Artículo sobre los cuidados de enfermería en pacientes con VIH

1. RESEARCH BRIEFS
HIV/AIDS Nursing Care: Instrument for
Measuring Students' Attitudes and Precautions
Katherine Wiley, RNC, EdD; John Edwards, PhD; Patrick Smillie, BS; Linda Heath, PhD; and Marvin Acklin, PhD
A
major challenge for nursing facul-
ty is to teach and evaluate all as-
pects of the HIV/AIDS curricu-
lum, including knowledge of and compli-
ance with universal precautions. To ad-
dress this challenge, an instrument was
developed and administered in 1991 and
revised and administered again in 1993.
The purpose and intended use of this
instrument is to survey students' atti-
tudes toward nursing HIV-seropositive pa-
tients and document their self-reported
understanding of and compliance with
universal precautions.
Several researchers have reported
studies of health care professionals or stu-
dents regarding attitudes and hehaviors
related to care of AIDS/HFV-infected pa-
tients (Goldenberg & Laschinger, 1991;
Kelly, St. Lawrence, Hood, Smith, & Cook,
1988; Lawrence & Lawrence, 1989). How-
ever, few researchers have published brief
instruments which were validated using
nursing students.
One such attitude instrument
(Bliwise, Grade, Irish, & Ficarrotto, 1991)
was developed for use in research on stu-
dents in a variety of health care profes-
sions, and it was validated using two dif-
ferent cohorts of medical and nursing stu-
dents. That instrument contains 15 items
and has a Cronbach alpha coefficient of
.86. The suhscales and Cronbach's coeffi-
cients for the total scale are Fear of
Dr. Wiley is Associate Professor, Maternal Child
Health Nursing, Dr. Edwards is Associate Pro-
fessor, Mr. Smillie is a Graduate Student, and Dr.
Heath IS Professor, Department of Psychology,
Loyola University, Chicago, Illinois; and Dr. Acklin
IS a Clinical Psychologist in Honolulu, Hawaii.
Address reprint requests to Katherine Wiley,
RNC, EdD, Loyola University Chicago, 6525 North
Sheridan Road, Chicago, IL 60626.
Contagion (.65), Negative Emotions (.70),
and Professional Resistance (.75). These
coefficients suggest good internal consis-
tency. However, the Bliwise, Grade, Irish,
& Ficarrotto instrument deals only with
attitudes and not with universal precau-
tions.
The only instrument of known mea-
surement properties that addresses hoth
attitudes and compliance with universal
precautions is the HIV-Impact Question-
naire (Wiley, Heath, Acklin, Earl, & Bar-
nard, 1990). That 15-item scale was used
to survey registered nurses on three sub-
scales: Precautions, Worry and Policies,
Eind Job Change. Cronbach's coefficient
for the total scale was .61, and for the
subscales, .51, .76, and .76, respectively.
This instrument has the advantages of
satisfactory reliability coefficients as well
as the dual focus on attitudes and uni-
versal precautions.
However, Wiley and colleagues (1990)
tested their instrument with a sample of
registered nurses, not students. The need
remained, then, for an instrument to as-
sess the impact of AIDS/HIV infection in-
struction on student nurses' attitudes as
well as their understanding of and com-
pliance with universal precautions. This
dual focus is important in order to explore
the possibility that the primarily late ado-
lescent student population would consider
themselves invulnerable (Weinstein,
1984) and therefore be less likely to
report compliance with universal precau-
tions. The present report describes the
development, measurement properties
and potential uses of the second revision
of the HrV-Impact Questionnaire: Student
Form for measuring nursing students'
attitudes about, and precautions in,
HIV/AIDS patient care.
Method
Participants—The sophomore, junior,
and senior nursing classes at a mid-sized,
urban CathoUc university participated in
this study after they had completed clini-
cal courses for that year. About a third of
the junior and senior classes were placed,
during their sophomore year, on an AIDS
unit for their initial clinical course.
Because of the high mortality rate of rela-
tively young persons, faculty selected stu-
dents whom they believed were more psy-
chosocially mature for placement on the
AIDS unit.
Demographic data for this school indi-
cate that 75% of the students repwrt that
they are Catholic; and 55% Caucasian.
About 90% of these students are age 20 to
23. Approximately 230 students received
the instrument, and 190 (83%) completed it.
Instrument—The instrument pre-
sented to the students was a 28-item scale
called the HIV-Impact Questionnaire:
Student Form. It was a third revision of an
instrument (hut the second revision of the
student form) used to survey this same
population in 1987 (Wiley, Heath, &
Acklin, 1988). The original instrument
addressed the concept of personal suscep-
tibility (Becker, 1974), and it queried stu-
dents about their perceptions of risk of
becoming HIV-infected while giving
patient care. That 66-item pilot instru-
ment used several different types of
response options. Students said they
found it confusing and that they spent
about 45 minutes completing it. Only 36%
returned completed questionnaires.
The first revision of the 1987 instru-
ment was developed to survey a registered
nurse population (Wiley, Heath, Acklin,
Earl, & Barnard, 1990). For the RN survey.
