Nurse Education Today
Volume 32, Issue 1 , Pages 15-20, January 2012

Undergraduate nursing student's attitudes towards caring for people with HIV/AIDS

Accepted 17 January 2011. published online 21 February 2011.

Article Outline

Summary 

The aim of this quantitative study was to determine the attitudes of Australian nursing students towards caring for people with HIV/AIDS. This research study was conducted among second year undergraduate nursing students at a university in South Australia, during August 2007. The survey tool consisted of six demographic questions and the AIDS Attitude Scale. This questionnaire was completed by 396 students, giving a response rate of 94.7%. The vast majority (95.7%) of students participating in this study demonstrated very positive attitudes towards caring for people with HIV/AIDS and only 4.3% demonstrated negative attitudes. No statistically significant differences were found in attitude score based on participants' age, gender, previous HIV/AIDS education, previous nursing experience or previous experience of caring for someone with HIV/AIDS. A statistically significant difference in AIDS attitude score was found in relation to participants' country/region of citizenship, with nursing students from China, East Asia, South East Asia, and Central Asia and Middle East having more negative attitudes than students from other countries/regions. As an increasing number of nursing students have been recruited to Australia from these countries/regions, nurse educators need to be aware of such differences when planning and delivering HIV/AIDS educational programs in tertiary institutions.

Keywords: Nursing education, Nursing students, HIV/AIDS, Attitudes, Research

 

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Introduction 

Background 

Acquired immune deficiency syndrome (AIDS) develops following infection with the human immunodeficiency virus (HIV). This virus is an acquired contagion with an estimated 42million people infected globally (Green, 2007). The first deaths from HIV/AIDS were reported in the early 1980s and around 20million people have since died from AIDS. There remains no known cure (Green, 2007). Despite the high number of deaths worldwide, people living with HIV in many Western countries are surviving for long periods due to the development of more effective treatments.

Ever since the first cases of HIV/AIDS were diagnosed, nurses have been at the forefront of providing care to those infected with the virus (Williams et al., 2006). The attitudes of nurses and nursing students towards people living with HIV/AIDS have long been under scrutiny. Past studies showed that some nurses and nursing students were reluctant to provide care for people with HIV/AIDS due to the fear of contagion (Goldenberg and Laschinger, 1991, Tierney, 1995, Robinson, 1998). In fact studies reported finding that between 8% and 26% of nurses were of the view that they should be able to choose not to care for HIV/AIDS patients (Froman and Owen, 1997, Sherman, 2000). According to a United Nations AIDS taskforce report (UNAIDS, 2006) negative attitudes and reluctance to provide care results in a poorer quality of care being provided.

In the literature, negative attitudes towards patients with HIV/AIDS were found in all countries examined, these included: China (Williams et al., 2006); Cameroon (Mbanya et al., 2001); Nigeria (Adepoju, 2006, Oyeyemi et al., 2006); Spain (Pita-Fernandez et al., 2004); Taiwan (Juan et al., 2004); Uganda (Walusimbi and Okonsky, 2004); and USA (O'Sullivan et al., 2000, Preston et al., 2000). Many nurses had a great reluctance to care for people with HIV/AIDS (Juan et al., 2004). Pita-Fernandez et al. (2004) found that almost 10% of the participating nurses in a Spanish study believed that all contact should be avoided with people who are HIV positive.

Almost 20% of the nurses in a Taiwanese study were seriously considering leaving nursing altogether due to their fear of contracting HIV/AIDS (Juan et al., 2004). High levels of fear of self-infection and of infecting family members with the HIV virus were found among nurses in various parts of Africa, such as Nigeria (Adepoju, 2006, Oyeyemi et al., 2006), Uganda (Walusimbi and Okonsky, 2004) and Cameroon (Mbanya et al., 2001). North American studies have linked reluctance to care for people with HIV/AIDS with fear of contagion and high levels of homophobia among the participating nurses (O'Sullivan et al., 2000, Preston et al., 2000).

Among nurses in the USA, one of the major causes of anxiety, fear, negative attitudes and reluctance to care for people with HIV/AIDS was identified as a lack of education (O'Sullivan et al., 2000, Preston et al., 2000). Similarly in a Taiwanese study, Juan et al. (2004) found that nurses' anxiety was reduced by education, and concluded that the ‘institution of appropriate AIDS/HIV educational programmes has the potential to change nurses attitudes’ (Juan et al., 2004, p. 36). These findings were supported by studies conducted in Nigeria (Oyeyemi et al., 2006), and China (Williams et al., 2006).

