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EDUCATION FOR NURSING CARE OF AIDS PATIENTS:
A STUDY OF LIFELONG LEARNING AND
MID-CAREER PROFESSIONAL ATTITUDES

By

Gail Patton Skomschek

A DISSERTATION
Submitted to
Michigan State University
in partial fuﬁllment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Adult and Continuing Education

1997

ABSTRACT
EDUCATION FOR NURSING CARE OF AIDS PATIENTS:
A STUDY OF LIFELONG LEARNING AND
MID-CAREER PROFESSIONAL ATTITUDES
By

Gail Patton Skomschek

Health care has become extremely complex. With a world wide epidemic like
AIDS and its threat to mankind, this battle knows no borders or national
boundaries. As the epidemic progresses, mid-career professionals will be
frequently called upon to care for People With AIDS (PWAs). Mid-career
professionals must therefore become more knowledgeable about AIDS and
AIDS care. One cannot expect to be fully prepared for a life-time career by an
initial academic program alone. Further growth and lifelong learning are
demanded in the highly dynamic environment of health care today and in the

future.

In this study of AIDS and mid-career professionals, an attempt was made to
provide a foundation for further discussion on attitudes towards lifelong learning,
AIDS, and AIDS care by utilizing the perceptions of mid-career professionals
oonceming AIDS and AIDS care. Since attitudes often inﬂuence behavior, a
questionnaire was developed and distributed to two hundred and ﬁfty (250) mid-
career nurses working in the Province Of Ontario, Canada, to determine the

personal and professional factors that were associated with attitudes towards

lifelong learning, AIDS, and AIDS care. The data provided an indication of
current problems for mid-career nurses concerning their knowledge and skills
about AIDS and AIDS care. The data indicated too, the perceptions of mid-
career nurses about the skills and knowledge that are needed for improved
nursing practice for PWAs. The results of the study indicated what the lifelong

leaming needs are for mid-career nurses about AIDS and AIDS care.

The identiﬁed knowledge that is needed is to change attitudes in order to
decrease the fear of AIDS, to eliminate the social stigma attached to AIDS and
PWAS, and to prevent the transmission of the disease from AIDS patients to
others. The data showed that knowledge about AIDS and skills were needed to
care for AIDS patients and could be obtained from courses offered at the
worksite by a joint, co-operative effort between employers and educational

institutions.

The focus Of the study was "Education for Nursing Care of AIDS Patients: A
Study Of Lifelong Learning and Mid-Career Professionals' Attitudes." Health
care organizations are currently "re-organizing" and "downsizing" in an effort to
cope with decreased funding while, at the same time, trying to satisfy the needs
and expectations of the clients. All of this activity has caused the health care
environment to be in a state of constant change. Identiﬁcation of the issues
faced by mid-career professionals in their pursuit Of lifelong learning about AIDS

and AIDS care will provide improved nursing care for PWAs in the future.

Copyright by
GAIL PATTON SKORNSCHEK
1997

DEDICATION

I dedicate this dissertation to all those who
share the pioneering spirit of lifelong learning

through all the stages of life.

ACKNOWLEDGEMENTS

I would like the express my deep appreciation for the faith, guidance, and
encouragement of my advisor Dr. Steve Weiland.

Special recognition goes to my dissertation committee, Dr. Howard Hickey,
Dr. Jim Snoddy, and Dr. John Dyrkx. Also special thanks goes to Jo Colby for
her superb administrative assistance.

Without the assistance and constant encouragement from friends and
colleagues Dr. Debra Preston, Dr. Winston Issac, and Mrs. Marion Lush, this
dissertation would never have been completed.

My sincere thanks also goes to my husband Hans Skomschek and to my
parents Florence and Bruce Patton.

Finally, thanks also goes to all my friends and colleagues who helped me to

achieve a lifelong goal.

ii

TABLE OF CONTENTS

LIST OF TABLES .............................................. iv
CHAPTER 1
INTRODUCTION ............................................... 1
AIDS and Health Care ......................................... 1
AIDS and Nursing .......................................... 4
History of the AIDS Virus ................................... 10
Description of HIV/AIDS Virus ............................... 11
Lifelong Learning and Role of Mid-Career Professionals in AIDS Epidemic12
Signiﬁcance of Attitudes of Mid-Career Professionals and AIDS ....... 16
Signiﬁcance of the Study ...................................... 20
Research Questions ....................................... 21
Assumptions . .............................................. 22
Limitations ................. g ................................ 23
Deﬁnition of Terms .......................................... 25
Organization of the Dissertation ................................ 29
Summary .................................................. 30
CHAPTER 2
RELATED LITERATURE ........................................ 32
Collaborative Learning Strategies ............................... 33
Increasing Understanding .................................. 33
Selective Perception ....................................... 35
Critical Thinking and Change ................................ 35
Self-Directed Learners ..................................... 36
Reﬂection ............................................... 37
Acknowledging the Experience of Adult Learners ................ 39
Attitude and Behavior Change .................................. 41
Attitude Theory ........................................... 42
Conceptual Foundation of Attitudes ........................... 44
The Many Faces of AIDS ...................................... 46
Children and AIDS ........................................ 46
Women and AIDS ......................................... 47
Natives and AIDS ......................................... 50
Prisons and AIDS ......................................... 50

