April 2007 - Volume 1, Issue 2

ROLE OF EDUCATION ON THE ATTITUDES OF NURSES TO HUMAN IMMUNODEFICIENCY VIRUS (HIV)/ ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) PATIENTS IN ISPARTA, TURKEY

Serpil AYDIN MD Assoc. Prof., University of Adnan Menderes School of Medicine, Department of Family Medicine. Aydin, Turkey (during the study period University of Suleyman Demirel School of Medicine, Department of Family Medicine, Isparta, Turkey) Turhan YAVUZMD Assoc. Prof., University of Suleyman Demirel School of Medicine, Department of Cardiovascular Surgery, Isparta, Turkey Sevgi YAVUZ Nursing Member of the Infection Committee, University of Suleyman Demirel School of Dentistry, Isparta, Turkey Canan AGALAR MD Prof., University of Kirikkale School of Medicine, Department of Infectious Disease and Clinical Microbiology, Kirikkale, Turkey Fatih AGALAR MD Prof., University of Kirikkale School of Medicine, Department of Surgery, Kirikkale, Turkey

Doc. Dr. Serpil AYDIN P.K. 112 09000 AYDIN/TURKEY Email: serpilden@yahoo.com, sdaydin@adu.edu.tr Phone: +90 256 219 6181 (home); +90 256 2197188 (office) Fax: +90 256 219 2011 (office)

ABSTRACT Introduction: AIDS is a serious disease, and victims of AIDS require special care. It is a reality that the care provided to AIDS patients by nurses, who have been educated about AIDS, is of superior quality. In this study, our main objective was to determine the knowledge level, societal beliefs, and awareness of nurses about HIV/AIDS, and to learn the role that education has on the attitude of nurses, who are primarily in charge of AIDS patients. Methods: Our volunteer-based study was performed with clinical nurses, who had no previous education in HIV/AIDS, working in two hospitals,. A questionnaire composed of 13 questions was given to the nurses before, and one month after, they had completed a two-day course on AIDS. The results of the second questionnaire were then compared to those of the first. Wilcoxon signed ranks test was used for the statistical analysis. A p value smaller that 0.05 was accepted as statistically significant. Results: A total of 130 clinical nurses participated in the study. The mean age of the nurses was 26.2±4.8 years. Before the course, only 2.9% of the nurses had any knowledge of HIV/AIDS. Even though they were informed during the course about transmission routes, 69.2% of the nurses (n=90) still felt uncomfortable caring for AIDS patients. Conclusion: Education about HIV/AIDS can significantly improve the knowledge and attitudes of the nurses; however, more time and educational programs are needed to help them overcome their preconceived beliefs, which cause them to hesitate, fear, and, feel anxious when caring for HIV/AIDS patients.

Key Words: Human Immunodeficiency Virus, Acquired Immunodeficiency Syndrome, nurse, healthcare, education, attitude INTRODUCTION

The spread of the Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) is increasing in spite of continuing efforts to limit it. According to a 2005 report on HIV prevention by the United Nations (UN) and the World Health Organization (WHO), the number of people in 2005 who were living with HIV increased to 40.3 million, while the number of newly infected people increased to 4.9 million; and deaths from AIDS increased to 3.1 million worldwide. (1) According to this report, treatment and prevention should support each other. The report also suggests that knowledge and awareness of HIV/AIDS transmission promotes reproductive and sexual health. Furthermore, preventing mother-child transmission and preparing and using vaccines and microbiocides are also reported to be important.

AIDS is a serious disease, and AIDS victims require special care. (2) It is a reality that the care of HIV/AIDS patients by nurses, who have been educated about the disease, is of superior quality (3).

In Turkey, nurses are dealing not only with caring for both out- and in-patients, but they are also taking a greater role in mother-child healthcare centers and primary care services. In addition, they are in charge of administering intravenous drugs and vaccines. Consequently, because of their increasing role in patient care, it is very important to educate Turkish nurses about HIV/AIDS.

Another aspect of this subject, which is as important as patient care, is determining the attitude of the nurses towards the HIV/AIDS patient and determining whether education causes any marked difference in their preconceived attitudes. Although many studies have been conducted about the approach of nurses to HIV/AIDS patients, (4,5) there is not much in the literature, especially about Turkish nurses.

In this study, our objectives were:

• to determine the knowledge level and awareness of nurses about HIV/AIDS;
  
• to learn their preconceived attitudes and approach in dealing with HIV/AIDS patients; and
  
• to determine the role that education plays regarding the nurses' knowledge of HIV/AIDS and their preconceived attitudes towards HIV/AIDS patients.
  

