A great deal of concern has been expressed about attitudes of health care professionals, including nurses, toward patients with HIV. It is generally agreed that providers' attitudes toward the people affected by the disease have an impact on willingness to treat patients, staff morale, and quality of service. Schools that prepare nurses are one focus of intervention efforts to reduce fear and improve attitudes related to HIV. However, there has been little systematic research examining attitudes of faculty and students together, which could identify differences that might affect educational efforts. The present study examines a constellation of student and faculty attitudes related to HIV at a nursing school that includes a certificate program for dental hygiéniste. The relationship of these attitudes to behavioral intentions and the natural change of these attitudes over time is also examined.
Nurses* and Nursing Students' Attitudes Related to HIV/ATOS
AIDS stress, fear of AIDS and anxieties among nurses, nursing students, and other health professionals regarding the care of patients with AIDS has been examined by many authors (Matocha, 1989; Royse & Birge, 1987; Sheard, 1990; Wiley, Heath, & Acklin, 1988). Fear of caring for AIDS patients has also been related to negative feelings about lifestyle issues of homosexuality and drug abuse (Currey, Johnson, & Obden, 1990; Katz et al., 1987; Kelly, St. Lawrence, Hood, Smith, & Cook, 1988). Douglas, Kaiman, and Kaiman (1985) surveyed nurses and physicians and found that both groups fell into the low-grade homophobic range. Thirty-one percent stated that they felt more negative about homosexuals since the emergence of AIDS. Nearly 10% agreed with the statement that homosexuals who contract AIDS are getting what they deserve. In a related study of nurses in a large metropolitan hospital, Reed, Wise, and Mann (1984) found that 22% of the subjects considered homosexuality either a disease or a sin. A survey by Blumenfield, Smith, Milazzo, Seropian, and Wormser (1987) revealed that more than 25% of New York nurses who responded reported fear when caring for homosexual men.
Lester and Beard (1988) studied baccalaureate nursing students to explore their knowledge, fears, beliefe, and attitudes regarding AIDS. They found a significant relationship between high AIDS fear scores and several variables related to homophobia: lack of sympathy for homosexual AIDS patients, uncomfortable feeling while caring for a homosexual patient, and belief that AIDS is God's way of punishing homosexuals.
Other studies have focused on attitudes and beliefe concerning alcoholics and drug addicts, establishing negative attitudes of health care providers toward this patient group. Furthermore, Ficarrotto, Grade, Bliwise, and Irish (1990) found that intolerance to drug use and drug users emerged as a significant predictor of students' resistance to working with AIDS patients.
Meisenhelder and LaCharite (1989) studied patient avoidance and neglect by health care workers. Nurses have also reported transferring units or changing their career to avoid caring for persons with HIV. Blumenfield et al. (1987) found that more than 50% of 340 New York nurses indicated that if they had to care for AIDS patients routinely, they would request a transfer to another unit. Fear of contagion has led to nurses' use of excessive and unnecessary protective gowns, gloves, and masks. Numerous research studies have described the unwillingness of nurses to care for patients with HIV (Armstrong-Esther & Hewitt, 1989; Barrick, 1988; Young, Koch, & Preston, 1989).
Student nurses have been surveyed regarding their behavioral intentions to care for AIDS patients. Ficarrotto et al. (1990) surveyed incoming medical and nursing students to determine knowledge of HTV and resistance to working with AIDS patients. Lack of clinical experience and homophobia associated with a lack of knowledge were predictive of resistance to work with AIDS patients as was intolerance of drug use and users. Lester and Beard (1988) concluded that 49% of the 177 baccalaureate students questioned preferred not to care for persons infected with HIV. Matocha (1989) supports this study by describing student nurses who have challenged their clinical faculty when assigned to care for an AIDS patient. In addition, families of students have voiced their concern about the exposure of HIV to students.
Dental Hygiene Students' Attitudes
A number of studies have reported dentists' and dental students' negative attitudes and reservations about treating AIDS patients (Bernstein, Ralskin, & Wolland, 1990; Cohen and Grace, 1989; Currey et al., 1990). The few studies that include dental hygiéniste indicate these professionals also hold negative attitudes toward HIV patients (Gerbert, Badner, & Maguire, 1988; Sato, Levy, Allard, & Pieries, 1989; Wright, Fitzgerald, Risi, & Marier, 1989). However, there are virtually no comparative data on dental hygiéniste' or dental hygiene students' attitudes concerning homosexuality or intravenous drug use.