iii

Contagion and Homophobia Related to AIDS ................... 51

Summary ............................................... 52
CHAPTER 3
DESIGN AND METHODOLOGY .................................. 56
Design of Study .......................................... 56
Study Sample ............................................ 57
Survey Design .............................................. 59
Pretest of the Survey ...................................... 60
Data Collection Procedures ................................. 61
Data Analysis ............................................ 62
Validity and Reliability ........................................ 64
CHAPTER 4
ANALYSIS AND INTERPRETATION OF THE DATA
Introduction .............................................. 66
Research Questions and Interpretation of Findings ............... 66
Proﬁle of Respondents ....................................... 80
Findings of Study ............................................ 85
Summary .................................................. 87
CHAPTER 5
FINDINGS, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS . 90
Summary of Findings ......................................... 92
Knowledge and Education About AIDS and AIDS Care ............ 92
Experience and Education About AIDS and AIDS Care ............ 95
Barriers ................................................. 98
Perceived Beneﬁts ....................................... 100
Conclusions ............................................... 102
Implications ............................................... 109
Implications for Mid-Career Professionals ..................... 109
Implications for Health Care Organizations .................... 111
Implications for Educational Institutions ....................... 11 1
Implications for Education and Health Care Beyond the Year 2000 . 112
Recommendations for Further Study .............................. 114
APPENDICES ............................................ 119-125
Appendix A - Letter of Introduction ............................ 119
Appendix B - Survey Questionnaire ........................ 120-125
BIBLIOGRAPHY .......................................... 126-133
GENERAL REFERENCES .................................. 134-144

iv

LIST OF TABLES

Table 1.1.0 AIDS Epidemic Statistics

Table 1.1.1 Questionnaire Record

Table 2.1.0 Response Means for Each Item of Question 1

Table 2.1.1 Valid Responses, Response Means and Standard Deviation-Question 1
Table 2.2.0 Response Means for Each Item of Question 2

Table 2.2.1 Valid Responses, Response Means and Standard Deviation-Question 2
Table 2.3.0 Response Means for Each Item of Question 3

Table 2.3.1 Valid Responses, Response Means and Standard Deviation-Question 3
Table 2.4.0 Response Means for Each Item of Question 4

Table 2.4.1 Valid Responses, Response Means and. Standard Deviation-Question 4'
Table 2.5.0 Demographics of Respondents to Survey Questionnaire
Table 2.5.1 Demographics of Respondents - Nursing Education

Table 2.6.0 Demographics of Respondents - Professional Background

CHAPTER 1
INTRODUCTION

AIDS AND HEALTH CARE

The focus of this study is EDUCATION FOR NURSING CARE OF AIDS
PATIENTS: A STUDY OF LIFELONG LEARNING AND MID-CAREER
PROFESSIONAL ATTITUDES. Since we can no longer deny that Acquired
Immune Deﬁciency Syndrome (AIDS) is a life-threatening illness that will involve
millions of people, it is our choice to grow and learn from it, to either help those
people with this dread disease using current knowledge and skills, or abandon

them.

No single virus in history has provoked such concentrated scientiﬁc attention
as the AIDS virus. Medical experts agree that no human illness or other
infectious disease has ever been as complex as AIDS. The complexity is that it

is not just one illness but a web of diverse infections and symptoms.

"Not even the devil could have designed a virus as ﬁendish as
HIV/AIDS . Clear it out of the bloodstream and it hides in the lymph
nodes. Bannish it from the lymph nodes and it lurks in the brain.
And even if it could be eradicated from the brain, it can still be
found cradled among the chromosomes of a few quiescent immune
cells, ready to pounce again when the hunters have gone away. "
Wu If, 1996

2

The AIDS epidemic, both nationwide and worldwide, has called attention to
the scope of problems related to Human Immunodeﬁciency Virus (HIV) infection.
Complicating the already devastating physiological aspects of AIDS is society's
reaction to the life-styles of vulnerable populations and peoples' fear of this
deadly disease. AIDS has been labelled the public health problem of the
century. There is no cure in sight. Central to all of this is the nursing profession
which is being increasingly called upon to provide direct patient care, family and
community counseling, AIDS education and preventative strategies (Larson and

Ropka, 1991).

Ofﬁcials at the Centre for Disease Control and Prevention (CDC) in Atlanta,
Georgia, as of June 1996, estimated that 946,170 Americans had AIDS and that
at least one million more Americans are infected with human immunodeﬁciency
virus (HIV), the virus that causes AIDS. In the United States of America in 1996,
the medical costs of AIDS and AIDS care alone was 23.4 billion dollars! Costs
vary greatly and are dependent on a variety of factors, including geographical
location; the lifetime medical costs for each individual person with AIDS in 1996
was estimated to be $225,000 and rising rapidly. Successful treatment for some
opportunistic infections associated with AIDS has prolonged the lifespan of

People with AIDS (PWAs).

The hidden faces of the AIDS epidemic are women and children. Although
the majority of the population with AIDS are men, women and children have also

been infected, with the numbers rapidly increasing. Women constitute the

3

fastest growing group of people with AIDS. The gender difference in incidence
of newly infected individuals is expected to disappear soon (Jemmott and
Jemmott, 1991 ). Women with AIDS tend to be younger than men with AIDS
indicating that many were infected as adolescents (Bradley-Springer, 1994).
Until recently, symptoms typical of HIV infection in women were not included in
diagnostic criteria for AIDS that were established by the Centers for Disease
Control and Prevention. These omissions led to failures in diagnosis and
treatment of HIV infection in women. Over 70% of HIV infected women are
persons of color, according to the CDC. They tend to be poor and over 50%
have contracted the disease through a personal history of injected drug use or
having had sexual relations with drug users. About 30% of infected women who
are pregnant transmit HIV to their infants (Bradley-Springer, 1994). In the future,
it will become the number one concern of adolescents and teenagers. Given
current trends, it is estimated that by the year 2000 over 80,000 American

children, ages seventeen and younger, will be left motherless because of AIDS.

