Nurse educators are faced with the dilemma of whether they should assign students to care for patients with AIDS. Some nurse educators maintain that graduating students should be able to provide care to any person if they have been presented with a body of knowledge that undergirds the principles of care without regard to the diagnosis. But knowledge alone may not be sufficient in the case of AIDS.
In this descriptive examination of student nurses' knowledge, attitudes, fears, and phobias about persons with AIDS, 39 freshmen nursing students (FS) and 105 senior nursing students (SS) voluntarily participated in a study to ascertain if the educative program was moving them toward the more humane treatment and care of these patients. Knowledge of AIDS scores, fear of AIDS scores, and homophobia scores were more positive for SS subjects than for FS subjects, which indicates that the present educational system had a positive impact on those who have been in the system the longest. Knowledge, coupled with personal contact with an AIDS patient, seems to be the most appropriate approach to the dilemma for educators and students.
June 1991 marked the 10th anniversary of the emergence of AIDS in this country. During those 10 years, 179,136 individuals were diagnosed with AIDS (Centers for Disease Control [CDC], 1991). More than half of those diagnosed have died and the remainder race the stark reality of death within the next few years (Breo, 1991). Even more terrifying is a prediction that during the 1990s a 10-fold increase will occur in the number of adults and children who develop AIDS worldwide (Mann, 1992).
Nurses, along with other health care providers, are expected to provide humane and accountable care of those with highly communicable diseases such as AIDS (Presidential Commission, 1989). The issue of how to prepare practicing nurses as well as future nurse practitioners is a prominent subject of debate in most nursing educational programs in the country. There is increasing speculation that knowledge of use of universal precautions is not sufficient preparation for equipping health care providers. Fears, attitudes, and beliefs about AIDS and those who carry the disease must be considered in conjunction with knowledge about how to protect oneself from contamination when caring for individuals with the disease.
Faculty in schools of nursing are groping with how and what to teach novice nursing students regarding the etiology of the disease and the care and treatment of individuals with AIDS. One nurse educator proposed that institutions of higher education must move aggressively to counter the prevailing misinformation about the means of transmitting AIDS so that the serious nature of the AIDS epidemic can be acknowledged (Copp, 1987). Are these processes occurring in nursing education programs?
Is Knowledge Enough?
Generally, it is assumed that knowledge is expected to modify behavior in a predictable direction. During the process of accumulating nursing knowledge through socialization into the profession, there is an expectation of change in feelings, attitudes, and behavior so that the health care needs of society can be met. Bennett (1987) asserted, however, that the presentation of facts must be supplemented with personal beliefs and individual perceptions and feelings when dealing with individuals that are somewhat different.
Young (1988) maintained that sex education cannot be taught to health care workers without considering the emotional impact that the educational content might have on the learner. Van Survellan, Lewis, and Leake (1988) corroborated Young's thesis in their observance of practicing nurses. They found that the emotional impact of caring for an individual with a differing sexual orientation modifies willingness to assume responsibility for that care. Steele (1986), a renowned nurse ethicist, maintained that nurses first must be willing to clarify their own values and then to change their value orientation if new knowledge calls for such change. Likewise, O'Donnell, O'Donnell, Peck, Rose, and Snarey (1987) recognized that coping with uncertainly is as fundamental to the learning process as facts and information.
Studies of Knowledge, Attitudes, and Beliefs Concerning AIDS
Studies regarding attitudes, knowledge, and beliefs about AIDS have been conducted with medical students, medical doctors, physician assistants, various segments of the general public, and practicing nurses (Bennett, 1987; Currey, 1991; DiClemente, 1986; Jowell & Airey, 1984; Rosse, 1985; Steele, 1986). Reports of findings from these studies acknowledge the wide discrepancies between knowledge of AIDS and attitudes toward those who have been diagnosed as having the disease, particularly homosexual males. More specifically, Goodwin and Roscoe (1988), in a study of 495 midwestern college students, found that knowledge level about AIDS was moderate, but fears and nonaccepting attitudes toward homosexuals were high.
Kelley, St. Lawrence, Hood, Smith, and Cook (1988) found that the attitudinal responses of a sample of 166 practicing nurses were more highly stigmatized and prejudicial towards AIDS patients than toward patients with leukemia. Wiley, Heath, and Acklin (1988) reported that a high proportion of student nurses felt that they should be allowed to refuse care for AIDS patients. Brennan (1988) found that practicing nurses were concerned about their family's welfare as well as their own when they were assigned to care for individuals with AIDS. Almost one half of the respondents in the study indicated that nurses should have the right to refuse to care for persons with AIDS. In summary, health care providers need to know the etiology of the disease, the means by which it is transmitted, and how to apply universally accepted precautions to protect themselves when caring for individuals with AIDS. Fears, phobias, prejudices, stereotypes, and other negative attitudes are often barriers to the application of accumulated knowledge when care expectations are for persons with AIDS.