Nursing Faculty Attitudes
Little research has been done on the attitudes of nursing faculty as a group related to HIV. If intervention during nursing training is to occur, it is important to understand how nursing faculty feel about HIV-related issues. Prior to this study, there have been no published data comparing nursing faculty and students that might help guide faculty in developing educational interventions at the clinical or curriculum level.
Change in Attitudes Over Time
Another issue related to curriculum planning concerns what types of educational or experiential interventions impact on attitudes concerning HIV and willingness to provide care for those affected by HIV. The existing literature has focused on discrete educational offerings and workshops (Armstrong-Esther & Hewitt, 1990; Haughey, Scherer, & Wu, 1989; Matocha, 1990; Young et al. 1989) and has found a positive impact on the anxiety, stress, and fear associated with providing care for patients with HIV (All, 1989; Armstrong-Esther and Hewitt; Baer and Longo, 1989; Boland, 1990). However, little attention has been paid to assessing the impact of HIV education that is infused into the nursing curriculum. Indeed, faculty at many programs may be reluctant to dedicate specific curriculum designed to make a direct impact on attitudes related to HIV because of the difficulty in making major curricular change. Rather, many programs might infuse HIV education into existing curriculum, often with a heavy emphasis on the medical aspects of the problem and with less emphasis on the personal experiences of the professional. Whether these less-focused educational and experiential interventions lead to changes in attitudes and willingness to treat HIV patients remains unknown.
The present study examines relevant attitudes and behavioral intentions concerning the treatment of HIV patients. It allows for a direct comparison of nursing faculty and their students and a group of dental hygiene students. In addition, a one-year follow-up of a sample of the nursing students is reported that examines change in attitudes and behavioral intentions after exposure to HIV education within a standard nursing curriculum.
Of the 222 participants who completed the questionnaire, 110 were undergraduate nursing students, 51 were dental hygiene students, 36 were graduate nursing students, and 25 were nursing faculty. All were members of a large state university's school of nursing program.
Follow-up data were collected one year later, when the first-year undergraduate students had completed their initial year of training (N= 57).
The 66-item questionnaire consisted of nine subscale s . Each subscale consisted of items derived from published scales or items created specifically for the use of this study. The Heterosexual Attitudes Toward Homosexuality subscale consisted of 1 1 items taken from the scale of the same name by Larsen, Reed, and Hoffman (1980) (e.g., Homosexuals should be free to date whomever they want). The Homophobia subscale consisted of five items derived from the Homophobia scale developed by O'Donnell, O'Donnell, Pleck, Snarey, and Rose (1987) (e.g., If a child of mine showed homosexual tendencies, I would want him to get psychiatric treatment).*
The AIDS-Phobia subscale consisted of 15 items (e.g., People with AIDS should not be allowed to work in public schools) and the AIDS-Stress subscale consisting of nine items (e.g., I am uncomfortable with AIDS patients) and were taken from scales developed by O'Donnell et al. (1987). The Marlow-Crowne Social Desirability subscale consisted of eight items taken from the scale of the same name (Crowne & Marlow, 1964) (e.g., I sometimes try to get even rather than try to forgive and forget [reverse scored]). The three behavioral intentions subscales, Behavioral Intentions to Work with Persons with AIDS (eight items, e.g., I plan to actively screen out AIDS patients from my professional work), Behavioral Intentions to Work with Homosexual Patients (four items, e.g., I plan to refer any homosexual patients to a homosexual professional, rather than treat them myself), and the Behavioral Intentions to Work with Intravenous Drug Users (four items, e.g., I will try to avoid treating TV drug users in my professional work); and the Attitudes Toward Intravenous Drug Users (two items, e.g., IV drug users that have AIDS should be given low priority for treatment) were each designed by our research team.
At the beginning of the academic year, all nursing faculty and students were asked to complete the questionnaire. All participants were asked to read and sign an informed consent form which was then separated from the remaining questionnaire. Code numbers were attached to both the informed consent form and the questionnaire, so that any follow-up data could be directly compared.
Approximately one year later, again at the beginning of the academic year, the informed consent form and the questionnaire were completed by the now second-year undergraduate students. On this second administration, students were asked to indicate the number (if any) of their friends who had contracted HTV and the number of patients with HTV that they had treated.