These fears and concerns are not confined to practicing nurses. An in-depth literature review (Pickles et al., 2009) found similar fears and concerns among nursing students from different regions of the world. These fears result in reluctance on the part of some nursing students to provide care for people with HIV/AIDS. Therefore, there is an obligation upon the nursing profession to develop strategies to understand and overcome such attitudes. Education and change based on research evidence must play a leading role in this challenge to the nursing profession. Nurse educators have a responsibility to ensure that nursing curricula provide students with sufficient knowledge of HIV/AIDS to enable them to provide safe, high quality and compassionate care to people with HIV/AIDS. In reviewing the literature no current studies from the South Pacific region were found highlighting the need for further research from this region.

Study aims 


1.To determine the attitudes of a cohort of nursing students in South Australia towards caring for people with HIV/AIDS.

2.To ascertain whether the following variables significantly influenced the attitudes of the nursing students towards caring for people with HIV/AIDS: gender; age; country of citizenship; previous HIV/AIDS education; previous nursing experience and previous experience caring for someone with HIV/AIDS.

3.To bridge a gap in the research literature on this issue from the South Pacific region.

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Methods 

Participants 

Second year undergraduate nursing students were administered a survey questionnaire prior to a scheduled lecture in an unrelated undergraduate topic during August 2007. Of the possible 450 students enrolled in the topic, 418 second year nursing students attended the lecture. Of these, 396 completed the questionnaire giving a response rate of 94.7%. The study sample represented 33% of the total number of undergraduate nursing students (n=1201) enrolled at that time.

Second year students were selected as some had participated in a HIV/AIDS option topic a few weeks before the survey was administered. In addition first year students had little clinical experience and third year students were more likely to be influenced by practicing nurses due to their extensive clinical placements; these factors also influenced the decision to select second year students. The Raosoft Sample Size Calculator (Raosoft, 2004) was used to determine an adequate sample size. To give a confidence level of 95% and a margin of error of 5%, a sample size of 208 was required. The actual sample size was 396, and, therefore, was deemed to be statistically adequate.

Data collection instrument 

The instrument used in this study was the AIDS Attitude Scale (AAS) developed by Froman et al. (1992) and further validated by Froman and Owen (1997). Permission to use this instrument was granted by the authors. The AAS was specifically developed to measure the attitude of nurses towards caring for people with AIDS, and has been used extensively. However, the AAS uses American vernacular and is based on attitudes and beliefs prevalent in the USA 10–15years ago. Therefore, it may have limited application in an Australian context.

The AAS is a 21 item self-report survey designed to measure two distinct dimensions of attitude towards people with AIDS. These dimensions, which are inversely related and form two subscales in the AAS, are empathy and avoidance. Nurses with little empathy for people with AIDS exhibit greater avoidance behavior in providing care for people with HIV/AIDS. The more empathy nurses have, the less avoidance behavior they exhibit when caring for people with HIV/AIDS. In addition to administering the AAS, study participants were also asked to provide socio-demographic data. Participants were asked to indicate their gender, age group, citizenship, previous HIV/AIDS education, previous nursing experience, and previous care for someone with HIV/AIDS.

Ethical considerations 

Approval to conduct this research study was granted by the University's Ethics Committee and the Dean of the School of Nursing. Students were free to complete the survey in their own time and to return it anonymously to a designated collection box. Maintaining the rights of participants remained paramount throughout this study and no identifying information was included with the instrument. All returned individual surveys have been stored as per the Australian National Health and Medical Council guidelines (NHMRC, 2007).

Data analysis 

Statistical analyses of the survey data were conducted using the computer software, Statistical Package for Social Science (SPSS v 14), to examine students' attitudes in relation to socio-demographic characteristics. The influence of the socio-demographic variables on attitudes to caring for people with HIV/AIDS was determined using the independent, 2 sample T-test. When comparing multiple variables, the Analysis of Variance (ANOVA) F-test was used to test for equality of more than two means. Where the F-test indicated a significant difference in means when comparing multiple variables, further analysis was carried out using the multiple comparisons Scheffe test.

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Results 

Demographic data 

Participants in this study were second year undergraduate nursing students, 85% were female and the majority (51.7%) were in the 18–24year age range. The overall age range of the participants closely resembled the overall undergraduate nursing population. The participating student population comprised citizens of 28 different countries. The majority (67%) was Australian citizens. The second largest group (11%) was Chinese citizens. The remaining countries only had a few representatives, with 15 countries represented by only one student, who therefore, were assigned to regional groups (see Fig. 1).

Experience and education 

The majority of participants (74%) had no previous nursing experience prior to undertaking the Bachelor of Nursing program. Of the female students, 18% had previous nursing experience, whereas only 2% of the male students had such experience. No significant difference was found in terms of prior nursing experience between the represented countries (Fig. 2). In terms of experience in caring for a person with HIV/AIDS, only 14% of all study participants had knowingly cared for a person with HIV or AIDS. Of these 82% were female and 18% male. China (4.3%) and East Asia (5.6%) had a much lower incidence of previous experience in caring for someone with HIV/AIDS compared with others among the study sample.