A pragmatic issue addressed in this study was whether the educational processes in one nursing educational program have assisted in alleviating fears and misconceptions about the disease of AIDS and the care of those who have the disease. The general purpose of the study was to assess undergraduate nursing students' knowledge levels of the disease and their attitudes toward those who have been diagnosed with the disease. The specific purpose was to compare AIDS knowledge level and attitudes toward persons with AIDS of nursing students just entering the educational program with nursing students who would soon complete the educational program. The sample comprised 39 FS and 105 SS; participation was voluntary.
Variables in the study included knowledge regarding the characteristics of the disease, the transmission and symptoms associated with it, and attitudes and beliefs about the disease and those afflicted with it. Demographic characteristics of the respondents also were examined.
The knowledge scale developed by Goodwin and Roscoe (1988) consisted of 32 dichotomous "true" or "false" questions about the characteristics and transmission of AIDS. The scale did not have a reported level of reliability or validity.
The Fear of AIDS scale developed by Bouton et al. (1987) consisted of 14 items that were arranged in Likert-type, forcedchoice format with response potentials ranging from strongly agree to strongly disagree on a four-point scale. The Homophobia scale, also developed by Bouton et al., consisted of seven items that were formatted in the same manner as was the Fear of AIDS scale. Reliability and validity values for both of these scales were reported to be high (Bouton et al.). In addition to demographic information solicited, questions were posed to the respondents regarding previous contact with persons with the disease, perceived right to refuse to care for such individuals, and concerns by family and others regarding exposure to persons with the disease.
There were four main findings of this study. First, while a higher number of SS had higher AIDS knowledge scores than did the FS, the majority of both groups' scores were at a "medium level" of correct knowledge. Items on the knowledge scale that evoked high levels of incorrect responses by both groups had to do with prevalence rates, means of transmission of the disease, individuals at high risk for contracting the disease, and early symptoms of the disease.
Second, while the SS had statistically lower fear-of-AIDS scores (p = .004) and homophobia scores (p = .001) than did the FS, a statistically significant number of respondents from both groups scored high on both the subscales (p = .02). Higher scores were obtained for both groups regarding items that presented homosexuals in a negative stereotypical fashion (e.g., disgusting, corrupting, illegal, unable to contribute to society, and should not have equal civil rights).
Third, a majority of both groups indicated that a significant other had expressed concern over their choice of nursing because of the AIDS epidemic (FS, n =27, 69.2%; SS, n = 85, 81%). From both groups of respondents, only one senior student indicated that she would "always* refuse to care for a person with AIDS. Most respondents from both groups indicated that they would rarely or never refuse to provide such care.
On the other hand, 72% (n = 28) of the FS subjects and 74% (ra = 77) of the SS indicated that nurses should have the right to refuse to care for someone with AIDS. An even larger proportion of both groups of respondents indicated that student nurses should have the right to refuse to care for someone with AIDS (FS, n =32, 80%; SS, n = 80, 78%). A majority of both groups of respondents had not known any individuals with AIDS personally as friends or relatives.
The fourth and prime finding of the study was that the greater the number of persons that SS respondents had known personally as friends or relatives with AIDS, the less their fear of AIDS (r=.22, p = .02) and the less their homophobia scores (r = .21, p = .03)). Contact seems to be a crucial variable in lessening fear of AIDS and in decreasing homophobia.
These findings indicate that the disease of AIDS cannot be easily separated from the concept of homophobia even though the incidence and prevalence rates of the disease have increased for heterosexual populations, particularly among drug users and babies from all that have been infected. Hands-on experience of caring for those with AIDS is a critical knowledgebuilding supplement to classroom learning and may decrease negative attitudes and deep-seated phobias and stereotypes. The acquisition of knowledge without a concomitant recognition, examination, and clarification of beliefs, attitudes, and values will fall short of what both teachers and students profess - the humane health care of all members of society.
Steele ( 1986) maintains that nurse educators must recognize the effect that each student's value system may have on the process of providing appropriate care to all societal members. Nurse educators must meet the challenge to equip appropriately this future generation of professionals so that they can assume this responsibility in full measure.
This study had limited generalizability as the subjects were volunteers from only one university. Additionally, it is possible that the two groups studied were inherently different. The study would have had greater power if the design was longitudinal rather than cross-sectional. Another limitation of the study was the threat to internal validity, including the history threat. Events external to the educational process could have affected the dependent variables.
The study findings are quite important to nursing educators and their students, but further examination is warranted in other settings and with a longitudinal design. Future nursing research must be aimed toward developing a more definitive relationship between nurses' knowledge, attitudes, and beliefs, and their capacity to provide compassionate care for those with any disease, including AIDS.
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