Over the last 10 years, the Acquired Immune Deficiency Syndrome (AIDS) has become one of our nation's major health problems. The nature of HIV infection and the trajectory of AIDS have ramifications for nursing education, the Centers for Disease Control make recommendations to prevent the transmission of HIV in health care settings (Centere for Disease Control, 1987, 1989, 1990). These recommendations have not alleviated the intense fears of student nurses Relating to caring for patients with AIDS. Studies show that nearly half of students do not want to care for these patients Lester & Beard, 1988; Wiley, Heath, & Macklin, 1988). Considering that these student nurses will be the future health care practitioners at a time when AIDS will be more prevalent, it is imperative that nurse educators assess the fears and take measure to alleviate them. Toward this and, the purpose of this article is to decribe the measures that one School of implemented to assist students to face the challenges of providing care for patients with AIDS.
Review of Literature
The National League for Nursing (1988) puhlished guidelines in 1988 regarding AIDS for schools of nursing. These guidelines are organized into three categories: 1) institutional policies for students and employees who have HD7 infection; (2) clinical experiences for faculty and students; and (3) prevention of HIV transmisdon. Ine guidelines are significant because they address not only epidemiologic findings, but also the fears and controversy that surround the care of people who have AIDS. The expectation that professional nurses will provide care to people who have AIDS is explicit. Nursing educators are responsible for preparing students to provide competent and compassionate care to people who have AIDS. The NLN suggests that career counseling may be in order if a student refuses to provide such care.
Nursing educators began to investigate the knowledge and attitudes of student nurses relating to HIV infection and AIDS in the mid-1980s. Wiley, Heath, and Acklin (1988) used a 66-item AIDS questionnaire to examine students' perceptions of their risk of HIV exposure in clinical practice and their attitudes toward caring for patients who are HIV positive. Undergraduate junior and senior students, RN/ BSN completion students, and MSN students were included in the study. There were no significant differences in the amount of worry by type of student concerning exposure to HIV infection in clinical practice. Almost half (45%) of the generic students, 40% of RN/BSN completion students, and 21% of MSN students stated they would probably or definitely refuse to care for ADDS patients. Over half (54%) of the total sample indicated nurses should be allowed to refuse to care for people who have ADOS. The investigators recommended that nursing faculty address the ethical issues surrounding care of HIV-infected patients as well as the protective measures to prevent HIV transmission.
Lester and Beard (1988) investigated the knowledge, fears, and attitudes of baccalaureate nursing students in relation to AIDS. One third (36%) of the students believed nursing students should not provide care for patients who had AIDS and one half (49%) preferred not to care for these patients. In contrast, nearly all (97%) students indicated that people who have AIDS have a right to care. The majority (70%) of students obtained their AIDS information from the media. The authors recommended that nursing faculty provide accurate AIDS information and encourage students to explore their fears relating to AIDS.
Brown, Calder, and Rae (1990) studied the effects of increased knowledge on baccalaureate nursing students' attitudes toward people who have AIDS. Firstthrough fourth-year nursing students attended a one-day AIDS workshop. Preand post-questionnaires were administered to determine the students' knowledge and attitudes relating to: (1) AIDS, (2) caring for people who have AIDS, (3) homosexuality, and (4) caring for people who are terminally ill. Findings showed that the workshop increased students' knowledge and promoted positive student attitudes. The investigators concluded that education can help nursing students develop more positive attitudes toward caring for people who have AIDS. Nursing educators are advised to incorporate AIDS content in the first through the fourth years of the baccalaureate curriculum.
Chitty (1989) surveyed a national sample (N = 366) of NLN-accredited associate degree, diploma, and baccalaureate nursing schools to determine the amount and type of AIDS content included in their curricula. The questionnaire developed for the study identified 12 AIDS content areas that included, but were not limited to: (1) incidence, etiology, and epidemiology; (2) CDC guidelines; (3) financing HIV-related health care; and (4) funding sources for AIDS research (p. 153). Schools reported: (1) various types of didactic AIDS content; (2) number of didactic, observation, and direct care hours related to AIDS; and (3) policies relating to students caring for people who have AIDS.