The AIDS-related curriculum for these first-year undergraduate students covered mode of transmission, causative organisms, immunology, diagnosis, nursing care, high risk groups, universal precautions, epidemiology, prevention, and nutrition. For one half of these students (assigned to the mental health rotation), the curriculum also included brief exposure to psychosocial needs of HTV and ADDS clients, family coping and grief response, and student attitudes, values, and fears.t
Correlations among scales
Table 1 presents the correlations among the nine subscales based on the initial aóbninistration. In general, the two measures of attitudes toward homosexuality correlated relatively highly with each other ( - .76), as did the three behavioral intentions measures (.67 to .73). The Attitudes Toward Intravenous Drug Users scale was moderately correlated to the attitude and behavioral intention scales (.25 to .46). Aids-stress and AIDS-phobia were highly correlated to each other (.62), with AIDSphobia also highly correlated with behavioral intentions to work with AIDS and homosexual patients (.64 and .63, respectively). The generally low or absent correlations of all substantive scales with the measure of social desirability (.02 to .23) suggest that these measures are relatively independent of a desire to answer in socially desirable ways.
Comparisons across groups
A multivariate analysis of variance was conducted across all nine scale scores. This overall analysis indicated a significant difference between the four academic status groups, Hotellings T2 = 2.99, F(27,608) = 2.25, p<.001. A series of one-way analyses of variance were then conducted comparing scale scores across the four initial respondent groups (dental hygiene students, undergraduate nursing students, graduate nursing students, and nursing faculty). The mean scores and statistical results for each of these scales are depicted in Table 2.
These univariate analyses of variance indicated significant group differences on seven of the nine scales: Heterosexual Attitudes Toward Homosexuality, F(3,212) = 5.58, p<.001; Homophobia, F(3,212) = 6.47, p<.001; Attitudes Toward Intravenous Drug Users, F(3,212) = 7.77, p<.001; AIDS-Related Work Stress, F(3,212) = 5.74, p<.001; AIDS-Phobia, F(3,212) = 8.15, p<.001; Behavioral Intentions to Work with AIDS Patients, F(3,212) = 3.63, p<.02; and Behavioral Intentions to Work with Homosexual Patients, F(3,212) = 4.60,p<.01. There were no significant differences between academic groups on the Social Desirability scale, F(3,212)=1.62, ? = .19, or on the Behavioral Intentions to Work with Intravenous Drug Users, F(3,212) = 1.20, ? = .31.
Correlations Among Scales
Specific group differences were tested using Tukey's HSD analysis. As can be seen in Table 2, the nursing faculty held significantly different views from the dental hygiene students on all seven scales that produced overall effects. However, on only one of these scales (Homophobia) did the faculty and the graduate students' responses significantly differ, although the nonsignificant differences were often in the direction of more positive faculty views. The views of the undergraduate nursing students and faculty significantly differed on six of the seven scales (all but behavioral intentions concerning AIDS patients). Nevertheless, the undergraduate students held significantly more positive attitudes than the dental hygiene students on three scales: Heterosexual Attitudes Toward Homosexuality, Attitudes Toward Intravenous Drug Users, and AIDS-Related Work Stress.
One- Year Follow-Up Data
A multivariate analysis of variance was conducted on the difference scores (pre/post) across the nine scales combined. This overall analysis failed to indicate a significantly reliable difference related to time of testing, Hotelling's T2 = .36, F(9,44) = 1.78, ? = .10. Because of this lack of reliable difference, any subsequent tests must be interpreted with the greatest of caution. However, due to the surprising nature of this result, a series of correlated t tests were conducted to assess change over the year between initial testing and the follow-up on each of the nine scales separately. As can be seen in Table 3, only one significant change occurred, indicating a reduction in AIDS-related work stress over the course of the year, i(56) = 3.23,p<.01.
The present study examined attitudes of nursing and dental hygiene students and nursing faculty about HIV, the relationship of these attitudes to behavioral intentions, and the natural change of attitudes and behavioral intentions among nursing undergraduates over time.
In general, high correlations were found within the two measures of attitudes toward homosexuality and within the three behavioral intentions measures. Attitudes toward intravenous drug users were moderately correlated with attitude and behavioral intentions scales. AIDSstress and AIDS-phobia were highly correlated and AIDS-phobia was highly correlated with behavioral intentions.
Comparing across groups, nursing faculty and nursing graduate students were found to hold the most positive attitudes and behavioral intentions. Dental hygiene students reported the least positive attitudes and behavioral intentions. In the one-year follow-up of the undergraduate nursing students, only one significant change occurred, indicating a reduction in AIDfe-related work stress.
Mean Score for Each Scale as a Function of Academic Status
Mean Score for Each Scale at Initial Testing and One Year Later
The present results are important in a number of ways. First, they clearly indicate significant and reliable differences between nursing faculty and their undergraduate students on attitudes and behavioral intentions about HTV. Given the lack of differences on our measure of social desirability and the generally low correlations between our substantive scales and the social desirability measure, these differences on attitudes and behavioral intentions are not likely due to a positive response bias.