In Canada, natives are dying twice as fast as non—natives and live an average
of only three years after being diagnosed HIV positive, which is half the survival

rate of patients from the general population (Sanderson, 1996).

The epidemic of AIDS means a crisis for health care and nursing. From 1993
to 1994, AIDS increased 9.1% in rural areas and 3.1% in urban areas in the
United States. In rural areas a threefold increase in AIDS has occurred as

compared to urban areas. This creates more problems due to the lack of

4

information, geographical and financial barriers to health care, a shortage of
nurses, technological deﬁcits, conservative values, and lack of anonymity

(Preston and Romeo, 1994).

An estimated twenty-two (22) million people are infected with HIV/AIDS
worldwide and most live outside the industrialized countries (CDC, 1996). Many
of them cannot afford basic health care let alone high-tech treatments, and most
are infected with a different subtype of HIV than those most commonly studied in
the United States, Europe, and Canada. The Centre for Disease Control
(CDC), 1996, reports that every eleven (11) minutes someone in the United

States dies of AIDS.

AIDS and Nursing

Since 1981 when the ﬁrst AIDS cases were diagnosed in the United States,
considerable changes in knowledge and behavior have occurred in the general
population. By mid-1987 nearly every adult had heard of AIDS and only a few
were unaware of the major means of transmission. The changes in knowledge
have been attributed to the mass media, primarily television. Despite
widespread awareness however, misconceptions about transmission have
occurred in the general population as well as in the nursing profession. Studies
of nurses were of two types: (1) surveys of hospital workers which included

nurses, physicians, and technicians and (2) surveys of nurses exclusively.

5

Findings of these studies done on nursing groups in hospitals in the USA.
using mass surveys, including knowledge of HIV infection and AIDS, found that
most nurses had a working knowledge of HIV/AIDS. In spite of this, gaps were
also identiﬁed. It was found that many nurses had trouble identifying "at risk"
groups, knowing the correct means of transmission, distinguishing the symptoms
of AIDS, and being aware of and using infection control procedures. Since the
main source of information aboutAlDS was often through the mass media, fear
of AIDS transmission persisted despite the use of the recommended Universal
Precautions, and many nurses reported spending less time with people suffering
from HIV/AIDS than other patients. Some nurses refused to care for PWAs and
felt that they should have the choice to do so, while others stated that they would
question their career intentions if faced with an increased workload of PWAs

(Swanson et al, 1990).

In order to respond to the challenge of the AIDS epidemic, nurses, the largest
body of health care professionals, must have current and accurate information
about HIV infection and AIDS to make appropriate intervention possible.

Nurses' needs for knowledge are very great, not only because they care for HIV-
infected people and PWAs in a wide range of settings, but also because nurses
are involved in AIDS eduCation and prevention which are the only measures
currently effective against the disease. Nurses need information about
transmission of HIV, precautions for preventing transmission, and the related

psychosocial, ethical, and legal issues and concerns. All nurses, regardless of

6

their location or professional background, need to be prepared to deal with AIDS

either through direct patient care or educational channels.

Nurses also need to be able to recognize the uniqueness of each person's
experience with grief and loss. Although grief is a universal human experience,
each person ascribes her/his own meaning to a loss. Education of nurses
concerning bereavement must recognize the dynamic process involved in

grieving.

The situation of nurses in AIDS care is unique in several respects. As the
largest group of health care providers, nurses usually have more contact with
persons living with HIV/AIDS. Much of the care given by nurses involves
physical contact, some of which exposes them to blood and bodily ﬂuids.

Nurses can often experience fatigue and burnout, not only because of the heavy
care demands, but also because of the frequent need to work with patients who
are often young and dying. Nurses frequently face situations where counselling
is urgently needed but time is lacking. Coupled with improved crisis care for
PWAs has come increased patient admissions to critical care units where nurses
are heavily involved in aggressive invasive therapies and resuscitation
procedures necessary to restore these patients to optimal functioning. Since
HIV infection is a chronic condition, health promotion interventions are needed
to encourage a pattern of living that enables a patient to enjoy the fullest
physical and psychosocial capacity with due allowance for disabilities. Healthier

lifestyles can only be encouraged by knowledgeable nurses. Nurses can

7

function more as patient managers than technical deliverers of treatment
protocols. Nurses' efforts to help PWAs develop consistency in their
management strategies may encourage them to be cared for at home. This is
becoming more important as AIDS becomes a chronic condition. Nurses are in a
unique position to provide education concerning unsafe behaviors and lifestyles,
holistic care approaches, information concerning counseling services, and the
co-ordlnation of all services needed by these individuals. They are also in a
perfect position to conduct and disseminate research information, and provide
advocacy leadership for HIV/AIDS patients through professional and political
action. By taking an active role in community organizations and speaking out
against discrimination towards PWAs, nurses can help to decrease public stigma
against AIDS and advocate for improved public health policies and education

programs.

The rapid growth of the AIDS epidemic and the continuing changes of the
health care system demand that mid-career nurses take an active role in lifelong
Ieaming in order to keep their knowledge about AIDS and AIDS care current and
accurate. Learning opportunities must be made available to mid-career nurses
on an ongoing basis and need to include psychosocial support and education for

positive attitude development towards AIDS and AIDS care.