Findings on the proportion of participants with prior HIV/AIDS education have been illustrated in Fig. 3. Only 30% of participants had undertaken some form of formal HIV/AIDS educational program, the vast majority of these were female (88%) with only 12% male. Therefore, out of the overall sample, 25% of females and 3.5% of males indicated that they had HIV/AIDS education. Considerable variation also was noted between students from different countries/regions. Students from Central Asia and the Middle East comprised the largest group with HIV/AIDS education (46%), while students from Australia and the East Asia region comprised the next largest group (approx. 30%). Although students from China and Southeast Asia made up the second largest cohort in the study, only 22% had HIV/AIDS education. In contrast, only 10% of participants from Europe and North America indicated that they had previous formal HIV/AIDS education.

Students' attitudes toward people with HIV/AIDS 

Overall AIDS attitude score for all study participants 

The AIDS Attitude Scale (AAS) used in this study measured two distinct dimensions of attitude towards people with AIDS. These dimensions were empathy and avoidance. An overall attitude towards AIDS score was calculated for each participant by subtracting the avoidance score from the empathy score, the resultant scores ranged from −5 to +5. Positive scores indicated positive and supportive attitudes while negative scores indicated negative attitudes and avoidance behavior. The average AIDS attitude score for all 396 participants was 2.73 (±1.41 SD) which indicated generally positive attitudes by the participants. Only 4.3% of participants recorded a negative score (≤0) indicating that only a small percentage had negative attitudes towards caring for people with HIV/AIDS.

Impact of socio-demographic factors 

The influence that four of the demographic variables had on the AIDS attitude score is presented in Table 1. The variables: previous HIV/AIDS education; prior experience of caring for someone with HIV/AIDS; previous nursing experience and gender, were all found to have no significant impact on attitudes (P>0.05).

Table 1. Influence of four socio-demographic variables on mean AIDS Attitude Score.
VariableWith variable
Mean (±SD)		Without variable
Mean (±SD)
1. Previous HIV/AIDS education2.83 (±1.52)2.67 (±1.35)
2. Prior experience caring for someone with HIV/AIDS2.87 (±1.37)2.71 (±1.40)
3. Previous nursing experience2.85 (±1.39)2.69 (±1.41)
4. Gender2.77 (±1.42)2.46 (±1.27)

The remaining two socio-demographic variables of age and country/region of citizenship, had multiple sub-sets and were analyzed using an Analysis of Variance (ANOVA) (Table 2). While the result of this test suggested significant differences in attitude towards HIV/AIDS patients among the different age groups, a Scheffe test did not indicate where these significant differences occurred.

Table 2. Effect of age and country/region of citizenship on attitudes towards people with HIV/AIDS.
FactorMean squareF-ratioP
1. Age group5.8553.012<0.03
2. Country/region of citizenship32.26322.006<0.0005

Similarly, the country/region of citizenship was found to influence attitudes towards HIV/AIDS patients. Further analysis, through a multiple comparison Scheffe test, showed that students from China, East Asia, South East Asia and Central Asia and Middle East had mean AIDS attitude scores significantly lower than Australian nursing students. In addition, students who were citizens of China and East Asia also had significantly less positive AIDS attitude scores than nursing students from Europe and North America (Fig. 4). It should be noted that the results for African students could not be statistically analyzed due to insufficient sample size (N=3) and so have not been included in Fig. 4.

Summary of results 

Overall the sample students had positive attitudes towards caring for people with HIV/AIDS. Using the AIDS Attitude Scale, it was determined that only 4.3% of the sample recorded negative scores indicating negative attitudes. The variables of gender, age group, previous HIV/AIDS education, previous nursing experience, and experience of providing care for someone with HIV/AIDS, were found to have no significant influence on the AIDS attitude score.

The only variable found to have a statistically significant impact on the AIDS attitude score was country/region of citizenship. This influence was significant for students from four countries/regions, namely; China; East Asia; South East Asia; and Central Asia and Middle East. The mean AIDS attitude scores were significantly lower for these countries/regions compared with the other countries/regions.

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Discussion 

The vast majority of participants demonstrated positive, empathetic and compassionate attitudes towards caring for people with HIV/AIDS. Only 4.3% of participating nursing students recorded an overall AIDS attitude score equal to or less than zero. The implication being that this small number of students had negative and intolerant attitudes towards people with HIV/AIDS. This corresponds with the findings of studies from other nations, including: the USA (Earl and Penny, 2003); UK (Peate et al., 2002); Turkey (Bektas and Kulakac, 2007) and Singapore (Ngan et al., 2000). The small numbers of students found by this study to have negative attitudes also showed little empathy and were likely to exhibit avoidance behavior when it came to providing care for people with HIV/AIDS. These students were from all age groups and most countries/regions of citizenship.

