The AIDS epidemic is having a devastating effect on the health care system and the health care problems associated with this disease have not diminished. It is essential that health care professionals receive assistance in caring for those with AIDS. While issues may change as lay people and health professionals learn to deal with the AIDS epidemic, the intensity of nurses' needs for education in a variety of areas related to HIV will increase as the HTV epidemic continues to expand. Nurses' attitudes toward HIV/AIDS patients will heavily influence their willingness to learn about and provide clinical care for this population.
The purpose of this article is to describe a teaching methodology that creates a learning environment for the promotion of attitudinal and behavioral change related to AIDS. A review of current research will update the reader regarding nursing faculty and student attitudes regarding AIDS, Various educational approaches utilized in AIDS education will be summarized. Inquiry Based Learning will be presented as a proposed teaching methodology to address attitudinal change regarding AIDS and issues related to caring for persons with HIV disease.
Nursing Faculty and Student Attitudes Regarding AIDS
A review of the research literature over the last five years reveals that nurses' knowledge about HTV has increased dramatically (Goldenberg & Laschmger, 1991; Oermann & Gignac, 1991; Ryan, Jones, Irvine & Hodson, 1991). However, attitudes and fears have not changed commensurately with knowledge (Flaskerud, 1991; Mueller, Cerny, Amundson, & Waldron, 1992). Evidence indicates that many nurses, nursing faculty and nursing students hold negative social and moral judgments toward homosexuals and homosexuality, IV drug users, and persons with multiple sexual partners (Brown, Calder, & Rae 1990; Flaskerud, 1991; Martindale & Barnett, 1992; Mueller, Cerny, Amundson, & Waldron, 1992). Consequently, fears and anxieties influence nurses' willingness to care for Persons with AIDS (PWAs) and nurses' application of policies and procedures while providing care (Ryan, Jones, Irvine, & Hodson, 1991), Martindale and Barnett (1992) and Mueller and colleagues (1992) indicate that many nursing faculty and students share negative attitudes toward the care of PWAa. Homophobia, fear of contagion, attitudes toward drug users and behavioral intentions to work with homosexuals, drug users or ADDS patients were all correlated, while knowledge was not significantly correlated with any of the other variables, Jemmott, Jemmott, and Cruz-Collins (1992) found no evidence that AIDS knowledge has an impact on nursing students' attitudes toward homosexuals or intravenous drug users. Other research has documented that nursing education did not change these attitudes, and lectures on AIDS did not change learners' perceptions of risks or beliefs relating to the care of AIDS patients (Imperato, Feldman, Nayeri & De Hovitz, 1988). Attitudes and fears of the nurse toward PWAs constitutes a major barrier to the provision of optimal care. Teaching the facts about AIDS appears not to override these attitudes and fears. Previous AIDS education has been targeted to the cognitive learning domain, however, findings suggest that this education should be directed toward changing attitudes and values by promoting learning in the affective domain (Kemppainen et al., 1992; Martindale & Barnett, 1992).
The most effective educational strategies for influencing attitudes appear to incorporate a strong affective component in which feelings can be expressed openly and in a non-threatening atmosphere. This educational setting might include permission for the expression of negative feelings about what scares or angers the nurses. These negative feelings may be directed toward homosexuals, drug users, sexual practices or hospitals forcing nurses to care for FWAs. In order to provide humane care and advocacy for HIV-infected people, nurses must be able to explore and re-frame negative feelings about homosexuality and substance abuse, as well as fears of infections, if they are to achieve an adequate level of empathy (Rae, Brown & Calder, 1992), A major challenge for nursing faculty is incorporating the affective domain into their educational strategies in order to develop students' attitudes and values supportive of AIDS patients and their families and to create greater student willingness to participate in their care. The key to successful affective education is the instructor's ability to remain nonjudgmental as students express what seem to be insensitive, rigid, or irrational ideas and beliefs about PWAs (Peters & Connell, 1991). Affective competencies relate to the use of moral reasoning and development of a value system that guides decision-making. Assisting students in examining their own attitudes, beliefs and values, as well as in developing a value system supportive of the AIDS patient requires planned educational strategies. Wiley, Heath and Acklia (1988) recommend that faculty incorporate into the nursing curriculum discussions of ethical and moral issues relating to care of HIV-seropositive patients. The exploration of values often means confrontation, and this can become an important strategy for use by the faculty. Challenges to one's beliefe encourage growth. Hypothetical situations and clinical case studies involving value, moral or ethical conflicts related to AIDS patients are useful for teaching and provide strategy for students to examine their own decisions in these situations.