The fear of contagion has been characterized by four types of behavior.
These behaviors are avoidance, attempting extreme precautions, lack of regard

for PWAs, and verbal expressions about their fear of AIDS (Meisenhelder,

8

1993). The beneﬁts of lifelong Ieaming for mid-career nurses are numerous.)
Current, accurate knowledge about AIDS and PWAs will decrease the fear of
contacting AIDS, decrease the social stigma attached to AIDS, create more
positive attitudes towards AIDS and PWAS, increase willingness to care for
PWAS, provide more humanistic nursing care to PWAS, increase consistency in
practising Universal Precautions and decrease negative fears and behaviors.
Other positive outcomes will be decreased discomfort concerning sexual
preferences, different lifestyles, and substance abuse. There should also be
less concern about putting family and friends at risk, a reduction in the intense
emotional demands of caring for young, dying patients, and an increase in using
appropriate coping mechanisms when caring for PWAs generally. Lastly, job
stress should be reduced, working conditions improved, and a more positive
working environment created. As co-Ieamers, mid-career nurses will be able to
build upon each other's strengths and share knowledge and Ieaming
experiences. These experiences will help to deepen the understanding and
insight into AIDS and AIDS care. Lifelong Ieaming activities will assist mid-
career nurses to identify those at risk for AIDS, provide educational programs in
their communities, and become advocates for PWAs in the political arena.

"AIDS is not simply a disease of high-risk groups. It is a human

disease. We are all potentially at risk. No epidemic in history

remains conﬁned to one group alone. After all, biologically we are

all the same. "
D. Suzuki, 1990

TABLE 1.1.0

AIDS EPIDEMIC STATISTICS

FEBRUARY 1996

 

6%—

4%—

2%—-

 

0%

1
Years after contracting HIV

 
 
  
     

Percentage of

HIV-positive 0/3 h

patients who 50’ 3V9 progressed to AIDS
die in each year

50% are
dead

3° sare stillalive .—.

r3I4I5I6I7I8I9I10I11:

.. ,_ mmmmmswsmmmcsi;

 

CDC, February 1996

10

History of the AIDS Virus

Until AIDS was discovered, infectious diseases seemed a thing of the past.
Viruses are the oldest microbe known to man. They are very patient and can
wait years to ﬁnd a host such as man, animal or plant in order to grow and
multiply. Once the virus enters the host, we are always the losers. Viruses have
caused plagues such as the Black Plague; epidemics of smallpox and polio; ﬂu,
colds, and AIDS just to name a few. Viruses have adapted well to such changes

in the environment as over-population.

New viruses are continuing to emerge from the rapid destruction of the rain
forests. Mosquitoes from these rain forests have produced forty (40) newly
diagnosed viral strains in the United States (CDC, 1996). AIDS continues to
shape the history of this century. In Africa, AIDS has always been considered a
heterosexual disease. An interesting twist regarding the AIDS virus is that in
Kenya there are women who are HIV postive but have never developed full-

blown AIDS. There seems to be no logic to the progression of this disease.

In the future, viruses may help to cure genetic diseases such as cystic
ﬁbrosis by introducing new genes. As soon as one virus is understood and
becomes treatable another one emerges to continue the battle. AIDS,

unfortunately, is a very complex virus.

11

Description of HIV/AIDS Virus

In battling the AIDS virus, the body and virus engage in mortal combat from
the beginning. The main battleground is in the hard-to-reach lymph nodes.
Scientists have known from the beginning that AIDS is a disease of the immune
system, invading and destroying the white blood cells that ﬁght infection.
Recently, it has become known that the disease progresses in three distinct and
very different stages. The ﬁrst stage is over so quickly that it can easily be
missed. Within days after the virus has penetrated the body, ﬂu-like symptoms
occur which last only a few days. The time period between the ﬁrst stage and
the second stage varies considerably. The second stage is the longest. The
virus is now trapped in the lymph nodes which become swollen. Other on-going
physical symptoms may also appear. This is the stage when most people
discover that they are HIV positive due to the antibody test developed in 1984.
The third stage of infection is when the T-cells, which comprise part of the white
blood infection-ﬁghting cells, drop from an average of 1,000 cells per millimeter
of blood to fewer than 500 cells per millimeter. Opportunistic infections such as

pneumocystic pneumonia and Kaposi‘s sarcoma develop (Gorman, 1996).

12

LIFELONG LEARNING AND THE ROLE OF MID-CAREER PROFESSIONALS
IN THE. AIDS EPIDEMIC
Why is there a concem/interest regarding the need for lifelong Ieaming for
mid-career professionals? For any mid-career professionals working in today's
health care system, the environment is very dynamic and the need for currency
Of knowledge is being demanded. Even without the changes in the health care
environment, it can be seen that there are requirements for the development of

mid-career nurses. Lifelong Ieaming could be the way to maintain currency.

Lifelong Ieaming can be deﬁned as a process that allows individuals to share
ideas, information, and experiences as well as a process by which an individual
participates in lifelong Ieaming activities to prepare for current and future
changes in practices. Lifelong Ieaming is edUcation beyond the initial
preparation that is relevant to the type of patient care delivered in an institution
or organization and that provides current knowledge relevant to the individual's

ﬁeld of practice.