Setting
Our study was performed with both the Suleyman Demirel University Medical School and the Isparta District Hospital, which are located in the urban center of Isparta. These facilities serve an estimated population of more than one million, which includes both the urban and neighbourhood populations.(6) Our target population was composed of volunteer nurses, who had not previously received any HIV/AIDS education or training. All of the nurses worked in clinical services. In Turkey, secondary and tertiary care hospitals tend to be used for first attendance services (7), so our nurses are dealing with many patients and diverse medical issues. Receiving HIV/AIDS education is an important issue for these nurses.

Data Collection
This study centers on a two-part questionnaire. One part includes the socio-demographic data of the participants, and the second part includes 13 questions concerning the general attitude of the nurses towards HIV/AIDS patients and their level of knowledge about the disease. Answers were in the form of yes, no, or indefinite. Next, these nurses participated in a two-day training course presented in slide format. The course consisted of information about the clinical features of HIV/AIDS, the social and psychological problems of the patients, transmission routes of the disease, and progression of the disease around the world. One-month after the two-day training course, the nurses were given the same questionnaire again. Then, the results of the second questionnaire were compared to those of the first.

Statistical Analysis
Data were evaluated statistically by Wilcoxon signed ranks test. A p value smaller that 0.05 was accepted as statistically significant. RESULTS

A total of 183 clinical nurses work at the Suleyman Demirel University Medical School and the Isparta District Hospital. Our study included 130 of those nurses (71%), who volunteered to participate in the study; 70 of them work in the Suleyman Demirel University Medical School, and 60 nurses work in the Isparta Government Hospital.

The mean age of the nurses was 26.2±4.8 years (minimum 21, maximum 32). The age, service period, and educational status of the nurses is shown in Table 1.
Before participation in the two-day training course, only 26.9% of the nurses (n=35) had enough knowledge to prevent transmission of the disease. Following the course, the percentage increased to 72.3% (n=94). Even though they were informed about transmission routes in the training course, 69.2% of the nurses (n=90) still felt uncomfortable about caring for AIDS patients. Although the fear of caring for a HIV/AIDS patient decreased significantly, about one fourth (32) of the nurses were still afraid.

Before the course, 97.6% of the nurses thought that materials used by HIV/AIDS patients should be marked; that ratio increased to 99.2% after the course. Both before and after the training course, all of the nurses reported that hospital workers should have the right to know the HIV status of a patient.

The number of nurses reporting that they did not experience any anxiety in having social contact with these patients increased from 35 to 87 after the training. However, 29.2% noted that they still experienced some anxiety in caring for HIV/AIDS patients after the training.

Before the training course, 95 nurses felt that they had the right to refuse to care for a person suffering from HIV/AIDS. After training, only 24 maintained this belief. While 75 nurses refused to work in the same surroundings with AIDS patients before the course, this number decreased to 28 after the course. Before the training course, 59.2% of the nurses suggested that HIV (+) hospital workers should not work compared to only 29.2% after the course.

Before the training course, 70.7% (n=92) of the nurses were hesitant to have social interaction with HIV/AIDS patients; this ratio decreased to 26.1% (n=34) following the course.

Before the training course, 56.9% of the nurses felt uncomfortable providing care to AIDS patients, but this number decreased to 26.9 % (n=35) following the course.

Prior to the course, all nurses agreed that the materials of HIV/AIDS patients should contain a special marking, and all health area workers had the right to know the HIV status of the patient. Despite the training, 66.1% of the nurses still felt anxious about getting HIV from patients.

Statistical data about the nurses' answers to the questions before and after the training course are shown in Table 2. DISCUSSION

In Turkey, the first case of AIDS was diagnosed in 1985. By 1997, the number of HIV/AIDS cases had increased to 753, and by 2001, 1246 cases were reported. (8) It is estimated that today, nearly 20,000 persons in Turkey are infected with HIV. The Turkish Ministry of Health has taken some precautions against this rapidly transmitting disease. First, HIV/AIDS was included in the Declaration Obligated Diseases list, which means that all HIV/AIDS cases should be declared to the Ministry of Health when they are diagnosed. Following inclusion in this list, the Ministry required that all blood and blood products be tested for HIV. In 1987, an AIDS information center was established to provide information to doctors and health care providers as well as the general public. Next, use of disposable invasive tools gained popularity. In addition, the Ministry of Health, also put in place some controls concerning sex workers.