The variable of country of citizenship was shown to have a significant influence on the AIDS attitude score of students from four countries/regions. Nursing students included in the study whose country of citizenship placed them as being from China, East Asia, South East Asia or Central Asia and the Middle East, had significantly lower AIDS attitude scores than the rest of the study sample. This implied that these students had less empathy towards people with HIV/AIDS and would be less willing to provide care for these people.

Similarly, there were considerable differences between countries/regions in the number of participants who had some experience of caring for someone with HIV/AIDS. This may be a reflection of different infection rates in these countries/regions, or it may indicate differences in people's knowledge about their HIV status or willingness to disclose that status. Other explanations are possibly suggesting a need for further research in this area.

The current study has demonstrated that there are few concerns about the attitudes of nursing students in Australia towards caring for people with HIV/AIDS. A regular process of monitoring and evaluating attitudes is recommended to detect any significant shift in attitudes over time. As a small number have negative attitudes, further research is needed to explore the reasons underlying those attitudes.

The study revealed considerable differences between countries/regions in the degree of formal HIV/AIDS education received by study participants. These differences may have been a result of prevailing social and cultural factors in these countries/regions which influence the delivery of HIV/AIDS education. There is no doubt that there are differences in emphasis placed on HIV/AIDS education by governments and educational authorities represented by the study sample of nursing students. A large difference was also noted between the genders, with seven times the percentage of females than males having had formal HIV/AIDS education. The reason for these differences was not clear from the data, although it may be related to the small number of males in the sample.

Implications for nursing education 

Over the past decade Australian health care providers and Australian universities have been actively recruiting nurses and nursing students from overseas. This has been largely in response to the continuing shortage of nurses throughout the Australian health care system. The majority of those recruited overseas are coming from the same countries/regions where nursing students have been identified by this study as having significantly less positive attitudes towards caring for people with HIV/AIDS. Nurse educators need to be aware of such differences when planning and delivering HIV/AIDS education to nursing students, and educators need to be responsive to the changing demographic characteristics of undergraduate nursing students.

Recommendations for further research 

The following recommendations all relate to the attitudes of nurses and nursing students towards caring for people with HIV/AIDS. Further research has been recommended into:

1.The thoughts, feelings and beliefs that shape less positive attitudes among students from a number of Asian countries. Socio-cultural influences in the home countries of these nursing students need to be explored.

2.Possible changes in attitudes as people transition from nursing student to practicing nurse.

3.An in-depth exploration into the underlying causes of the negative attitudes shown by a small number of nursing students, particularly from the abovementioned Asian countries.

4.Similar studies to the current study, at different universities around Australia and other nations in the region to determine if the findings are typical.

5.The attitudes of practicing nurses in Australia and elsewhere in the region.

Limitations 

In undertaking this study the researchers were aware that the study had three main limitations. The sample was not randomly selected and came from only one Australian university. The AIDS Attitude Scale was developed in the USA 15years before this study which could call into question the suitability of the questionnaire for use in Australia. For statistical purposes, the study treated ordinal data (Likert scale) as interval data and used parametric tests when the data distribution approximated a normal distribution, however these are common assumptions in social research. These limitations were acknowledged and recognized as somewhat weakening the overall study. However, the researchers considered that these weaknesses did not seriously impact on the results of the research.

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Conclusion 

The evidence has shown that negative attitudes exist towards people with HIV/AIDS among some nursing students studying at an Australian university. These attitudes can result in reluctance to provide care and negatively impact on the quality of care provided to people living with HIV/AIDS. The nursing profession has a responsibility to develop strategies to comprehend and prevail over such attitudes. Tertiary educational institutions must play a primary role in fostering positive attitudes among nursing students by developing educational programs based on research evidence. In addition, programs must be continually evaluated to determine their effectiveness.

It was beyond the scope of the researchers and this study to make comment on attitudes or educational programs that exist in other countries. The study identified concerns in relation to the attitudes of some nursing students recruited from outside Australia towards caring for people with HIV/AIDS. Further research to examine why students from the identified countries/regions have less positive attitudes towards caring for people with HIV/AIDS should be undertaken. Detailed recommendations for changes could then be made to undergraduate nursing curricula at Australian universities.

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References 

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PII: S0260-6917(11)00021-9

doi:10.1016/j.nedt.2011.01.008

Nurse Education Today
Volume 32, Issue 1 , Pages 15-20, January 2012

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