The purpose of lifelong Ieaming is to build upon one's educational base for
enhancement of knowledge and skills and to decreaSe the barriers to AIDS by:
. Decreasing the fear of AIDS
. Decreasing the social stigma of AIDS

. Improving nursing practice for PWAs

13

Three factors are characteristic of present day society that affect what adults
want to learn. First, dramatic changes are occurring in the demographic base of .
our society. Our population as a whole is better educated than ever before and
there is more cultural and ethnic diversity. The second and third factors shaping
the Ieaming enterprise are economics and technology. The effect of the global
economy and technological advances on the nature of adult Ieaming is
staggering. Adults are now ﬁnding that they must continue to learn well past
formal schooling in order to function at work, in the community, and in society.
What one wants to Ieam, what is offered, and the ways in which one learns are
determined to a large extent by the nature of the society at any particular point in
time. Changing demographics is a social reality shaping the provision of

Ieaming in contemporary society.

Technology and the information age are changing the nature of adult
Ieaming. Understanding who adults are as Ieamers, why they participate or do
not participate in Ieaming, what changes they undergo as they age and how
those changes interface with lifelong Ieaming are important considerations in

facilitating meaningful Ieaming experiences.

What can/should be done to facilitate opportunities for lifelong Ieaming
activities about AIDS for mid-career nurses which are consistent with the needs
of the Individual, the organizations, institutions, and communities in a changing
health care system? It is hoped that this question will be answered in the pursuit

of the ﬁve areas of interest as outlined in the research questions which can be

14

found later in this chapter. The full survey instrument is presented in

Appendix B.

As long as more than half of the adult population fail to participate in lifelong
Ieaming activities, questions about barriers to participation are of legitimate
concern. Researchers have identiﬁed a number of social and psychological
barriers to participation related to a lack of self-conﬁdence, including a fear of
failure, a fear of school, and a fear of change. There are good reasons why
nurses resist change. Many are richly enmeshed in a fabric of relationships
which hold them as they are and many of their peers, friends and relatives do
not wish them to change. Change demands a complex kind of renegotiation of
relationships with others. Sometimes it is simpler to stay right where they are.
The price of change may be too high (Daloz, 1988). Studies have indicated that
nurses with negative attitudes about AIDS were more anxious about caring for
PWAs; or else they refused outright to care for PWAs. By taking an active role
in lifelong Ieaming, mid-career nurses can decrease their fear and stress in
caring for PWAs and can gain a better understanding of PWAs and ultimately
improve quality of care with a more holistic approach. Failure to combine the
elements of knowledge and opportunity for attitudinal examination and
modiﬁcation of behavior may result in a mid-career nurse who, though
knowledgeable, is immobilized by personal feelings and is poorly prepared to
deliver quality care. The challenge of working with People With AIDS is to

provide quality care. As the largest group of health care providers, nurses

15

usually have more contact with people who are living with HIV/AIDS than any
other group of health care workers. Virtually all PWAs at some point in time will
be cared for by nurses. Therefore, mid-career nurses need to pursue lifelong
Ieaming about AIDS and the AIDS epidemic which is critical for nursing practice

in the future.

l6

SIGNIFICANCE OF MID-CAREER PROFESSIONAL ATTITUDES AND AIDS

The purpose of this study is to explore the signiﬁcance of attitudes of mid-
career professionals towards lifelong Ieaming, AIDS and AIDS care. This study
will seek to contribute both theorectically and practically to the study of attitudes

of mid-career professionals.

What is Attitude? Attitude, as deﬁned by Webster's Collegiate Dictionary, is
a "mental position with regard to a fact or a state; feeling or emotion toward a
fact or state; a position assumed for a speciﬁc purpose." Attitude can be a
behavior toward a person, group, thing, or situation representative of conscious
or unconscious mental views developed through cumulative experience
(Preston, 1994). Attitude is a composite variable that has both cognitive and
affective components. Cognitive components are composed of opinions and
judgements while affective components are made up of feelings. Attitude is a
mental position with regard to a fact or state; a composite variable that has both
cognitive and affective components (Schuman and Johnson, 1981). An attitude
is usually thought of as having three components (1) an affective component
which consists of the individual's feelings about the object (2) a cognitive
component which is the individual's beliefs or knowledge about the object (3) a
behavioral component which is the individual's predisposition to act toward the
object in a particular way.

An attitude always has a focus; it may be a person, a group, or a nation.

When the focus is known to many, the corresponding attitude can be used for

17

the comparative characterization of many persons. The dimension of
characterization extends from positive (or favorable) through neutrality to
negative (or unfavorable). Persons are thought of as occupying positions on this
dimension corresponding to their disposition to behave favorably or unfavorably
toward the focus. Behavior predicted but not yet produced is expected to appear
when relevant circumstances arise. There is an assumption to exist in a person,
a disposition to it or readiness for it. The disposition is the attitude. Attitudes
are not directly available to the senses, but the discovery in others must be an
inference from their behavior. The right answers are sometimes hard to ﬁnd
especially when the individual's reports of her/his own attitudes are misleading.
An individual's real goals in her/his work and real attitudes towards members
of her/his family, another person or group are not necessarily known to her/him.
Jung distinguishes two major attitudes or orientations of personality; the attitude
of "extraversion" and the attitude Of "introversion". The extraverted attitude
orients the person toward the external, objective world while the introverted
attitude orients the person toward the inner, subjective world. These two
opposing attitudes are both present in the personality but, ordinarily, one of them
is dominant and conscious while the other is subordinate and unconscious. If
the ego is predominately extraverted in its relation to the world, the personal
unconscious will be introverted. Changing attitudes refers to the Ieaming
necessary for the solution of personal, social, and economic problems of living
encountered by individuals, groups, and communities. Positive attitude refers to

the positive state of mind of an individual towards a value and can include a

18

speciﬁc emotional or non-emotional disposition such as tolerance, radicalism, or
scepticism. It also implies a positive mental position with regard to a fact or a
state of mind and includes a tendency to respond, in a positive way, towards

certain persons, objects, or situations.