These faculty-student differences should alert nursing educators and trainers that students, especially undergraduate nursing students and dental hygiene students, may hold significantly less positive and more negative attitudes and may be significantly less willing to treat HIV-positive patients than their faculty. If ignored or unrecognized, such differences can lead to inefficient educational efforts, misunderstanding between faculty and students, and a lack of appropriately focused educational interventions. For example, were faculty to assume their students hold highly similar attitudes about HTV, they might feel attitudinal and values clarification exercises are not needed in the curriculum. In fact, many of the faculty in the school studied were resistant to HIV training on the basis that such efforts were unnecessary.
A second implication of these results is that without specifically targeted educational/training interventions, many attitudes remain unchanged. If these attitudes affect a nurse's willingness to treat a patient, or in any way compromise the quality of care provided, then leaving negative attitudes unaddressed is problematic. That these attitudes and behavioral intentions did not change over the course of the first year of nursing education was quite surprising. The curriculum contained significant instruction about AIDS and HIV and these topics were infused throughout the curriculum. However, this particular curriculum did not dedicate a significant educational effort at exploring feelings, attitudes, beliefs, or behavioral intentions about HTV-related topics. Such value clarifications, addressing of fears, and frank but supportive discussions of these topics might facilitate change. However, a curriculum that covers HTV and AIDS but does not directly address these concerns is likely to have little influence on changing attitudes and willingness to treat.
The third implication relates to the impact of personal and/or professional exposure to people with HIV. Considerable discussion in the health provider education literature suggests that personal experience with someone infected with HIV will have a salutary effect on a provider's attitudes and behaviors. Unfortunately, this does not always seem to be the case. At follow-up, we asked our students to indicate the number of HTV patients and the number of friends with HIV that they had encountered. We then compared these responses to initial attitudes and behavioral intentions, follow-up attitudes and behavioral intentions, and change in attitudes and behavioral intentions over the course of the year. No meaningful correlations or relationships resulted. Exposure per se did not influence attitudes or behavioral intentions. We did not assess whether these experiences were adequately discussed and processed, nor do we know much about the nature of these experiences. We do know, however, that while exposure may be necessary for attitude and behavioral change, it is in no way sufficient.
A fourth implication relates to the low scores of the dental hygiene students. Studies of other dental health professionals and students have indicated generally negative and fearful attitudes about HIV (Filler, 1988). Our data suggest that negative attitudes toward patients with HIV are related to general attitudes about homosexuality and drug use, as well as about AIDS and HTV. Specifically, these results suggest that some of the apparent resistance to treating patients with HIV by some dental hygiéniste may relate to pre-existing attitudes about homosexuality, intravenous drug use, and HTV.
Derived from this study, we recommend continued assessment by nursing educators of the attitudes and behavioral intentions of faculty and students concerning HIV. This assessment should include attitudes about homosexuals and intravenous drug users, fear of contagion, and behavioral intentions to work with a range of HIV-infected patients.
In addition, other variables not included in the present study must also be considered. These additional variables include feelings of helplessness and powerlessness with being unable to cure the illness, difficulties in coping with death and dying of a generally younger population, and guilt over negative views about caring for patients with "setf-inflicted" diseases. Finally, assessment should also include examining beliefs and attitudes about the social, political, and cultural aspects of HIV. Such an assessment might identify dissonance in students or faculty which can then be addressed.
Curriculum planning and educational efforts should emanate from this assessment. If faculty and students have similar positive empathie attitudes and share a genuine and deep commitment to quality care for those affected by HTV, then a curriculum that addresses knowledge and skills concerning the care of HIV patients might be adequate. If faculty and students share common but negative attitudes and behavioral intentions, then faculty and staff development activities would be indicated as a possible first course of action. If students have more positive attitudes than faculty, a strong argument for faculty development activities can be made.
If, as in this study, faculty hold significantly more positive views than the students, a different approach is indicated. Curriculum designed with more direct interventions related to clarification of values and beliefs, attitudinal change, and ethical considerations might be implemented. Faculty would be encouraged to develop specific focused educational interventions that examine attitudes and barriers to effective care. In addition, faculty would be encouraged to act as models, not only relating to professional behaviors, but by demonstrating professional attitudes and values. Based on the present results, such educational efforts may well be directed at undergraduate students and might productively enlist the aid of the graduate student body.
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Correlations Among Scales
Mean Score for Each Scale as a Function of Academic Status
Mean Score for Each Scale at Initial Testing and One Year Later