiency Syndrome, Nursing Forum, vol.21, no.4, p.153-56.
Sherman, D. 1996, `Nurses' Willingness to Care for AIDS Patients and Spirituality, Social Support, and Death Anxiety', Journal of Nursing Scholarship, vol.28, no.3, p.205-13.
Steele, A., Melby, V. 1995, `Nurses' Knowledge and Beliefs About AIDS: comparing nurses in hospital, community and hospice settings', Journal of Advanced Nursing, vol.22, p.879-87.
Tessaro, I., Highriter, M. 1994, `HIV and the Work Intentions of Public Health Nurses', Public Health Nursing, vol.11, no.4, p.273-80.
Wallack, J. 1991, `AIDS and the Health Care Professional: evolving attitudes and strategies to effect changeí, Psychiatric Medicine, vol.9, p.483-510.
World Health Organisation, 1993, Proceedings of the ninth international conference on AIDS, Berlin..
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