Data from studies show a high percentage of nurses who indicated not only a
reluctance to care for PWAS but unwillingness to verbally interact, socially
interact, co-work, touch, or maintain friendships with PWAS. Thus the
manifestations of fear occur not only in potential risk situations, but also in risk-
free situations such as verbal interaction or hand-shaking. These studies
suggest ways Of decreasing extreme fear through effective and continuing
educational programs for nurses (Meisenhelder, 1993). Results from several
studies on nurses' attitudes about AIDS have shown that nurses with negative
attitudes were more fearful about catching the disease. Additional research has
shown that nurses' fear of AIDS has resulted in lack of regard for PWAS, inferior
care due to avoidance of carrying out procedures, or attempting extreme
precautions. A study by Preston and Romeo (1994) found negative attitudes
towards AIDS were related to nurses' lower educational levels and religious
beliefs and values. Some areas of human attitudes appear largely to be
inﬂuenced and shaped by cultural knowledge. Although hidden from view, it is
constantly used to generate attitudes and interpret experience. Education,
professional experience, personal history, beliefs, values, and religion contribute

to the way people in any given society react or behave. Sample and Warland

19

(1973) state that attitudes, experiences and values have been shaped by the
society in which we live and work, as well as by the professional tenets that

guide our practice.

Attitude and behavior are highly correlated when treated as multi-item
dimensions. There is considerable evidence that human beings are greatly
inﬂuenced, especially in situations of uncertainty, by the behavior of others and
often these "others" are barely known to them. If we discriminate against those
with AIDS, we will end up lacking sufﬁcient funds for research and medical
treatment when the caseload continues to swell. Not only do people with AIDS
have to go through the "stages of dying," they are also faced with issues the
world has never had to deal with to this extent, in such massive numbers, and
from every direction. AIDS has become our largest sociopolitical issue, a
dividing line of religious groups, a battleground for ambitious medical

researchers, and a demonstration of man's inhumanity to man.

Determining the relationship of mid-career professionals' attitudes about
AIDS and PWAS to the delivery Of humanistic nursing care is of paramount

importance.

20

SIGNIFICANCE OF THE STUDY

It is hoped that the information gathered from this group of mid-career
professionals about attitudes toward lifelong learning, AIDS and AIDS care will
contribute to the body of knowledge concerning their need for and commitment
to lifelong learning.- Important too, are the questions that will be raised for
further research of a theoretical and practical nature. Future research may
include a replication of this study with a larger sample and with a focus on
speciality areas of health care. In many studies of attitudes, both positive and
negative; accepting and rejecting attitudes are identified. The tendency towards
discrimination such as quarantine and use of universial precautions for those
who are HIV/AIDS positive, may induce HIV/AIDS patients to conceal their
condition to avoid social rejection and isolation. The social shame associated
with revealing one's diagnosis and being rejected by society thus may cause the

epidemic to prevail.

Speciﬁc organizations with an interest in the results of the ﬁndings will be
health care organizations, institutions of nursing education, the Registered
Nurses Association of Ontario, the Canadian Nurses Association and the

Ministry of Health of Ontario.

The topic of this study has not been extensively researched in Ontario,
hence, additional data sources will be less well developed and the research

report from this study will make a Signiﬁcant contribution to the related literature

21
and to those involved in nursing education. Studies of this type cannot be based
on "hard" data alone. Attention was paid to the qualitative information which was
added to the survey responses by individuals. An effort was made to combine
the information gained from these sources with quantitative data to develop the
most complete understanding of issues. Data collected from the survey

questionnaires was analyzed in terms of the study questions and reported in

summary data and narrative information formats. _
Research Questions

The research questions which this study addressed were:

1. What knowledge do mid-career nurses have about AIDS and AIDS care?

2. What education and experience do mid-career nurses have about AIDS
and AIDS care?

3. What attitudes and opinions are shared by mid-career nurses about the
barriers hampering their pursuit of lifelong Ieaming about AIDS and AIDS
care?

4. What are the perceived beneﬁts for mid-career nurses in pursuing lifelong
Ieaming about AIDS and AIDS care? What are the potential

consequences for nursing practice for PWAS?

22

ASSUMPTIONS

It is assumed that a common form of reference exists for terms and concepts
used. It is further assumed that mid-career nurses would provide the time
necessary to state their opinions in an honest manner. Another assumption is
that many mid-career nurses and institutions, would be interested in the ﬁndings.
Lastly, is the assumption that mid-career nurses perceive lifelong Ieaming as

enhancing their personal and professional knowledge and nursing skills.

The individuals surveyed are mid-career nurses who graduated between
1960-1980 prior to the AIDS epidemic, and who are practicing nursing in Ontario
and members of the Registered Nurses Association of Ontario. It is assumed
that colleges and universities will be interested in the attitudes towards lifelong
Ieaming and knowledge about AIDS and AIDS care of this professional group.
This information could also be used to improve the basic nursing education

programs as well as the continuing education programs for all nurses in Ontario.

23

LIMITATIONS

The current economic climate may influence some of the responses and
should be taken into consideration when interpreting the data. Budget
constraints might have had an effect on institutions providing for continuing

education programs and activities for mid-career professionals.

There is always a concern for "interpretation" Of certain terms and it could be
different for individuals based on many factors. Two possible limitations of this
study are low response rate (50% or less) which may mean a biased sample with
reduced power; and/or self-reported behavior and opinions may not represent

their actual attitudes, opinions and behavior.