Inquiry Based Learning (IBL)
Inquiry Based Learning is operationally defined by the nursing faculty at the University of Hawaii Department of Nursing as "an orientation toward learning that is flexible and open and draws upon the varied skills and resources of faculty and students." Faculty members are colearners who guide and facilitate the student-driven learning experience to achieve goals of nursing practice. This includes an interdisciplinary approach to learning as well as problem-solving, critical thinking and assumption of responsibility by students for their own learning.
Inquiry Based Learning is a way of learning and a teaching methodology which actively engages students in the modification of attitudes and values. It is grounded in the belief that learning is most effective when students are actively involved and learn within the context that the knowledge is to be used (Boud & Feletti, 1991).
The principles of EBL are a modification of the tenets of Problem Based Learning (PBL); the small group analyses of problem situations as a basis for acquiring relevant knowledge, skills and attitudes. This learning environment is most effective in developing student skills because it allows the student to structure learning in the way it will be used through the creation of opportunities for clinical reasoning and the facilitation of self-directive, self-reflective and self-evaluative abilities (Barrows & Tamblyn, 1980). This method also assists nurse educators to address many of the problems occurring in traditional teaching-learning modes. These difficulties include students' lack of problem-solving capabilities, and an increasing body of knowledge that contributes to an overloaded curriculum and the potential for use of irrelevant subject material (Creedy, Horsfall, & Hand, 1992; Ferrier, 1990). Many schools of nursing, medicine and dentistry have adopted this learning philosophy as their primary teaching methodology (Boud & Feletti, 1991; Branda, 1990; Coles, 1985; Creedy, Horsfall, & Hand, 1992; Walton & Matthews, 1989).
An important question is whether Inquiry Based Learning makes a difference in student and faculty outcomes. According to McMillan and Dwyer (1989), research findings from the School of Nursing and Health Studies at the University of Western Sydney confirmed that change occurred after utilizing Problem Based Learning in the classroom, and that the outcomes were positive. After interviewing 50 of the 128 nursing graduates from the class of 1988, the graduates indicated that, on most occasions, they were automatically using a problem-solving strategy. In addition, the graduates reported they were more self-directed in their approach to patient care, and this methodology was very relevant to their everyday practice. The outcomes for faculty had not been fully evaluated, but the anecdotal evidence indicated satisfaction and personal growth.
According to Tbwnshend (1990), also a faculty member at the University of Western Sydney, the faculty tutor became more person-oriented and autonomous, communicated more honestly and openly, and fostered self-directed responsive students. Ibwnshend also stated that students felt free to experiment and express ideas in a secure environment, found the subject matter had new meaning and usability, and interacted more with the tutor. By the third year, these nursing students functioned with little guidance from their tutor. They were also able to more accurately identify their own learning needs and take responsibility for their actions. This shared responsibility within the group facilitated the shift from passive to active learning (Little & Ryan, 1988).
Integrating the IBL Method
Inquiry Based Learning can be adopted as an innovative and productive teaching methodology for nursing education. Boud & Feletti (1991) realized the most significant factor which facilitated the rapid growth of curriculum change at the MacArthur nursing program was the adoption of PBL as a philosophy and a methodology into the original nursing curriculum. Such curriculum reform is needed in schools of nursing in order to allow students to actively examine their attitudes and values regarding patient situations.
Inquiry Baaed Learning is integrated throughout the nursing curriculum at the University of Hawaii and primarily through the use of tutorials. The faculty/tutor focuses on learning processes which are central in the application of the inquiry-based approach. Tutors are active participants who respond appropriately to the particular dynamics of the group with discussions, exercises, role play and other input. Emphasis is given to student interaction and knowledge, including what is based on life experiences. Using actual or hypothetical case studies, the students build their skills on problem-solving various health situations and verbalizing how they feel about different issues. By doing this, IBL clearly encourages the nursing students to express their attitudes, beliefs and values which will ultimately assist them in implementing optimal care to their clients and patients.