Findings showed that nearly all (98%) of the schools included some AIDS content. Most teaching related to AIDS was didactic with a range of 1 to 20 hours. Three fourths (72%) of the schools reported 1 to 5 didactic hours. No statistical differences occurred in time allotted to AIDS content in associate degree, diploma, and baccalaureate nursing programs. The 12 AIDS content areas were not covered by all schools. For example, nearly all (98%) schools reported teaching the incidence, etiology, and epidemiology of AIDS, but less than half (40%) included content on local, state, and national resources. Policies relating to students providing care to people who have AIDS were reported by less than 9% of schools. Chitty (1989) concluded that observation of role models and the direct care of people who have AIDS should be included in nursing curricula. Nursing educators influence the quality of nursing care people with AIDS will receive in the future.
AIDS Task Force
Kent State University School of Nursing, main campus, offers baccalaureate and master's programs in nursing. The baccalaureate program is the largest nursing program in Ohio. The graduate program ranks third in size in the state.
In the 1987-1988 academic year, the School of Nursing AIDS Task Force was formed to help faculty respond to the challenges of HIV infection and AIDS. Faculty volunteered for membership on the task force. Collectively, task force members represented expertise in providing comprehensive nursing care across the life span in ambulatory clinics, homes, and inpatient facilities.
A faculty survey was conducted to determine: (1) clinical agency policies regarding AIDS, (2) availability of supplies for universal precautions, (3) AIDS content included in the curriculum, and (4) faculty concerns/suggestions regarding the challenge of AIDS. At the same time, an AIDS reference book was developed that included CDC recommendations, clinical agency policies, journal articles, educational media, and community resources. The NLN AIDS Guidelines for Schools of Nursing, published in 1988, were distributed to faculty. The task force sponsored a continuing education program on HIV and hepatitis B for faculty and eUcited consultation from a nurse infection control practitioner.
Faculty ADDS Curriculum Survey
In 1990, the task force developed a faculty curriculum survey using the 12 content areas Chitty ( 1989) identified. Faculty reported the amount of time and type of learning experience provided for each content area. According to the survey, a total of 13.9 hours (lecture = 7.5 hours, seminar = 2.0 hours, and clinical =4.4 hours) of the undergraduate curriculum contained AIDS content. All 13 content areas were covered, but to varying degrees. For example, more time was allotted to the incidence, etiology, and epidemiology of AIDS than to local, state, and national resources. Some faculty found it difficult to report the specific amount of time spent on each content area because the areas were interrelated. The graduate faculty reported 5.25 hours of AIDS content. The survey also asked questions regarding beliefs about assigning students to patients who had AIDS and other issues related to ATDS that are relevant to educators. The faculty agreed that student clinical assignments follow the same guidelines regardless of the patient's diagnosis and be based on the student's preparation and ability to provide care. Several faculty reported that there were no patients with AIDS in the clinical sites used for student placements.
Undergraduate Student ADDS Curriculum Survey
In the next phase of curriculum evaluation, the task force focused on the generic undergraduate student population RN completion students were omitted because of the diversity of their education and practice experiences. Task force members decided that student perceptions from all four levels of the undergraduate program, freshman through senior year, should be examined.
The task force developed the Undergraduate Student AIDS Curriculum Survey to elicit students' perceptions. The 12 content areas used in the faculty survey were included in the student survey. A 13th content area, Safe Sex, was added since task force members agreed that the curriculum should also address the personal lifestyle behaviors of student nurses relating to AIDS. Three additional items were added. Two items addressed student attitudes toward professional nurses and student nurses providing care for people who are HIV positive or who have ADDS. The third item asked the number of contaminated needlestick injuries the student had incurred in student clinical assignments.
A four-point Likert Scale ranging from "strongly agree" to "strongly disagree" was used to determine the extent students agreed that the 13 content areas were included in the curriculum, as well as the extent students agreed professional nurses and student nurses should care for people who are HIV positive or have AIDS. The range for needlestick injuries was 0, 1, 2, 3, and 4 or more. A nursing educator, who developed an AIDS questionnaire that wat being used to measure registered nurses' perceptions of their risk in relation tc AIDS in the emergency room setting, reviewed the survey.
Students who participated in the survey! included freshmen (n=64; 67%), sophomores (n = 124; 65%), juniors (n = 100; 73%) and seniors (n = 124; 82%), for a total of 432 students (75%). Student responses were anonymous, i.e., students were in-! structed to omit their names and social security numbers. Identification by level in the program (freshman, sophomore, junior, or senior) was requested. The survey was administered during regularly scheduled class time by a member of the AIDS Task Force who explained the purpose of the student survey. We did not conduct a follow-up of students who were absent from class on the day that the survey was administered. However, students who responded to the survey were demographically similar to the total student body, indicating that students who completed the survey were similar demographically to those who did not complete the survey.