230 Journai of Nursing Education

2. bKlKKS
15 statements were selected from the orig-
inal instrument, and respondents rated
the items using a Likert-type response
scale. The response rate to the survey was
54%; 323 nurses responded. Cronbach's
coefficient for the 15-item scale was .61;
three subscales were identified.
In 1991, when the 15-item registered
nurse questionnaire was adapted for the
student population, some items were
revised and others added to improve the
reliability of the three subscales. To
address content validity of the Student
Form, one of the non-nursing authors dis-
cussed the instrument with a group of
clinical nursing students. These students'
comments were used to add new items and
revise other items in the 1991 and 1993
instruments.
The 1991 edition of the HIV-Impact
Questionnaire: Student Form was admin-
istered to sophomores and juniors during
the last class of the year. The response
rate was 99%; 118 students responded.
Recognizing that the sample size was
small for factor analyses, the authors
examined with caution several analyses.
The best fit was a seven-factor solution of
Worry (4 items). Satisfaction (3 items).
Refusal (4 items). Prevention (2 items).
Precautions (3 items). Job Change (2
items) and Test Results (1 item). One item
did not load on a factor. Cronbach's coeffi-
cient for the entire scale was .78.
In Spring 1993, the instrument was
revised using the above data. Eight items
were added, including ones about stu-
dents' confidence in universal precautions.
The questionnaire presented to students
had 28 items.
At the top of the instrument, students
were informed that HFV-seropositive body
fluids "excluded those body fluids consid-
ered to be lowly infectious, such as blood-
free saliva, tears and urine." For the 28
statements, students were instructed to
mark one of four responses: strongly
agree, agree, disagree, and strongly disag-
ree. In the statements, the phrase "HTV-
seropositive patients" was used; there was
no distinction made between HTV-infected
patients and AIDS patients. And, although
students have been taught "Body Sub-
stance Isolation," the term "Universal
Precautions" was used throughout be-
cause the latter term is more widely used.
Procedure—For the sophomore and
junior classes, the survey was conducted
during the last non-exam class of the year;
for the senior class, it was conducted at
the end of a final exam. Students were
informed that participation in the re-
search was voluntary and that their res-
ponses were anonymous. They were also
informed that no nursing faculty would
see the students' responses, and that a
psychology graduate student would tabu-
late the data and keep the raw data in his
possession. The consent form was "signed"
by having the student choose two digits
and writing those digits in the two blank
spaces provided.
Of the approximately 230 students
who were asked to participate, 190 com-
pleted the survey. The sophomore class
had the lowest response rate (80%); the
response rate for the three classes togeth-
er was 83%.
Results and Discussion
Afler tabulating the percentages of
agreement with each item, responses to
approximately half of the 28 items were
reverse scored so that higher scores indi-
cate a more favorable orientation toward
HIV/AIDS patient care. The Table lists the
reverse scored items as well as the per-
cents of agreement before the items were
reverse scored.
Using Factor Analysis with Maximum
Likelihood Extraction and Varimax Rota-
tion, the 28-item instrument was ana-
lyzed, and items with low factor loadings
were deleted and the resulting 22-item
scale was analyzed. The following discus-
sion reports the findings of the 22-item
scale analysis.
The seven factors of the 22-item scale
and the percent of variance accounted for
are found in the Table. Although the 1993
analysis included the same number of fac-
tors as were found in the 1991 analysis,
the best fit solution was slightly different
than the solution foujid in the 1991 study.
Both the 1991 and 1993 factor analyses
suggest these five factors: Satisfaction
(items 1, 12,13, 21, 22), HIV-testing (items
8, 9,15, 16, 19, 20), Refusal of Assignment
(items 17, 18), Precautions (items 4, 5),
and Prevention (items 3,10,11). However,
for the purpose of clarity, the Prevention
factor was retitled. Confidence in
Universal Precautions. In addition, the
1993 analysis suggested that the Worry
Factor be divided into two separate fac-
tors: I worry (items 2,7), and Others worry
items (6,14). Lastly, the Job Change factor
found in the 1991 study was deleted and
one of the items formerly found in Job
Change loaded on the satisfaction factor.
Cronbach's coefficients for the seven
factors are: Satisfaction (.80), HTV-testing
(.72), Knowledge/Use of Universal Pre-
cautions (.75), Others Worry (.79), I Worry
(.71), Confidence in Universal Precautions
(.61), and Refusal of Assignment (.63).
Cronbach's coefficient for the 22-item
scale was .82.
Also included in the Table are the p)er-
cents of agreement with the statements.
For the purpose of reporting the results
concisely, the authors combined the res-
ponses of strongly agree and agree into a
"percent of agreement" total. When read-
ing these percents, the reader should keep
in mind that the students may have
responded in the manner they believed
was wanted by faculty. No measure of
"social desirability" (or lying) was used.
There was 100% agreement with item
4 (I understand the guidelines for univer-
sal precautions), and 99%- agreement with
item 5 (I routinely follow universal pre-
cautions for all patients). Also, 96%> agreed
with item 3 (On-the-job exposure to HIV-
infection can be prevented if nurses use
blood and body fluid precautions for all
patients) and 64% agreed with item 11 (If
I always use universal precautions, there
is virtually no chance of me becoming HFV-
infected during my nursing practice).