Students at the University of Hawaii School of Nursing have indicated that EBL provided more opportunity for discussion of their attitudes, beliefs and values. Thirtyfive percent of surveyed students stated that EBL provided a non-intimidating atmosphere in which they were more willing to participate. Nursing faculty have stated that a vital segment of the tutorial process is the verbalizing of attitudes by their students regarding various case situations. It is a difficult challenge for the tutor to find ways of encouraging the students to express their feelings. By utilizing the tutorial process and case studies, the faculty has seen a great increase in the students' verbal participation.
Figure. Inquiry Based Learning Model for clinical nursing courses.
Inquiry-Based Learning and AEDS Education
Case studies involving HIV infection are readily incorporated into the IBL curriculum. Clinical examples provide sufficient complexity and solicit strong affective reactions. At the University of Hawaii, the Community Health Nursing faculty developed an HIV-IBL case titled, "Adolescents and Sexually Transmitted Disease". This case describes a 15-year-old female who has been referred to the adolescent clinic at a community health center with a history of alcohol abuse and repeated episodes of chlamydia. She is awaiting pregnancy test results and has been referred for education on STDs, safer sex, and the role of alcohol in decision-making. As the story unfolds throughout the six parts, it is revealed that her boyfriend has just tested positive for antibodies to the Human Immunodeficiency Virus (HIV) and her pregnancy test results are positive. The adolescent expresses concern about her HIV test results and how to inform her parents about this situation.
The IBL Model depicted in the Figure maps out specific segments of the tutorial process with an emphasis on affective analysis that assesses the attitudes, beliefs and values of the students, Students are guided by the tutor to ask themselves questions regarding this and other cases. For example, "How am I responding to this family crisis? What are the values of the family members? Is there more than one way to look at this situation?" Processing, as shown at the end of the model, is also an excellent opportunity for the students to express any feelings they may have regarding this case. Time at the end of the tutorial must be allotted to process group dynamics. Furthermore, the students may identify how this case relates to their personal life. Ultimately, these values and beliefs can affect their nursing education and their patient care.
Processing (as shown in the Figure) should take place at any time during the tutorial when necessary. For example, during the tutorial for this case, one of the students became very agitated. The tutor, at this point, stopped the discussion. The student explained that he felt uncomfortable because the group was discussing the location and services of various planned parenthood resources in the community in the event the teenager decided to terminate her pregnancy. During processing, it became apparent that the student had a conflict between his personal values and professional responsibilities regarding abortion. As the tutorial continued, other students began to express their own values regarding abortion. If time had not been allowed for processing, attitudes and beliefs would have remained buried and may have interfered with the learning process.
The Figure also provides a list of questions to consider when evaluating the TBL process, They include: What did I learn? How well did we learn? How can we make the learning process better? The student evaluations at the University of Hawaii collected at the end of each semester displayed highly positive comments regarding IJBL for this upper level Community Health Nursing Course. The majority of these senior students and faculty were very familiar with the IBL teaching methods, The students wrote that when using IBL, they had a greater opportunity to express their thoughts and attitudes regarding the situations in this HIV case. Time was also allotted for discussion regarding other ethical and moral situations that nurses will encounter in their practice; for example, homosexuality and the risks to the health care worker who cares for the HIV patient. Furthermore, students stated they were able to express their feelings and values better about other paper cases and actual clinical experiences using D3L as opposed to the more traditional methods of teaching.
This article has reviewed the current literature pertaining to nursing faculty and student attitudes regarding AIDS. Inquiry Based Learning has been demonstrated as an excellent teaching methodology to actively engage students in examining their values and attitudes. Integrating DBL and the tutorial process into the nursing education curriculum has produced positive opportunities for discussion of a variety of attitudes. Inquiry Based Learning can be especially useful to address students' attitudes and values regarding AIDS. This innovative methodology has provided an arena in which to examine attitudes about the current AIDS epidemic where quality patient care depends on positive accepting attitudes as well as state of the art knowledge.
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