The collection of information was dependent on the willingness of individuals
to complete the questionnaire. There is no way of knowing if the task had been
assigned to someone else. The questionnaire was designed to be self-
administered, hence, its validity could be affected by the clarity of the questions
and the honesty of the respondents. The biases of the investigator may have
inﬂuenced the construction of the questionnaire and the interpretation of the
qualitative findings. Assessment by other individuals was sought so as to

eliminate or, at least, decrease any biases.

The findings of this study can only be generalized to mid-career nurses in
Ontario who are members of the Registered Nurses Association of Ontario and

who, at the time of the survey, were working in hospitals, colleges, universities

24

and communities. Not every mid-career nurse in Ontario was polled for her/his
opinions, views and comments on AIDS and PWAS and lifelong learning. Mid-
career nurses who work in the hospitals and communities of the larger university
cities in Ontario may well have different opinions and knowledge about AIDS
and PWAS and needs for lifelong Ieaming than their counterparts in different

work environments and locations.

25

DEFINITION OF TERMS

The following terms are defined in the context in which they are used in this

study:
AFFECTIVE - refers to a person's feelings and emotions

AIDS - Acquired Immune Deﬁciency Syndrome - refers to the state of the body
at which time life-threatening diseases such as pneumonia or cancer have

manifested themselves or are difficult to overcome

ATTITUDE - is a mental position with regard to a fact or state; a composite

variable that has both cognitive and affective components

BARRIER - an obstacle or circumstance that keeps people or things apart by

barring access or advance

BEHAVIOR - the way a person behaves or acts, their conduct or manners _
CDC - Centre for Disease Control and Prevention in Atlanta, Georgia
COGNITIVE - components are composed of opinions and judgements
CONATIVE - to undertake or attempt; expressing endeavor or effort

CONTAGION - the spreading of disease from one individual to anOther

26
CONTINUING EDUCATION - is typically viewed in terms of formal programs
centered around particular topics and targeted at particular audiences; it is the
process by which an individual participates in professional development

activities to prepare for current and future changes in practice

EDUCATION - systematic and sustained Ieaming activities for the purpose of

bringing about changes in knowledge, attitudes, values, and skills

EPIDEMIC - an outbreak of disease that occurs suddenly, spreads rapidly to a

large population, and continues to develop for a period of time

FEELINGS - are responses that are considered to be positive, neutral or

negaﬂve

HUMAN IMMUNODEFICIENCY VIRUS (HIV) - a virus that weakens the immune
system (the body's defense against infection) resulting in life-threatening
illnesses such as AIDS being able to ovenNhelm these defenses. HIV is
transmitted only by blood and body fluids. This contact can be via the blood
through sharing contaminated needles, via semen through direct sexual contact,

or via the placenta of a pregnant woman to her fetus

HOMOPHOBIA - abnormal fear of homosexuals

JUDGEMENT - is an evaluation an individual places on an object or situation as

to whether or not it is good or bad, right or wrong

27

LYMPH NODES - are rounded masses of lymphatic tissue found in a number of

areas of the body which act as part of the body's defense system protecting it

from bacteria and viruses
MANDATORY - an ofﬁcial command or instruction, compulsory

MENTORING - a trusting relationship between an experienced and a novice
employee for the purpose of providing exemplary support, direction, insight,

guidance, and advice to the latter with regard to the complexity of their roles

MID-CAREER NURSES - all those registered nurses who graduated between
1960 and 1980 prior to the AIDS epidemic, and who are working in the health

care system in Ontario including educational institutions and who are members

Of the Registered Nurses Association of Ontario

NATIVES (NATIVE CANADIAN TRIBES) - a person born in a certain place or

country; natural origin is in a particular region; a person belongs to a locality or

country by birth

OPINION - is an idea that an individual holds to be true and is Often shared by

her/his social group

PWAS - People With AIDS

28

PWAS - People With AIDS

UNIVERSAL PRECAUTIONS - steps taken to protect oneself from coming into
contact with blood and body ﬂuids by the use of gloves, a mask, protective

eyewear, and a protective gown

29

ORGANIZATION OF THE DISSERTATION

Chapter 1 - introduces the dissertation topic and. includes discussion about
education, health professionals, AIDS and health care, lifelong learning
and the role of mid-career professionals in the AIDS epidemic,
significance of attitudes of mid-career professionals. It discusses the
significance of the study, a listing of research questions, the identiﬁcation
of assumptions, an outline of limitations, the deﬁnitions of key terms, and

the organization of the dissertation.

Chapter 2 - includes the literature related to the study being explored and
analyzed. The chapter is divided into several sections so as to capture
the major areas of interest which form the study while providing a
backdrop against which lifelong learning and attitudes of mid-career

nurses could be understood.

Chapter 3 - provides the design and methodology of the study. It includes a

desCription of the population, survey design, information gathering, and

data analysis.
Chapter 4 - contains a presentation and analysis of the ﬁndings of the study.

Chapter 5 - summarizes the study, presents the conclusions, examines the

implications of the ﬁndings, and provides suggestions for further research.

30

SUMMARY

An examination of mid-career professionals reveals a group needing new
knowledge and skills to care for people with AIDS. In order for mid-career
professionals to remain current, they must constantly be learning and seeking
new knowledge. Due to the number of different routes for the preparation of

nurses, there is no common body of knowledge nor equality in skills.