Data from the four-point Likert Scale were reduced to "agree" and "disagree* categories. Collecting data from each level of the program allowed for comparison among all levels and between select levels. We were particularly interested in the comparison between sophomore and senior level students regarding the extent to which they believe specific AIDS content areas are included in the school curriculum. Those content areas that the greatest percentage of students saw as included in the curriculum were as follows: safe sex, CDC guidelines, and incidence, etiology, and epidemiology of AIDS. Financing HIVrelated health care and funding sources for AIDS research were the two content areas that the fewest percentage of students considered included in the curriculum. In all content areas except three, a greater percentage of seniors compared to sophomores believed the specific content was included in the curriculum. This finding means that as students progress through the program, they are more likely to agree that the various types of AIDS content are included in the curriculum.
Students were asked the extent to which they agreed that professional nurses or student nurses should care for patients who have AIDS. Two findings were apparent. First, in general, as students progress through the program, they are more willing to care for patients who have AIDS: freshmen (71%); sophomores (78%); juniors (89%); and seniors (91%). Second, students believe that professional nurses have a greater responsibility to provide nursing care for patients who have AIDS than do student nurses.
In the U.S., case histories of the majorty (84%) of the 31 HIV-infected health care workers with no reported nonoccupational risk factors and documented HTV seroconversion, cited percutaneous injury e.g., a needlestick or cut with a sharp object) as type of exposure (Centers for disease Control, 1992; Chamberland, Convey, Bush, Ceisielski, Hammett, & Jaffe, 1991). The modes of transmission of HD7 are similar to those of hepatitis B virus (HBV), but the potential for virus transmission is greater for HBV than HIV. Levels of HBV concentration are higher in people infected with HBV than the levels of HIV concentration in people infected with HIV. The risk for HBV transmission approximately 30%) following a percutaneous exposure to HBV-infected blood is greater than the risk for HD7 transmission 0.3%) following a percutaneous exposure to HIV-infected blood (Centers for Disease Control, 1991). Adherence to universal precautions minimizes the risk of HBV HIV transmission in health care settings. Although needlestick injury is only one of the types of exposure to these bloodborne pathogens, task force members considered that collection of data regarding student needlestick injuries was a useful starting point for a more thorough examination of events surrounding these injuries. Additionally, these data were considered to support the importance of students receiving hepatitis B vaccine prior to their potential exposure to blood and other potentially infectious material in clinical practice (Centers for Disease Control, 1990; Occupational Safety and health Administration, 1991).
Prior to the survey, faculty's knowledge regarding dstudent-contaminated needlesitick injuries was confined to their individual courses. Survey results helped faculty examine the magnitude of the problem for the overall program. Three junior nursing students (n= 100) and seven senior nursing students (n = 124) reported one contaminated needlestick injury during a student clinical practicum. Two senior nursing students (n = 124) reported two contaminated needlestick injuries.
Discussion and Implications
The AIDS Task Force reported findings from the Faculty and Undergraduate Student AIDS Curriculum Surveys to faculty. The faculty found the results of the Student Survey to be particularly helpful because it gave feedback regarding those content areas, which were successfully disseminated to students through the curriculum. Faculty were encouraged by the increase in students' willingness to care for patients with AIDS as the students progressed through the program.
We also found it useful to present specific recommendations to the faculty and to the Baccalaureate Curriculum Steering Committee. These recommendations were: (1) strengthen the content areas of AIDS clinical symptoms and HIV testing; (2) evaluate the need to strengthen content areas for which less than 59% of seniors considered to be included in the curriculum; (3) administer the student AIDS Curriculum Survey on an annual basis; and (4) develop a protocol of procedural guidelines for faculty to use when a student has a significant exposure to blood and other potentially infectious material in the clinical practicum.
The Kent State University School of Nursing faculty believe that the annual administration of the Student Curriculum AIDS Survey is crucial to their responsibility for preparing student nurses to function as professional nurses who are equipped to meet the challenges of AIDS. The goal of this education is the provision of competent and compassionate professional nursing care to people who are HIV infected or who have AIDS.
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