Because of the information broadcast by the Turkish media, AIDS was thought to be a disease specific only to homosexuals. More than 90% of the people in Turkey are Muslims, and according to their religious belief, homosexuality is not accepted, and polygamy is a sin. For these reasons, HIV/AIDS patients were isolated. People thought that being in the same environment, shaking hands, or eating with them would increase their risk of contracting HIV/AIDS. These false beliefs became ingrained and have been difficult to change. When asked to take an HIV test to control the spread of the disease, Turks were both insulted and unwilling to participate because of their beliefs that the disease resulted from homosexual or polygamous acts. (9) Many studies have dealt with the approaches employed by health area workers in caring for HIV/AIDS patients and the associated psychological results. (4,5,9,10,11)

In Turkey, people who are HIV (+) have been excluded from social events due to people's perceptions about how this disease is spread. (12) It is important for AIDS patients to have contact with their doctors and nurses. (9)

In our study, before the training course, 61.3% of the nurses felt anxious around HIV (+) patients, and 63% feared social contact with HIV (+) persons. These results are concordant with results of other studies conducted outside Turkey. (11,13) Our study indicates that health area workers experience anxiety while caring for AIDS patients, which is also concordant with other studies,(2,9,11,14) Although following the training, these ratios decreased, it is interesting that about one fourth of nurses still experienced anxiety or fear when dealing with HIV/AIDS patients. This may be due to their lack of experience because about one fifth of the nurses stated that they did not have enough knowledge about the transmission of HIV/AIDS even after the course. Before the training course, 73% of the nurses thought that they had the right to refuse to treat a HIV/AIDS patient. This finding indicates that uneducated health area workers had a negative attitude towards HIV/AIDS patients. There are some studies about the emotional effects of AIDS on health area workers.(9, 14, 12) Duyan et al found that doctors feared or were anxious about interacting with HIV/AIDS patients, which affected the care of those patients.(9)

It is very interesting that the training course did not make a difference in the feelings of the nurses despite their increased knowledge about transmission of the disease. Although three fourths of them thought that they had enough knowledge about preventing transmission, knowledge could not alter the feelings for 69.2%.
All of the nurses thought that they have a right to know the HIV status of a patient, and they suggested marking patients' materials with special indicators. This may be an indication of the nurses' anxiety about the disease, and their attempt to prevent transmission of HIV/AIDS to themselves.

In some studies, it has been concluded that even with the negative messages about HIV/AIDS from the media, with education, people experience an improved attitude towards HIV/AIDS patients, and they can tolerate being in the same surroundings with those patients.(15) This is concordant with our study.

Currently, the number of HIV/AIDS cases diagnosed in Turkey is 1246. Of that number, 340 are sick, and 727 of them are HIV (+). Nurses, experienced in the treatment of AIDS patients, are limited. It is a fact in Turkey that the lack of HIV/AIDS education and training for nurses is a serious problem. Over the last 15 years, a thorough HIV/AIDS education has not been provided to nurses to improve AIDS patient care even though some studies show that educating nurses in AIDS improves patient care.(13, 16) Unofficially, it is estimated that nearly 20,000 people in Turkey are infected with HIV so the lack of educated nurses can become a major issue in the future care of HIV/AIDS patients.

In our study, it was shown that even though a short training course in AIDS significantly improved the nurses' knowledge about the disease and had a positive affect on patient care, the nurses still have some hesitation, fear, and anxiety. Further courses or educational programs may be needed to resolve any remaining negative attitudes.

There are some limitations of this study. Although the questionnaire was used in another study (9), it was not validated. None of the nurses had any previous experience with AIDS/HIV patients; thus, we could not compare experienced and inexperienced groups. As this study was based on self-report, further studies may be needed to research nurses' actual approach. CONCLUSION

From this study, we gain some insight into the educational needs and false beliefs of our clinical nurses. We conclude that HIV/AIDS education can significantly improve their knowledge level and attitudes, but more time and educational programs are needed to help them overcome their hesitation, fear, and anxiety resulting from societal misconceptions. In order to overcome these issues, to have nurses provide adequate care for HIV/AIDS patients, and to further patient/community education, we have to initiate a countrywide educational program on HIV/AIDS.

Table 1. Demographic data of the nurses

We thank to study participants and Dr. Y. Olaniyan for his comments on this study and we acknowledge Janice O. Vantrease for her grammatical review.
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