These percents of agreement suggest that
students have confidence in universal pre-
cautions but also know that accidental
exposure can happen.
Generally speaking, the students ex-
pressed satisfaction with nursing HTV-
seropositive patients. Unfortunately, be-
cause students were not randomly as-
signed to the AIDS unit, conclusions can-
not be drawn about the causal role of the
AIDS unit experience in influencing their
attitudes.
In future research, larger and diverse
populations will be surveyed to enable the
researchers to analyze further the validity
of this instrument. These replication stud-
ies also will enable faculty elsewhere to
evaluate their teaching of HFV-related
content.
Although brief enough to be complet-
ed in less than 15 minutes, the HIV-
Impact Questionnaire: Student Form
May 1996,Vol. 35, No. 5 231

3. VII. REFUSAL OF ASSIGNMENT (4.5%)
17.* If I were given the option, I might, under some circumstances, refuse assignment
to HIV-seropositive patients.
18.* Agencies should permit nurses to refuse, under selected circumstances, assignment
to HIV-seropositive patients.
'Item recoded after percents of agreement were calculated.
Cronbach alpha coefficient for total scale=.82.
Factor
Loading
.74
.75
.42
.62
.68
Percent
Agree
80%
75%
95%
20%
43%
.53
.65
.97
.67
.60
.61
.57
71%
Table
Results of Factor Analyses Using Maximum Likelihood Extraction and Varimax Rotation and Percents of
Agreement with Statements
Name of Factor (Percent of Variance Accounted for)
Statements in Factor
I. SATISFACTION (22.8%)
1. I find it a satisfying and rewarding experience to give direct nursing care to
HIV-seropositive patients.
12. Working with HIV-seropositive patients gives me opportunities to face many
of the challenges that attracted me to nursing.
13. All HIV-seropositive patients deserve the same compassionate nursing care
regardless of how they became HIV-infected.
21.* If I were given the option, I would routinely refuse to be assigned to HIV-
seropositive patients.
22. When I graduate, I will consider working on a unit that has a high census of
HIV-seropositive patients.
II. HIV TESTING (11.2%)
8.* All patients should be tested for HIV upon admission to the health care agency.
9.* As soon as HIV test results are available, nurses who give direct nursing care to
a patient should be informed of that patient's HIV test results.
15.* Student nurses should be tested annually for HIV infection.
16.* If a student nurse tests positive for HIV, her/his faculty should be informed that
she/he is HIV-seropositive.
19. An HIV-seropositive nurse who is asymptomatic should be allowed to give all
types of nursing care.
20.* If a nurse is HIV-seropositive, her/his patients should be told their nurse's HIV
status if the patient asks about it.
III. KNOWLEDGE/USE OF UNIVERSAL PRECAUTIONS (8.5%)
4. I understand the guidelines for universal precautions.
5. I routinely follow universal precautions for all patients.
IV. OTHERS WORRY (7.3%)
6.* My family and friends worry about me becoming HIV-infected during my
nursing practice.
14.* Because of the AIDS risk, my family and friends are worried about me becoming
a nurse.
V.I WORRY (6.1%)
2.* Because of my clinical practice, I worry about exposing my family and friends
to HIV infection.
7.* Because of my clinical practice, I worry about being exposed to HIV infection.
VI. CONFIDENCE IN UNIVERSAL PRECAUTIONS (5.3%)
3. On-the-job exposure to HIV infection can be prevented If nurses use blood and body
fluid precautions for all patients (called universal precautions).
10. Even in busy situations, I am able to prevent my exposures through broken skin or
mucous membranes, to all blood and other infectious body fluids.
11. Ifl always use universal precautions, there is virtually no chance of me becoming
HIV-infected during my nursing practice.
.45
.64
.62
.34
.60
.86
.67
93%
47%
54%
47%
57%
lOO"/,
99%
60%
37%
45%
61%
42
55
72
96%
77%
64%
46%
68%
232 Journal of Nursing Education

4. yields both a reliable overall score as well
as suhscale scores for several aspects of
AIDS/HIV-related teaching of nursing
students. Included in the subscales is
documentation about students' self-
reported understanding of and compli-
ance with universal precautions.
References
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model and personal health behavior Health
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nursing students' attitudes towards AIDS.
Health Psychology, 10(4), 289-295.
Goldenberg, D., & Laschinger, H. (1991).
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with AIDS patients: A test of the Ajzen-
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Kelly, J., St. Lawrence, J., Hood, H., Smith
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Lawrence, S., & Lawrence, R. (1989).
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Weinstein, N. (1984). Why it won't happen to
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ty. Health Psychology, 3(5), 431-457.
Wiley, K., Heath, L., & Acklin, M. (1988).
Care of AIDS patients: Student attitudes.
Nursing Outlook, 36(5), 244-245.
Wiley, K., Heath, L., Acklin, M., Earl, A., &
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