Adult Ieaming theory and practice provides a growing body of knowledge
about the characteristics and needs of adults and about how they prefer to learn
and how they best can be taught. Developmental theorists have found that
when adults return to education at different times in their lives, they do so for
different reasons depending, in part, on their developmental stage. Being at a
-particular developmental level also has implications for how the adult perceives
and makes meaning of the situation. Although it has long been known that
adults change as they age, not until fairly recently has there been extensive
research about the process and the implications for lifelong Ieaming.
Development through the lifespan has been addressed both in terms of age-

related changes in the way the adult views the world and how she/he makes

meaning of experience.

There are many issues facing health care organizations which must be
addressed within the context of a changing environment. There is a need for

mid-career nurses to possess a solid understanding of AIDS and PWAS, their

3I

needs, and the community needs. Increased knowledge and positive attitudes
are necessary for the delivery of care to PWAS in a humanistic and holistic

manner.

It is apparent that the knowledge gained about the favorable or unfavorable
attitudes held by mid-career nurses concerning AIDS and PWAS will profoundly
affect the delivery of humanistic nursing care to PWAS in acute care settings,
and in the community. Therefore, a thorough investigation of this issue is
extremely important, timely and relevant. A person's health, or a nation‘s is an

almost priceless asset.

CHAPTER 2

RELATED LITERATURE

This study will explore education for nursing care of AIDS patients. It will
include lifelong Ieaming and mid-career professionals' attitudes towards AIDS in
general and how these attitudes affect nursing practice for PWAS. Although
research has supported the relationship berween various attitudes and many
non-nursing behaviors, few studies have been conducted on nursing
populations. Those that have been attempted are generally atheoretical,
theoretical, or descriptive studies which have not employed valid and reliable

instruments (Swanson, Chenitz, Zalor, and Stoll, 1990).

The establishment of an empirical basis for effective nursing interventions
directed at the prevention, control, and management of HIV infection in the

individual and community is crucial (Turner, 1990).

"Gaining competence occurs through new Ieaming. Life changes

trigger new learning activities and a need to become competent at

something new. The drive for competence is lifelong. "
Schlossberg, 1991

"Learning rarely occurs in isolation from the world in which the
learner lives and it is intimately related to that world and affected by
it. "

Jarvis, 1987

32

33

COLLABORATIVE LEARNING STRATEGIES

Increasing Understanding

Learning models can range from simply "depositing" materials in an
individual's mind to collaborative approaches in which educators and adult
learners are active co-Ieamers. Collaborative Ieaming strategies capitalize on
an individual's way of Ieaming through self-reﬂection and interaction with others.
Learning is deﬁned as insight. TO learn "actively" means "to process"
information rather than "to receive" input passively. Personal knowledge

evolves throughout our lives (Young, 1995).

Polanyi (1969) argued that all knowledge is personal knowledge. We cannot
"know about" anything that is outside our realm of awareness. Furthermore,
objectivity is a "false ideal". Polanyi explained that all knowledge is "subjective"
in the sense that "it has been perceived" by the person. Consequently, careful
examination of perspective is an essential part of Ieaming. Creating personal
knowledge means to increase understanding. This does not mean that our
personal opinion, values, and beliefs are "right" or that they are to be imposed
on others. We will retain unique perspectives as we construct meaning for
ourselves, inﬂuenced by our view of the past and our vision of future
possibilities. Self-reﬂection and interaction with others are the keys to the
Ieaming process. Dialogue with ourselves and with others will expand our realm

of awareness and enable us to "see" the broader view (Young, 1995).

34

Learners construct personal knowledge which has meaning, significance. and
relevance for them. We create and cherish our own opinions. However, at the
level of understanding reality, "evolving commitments" or "constructed
knowledge", we develop our understandings, while respectfully acknowledging
other views. When we accept that various perspectives exist, there is no need
to compete with others to be "right". Shared meanings and new understandings
arise through the interplay of views.

"Humanistic orientation to learning is the emphasis on human
nature, human potential, human emotions, and affect."
Merriam and Caffarella, 1991

Personal understandings evolve as new information is considered. When
learners sense a "misfit" between incoming information and their understanding,
they may feel discomfort. This phenomenon is described as "cognitive
dissonance". We make decisions about new ideas. We reject, partially reject,
incorporate, or partly incorporate new ideas. We "Choose", we "select", and we
"create", meaning for ourselves. Personal understandings are shaped by our
perceptions and our choices. Since to learn is to change, effective learning
experiences will enable personal understandings to evolve (Young, 1995).
Learners are part of an enVironment. An experience is always what it is because
of a transaction taking place between an individual and what, at the time,
constitutes the environment. Similarly, cognitive-ﬁeld Ieaming theorists describe

"lifespace" as the sphere of a person's awareness.

35

Selective Perception

We are never consciously aware of everything in our environment. We are
selectively preceptive. However, our understandings can change as our
perceptions and perspectives change. We can refocus our attention to "see"
what was previously unnoticed. Personally meaningful Ieaming enables you to
perceive the world differently—to see things you didn't see before. Everything
changes. Many "facts" that are taken for granted in a fact world are a "socially
constructed" reality. Although other "realities" are possible, the power of the

established order maintains the current state (Young, 1995).

Critical Thinking and Change

Thinking critically about the "way things are" and reﬂecting on "accepted
practice" leads to change. The widely accepted may become "unacceptable."
First comes awareness, then comes planning and working to create the desired
change. Effective Ieaming experiences encourage active involvement,
questionning, and processing of information. Long (1991) identiﬁed leamers’
experiencing, reﬂecting, and interpreting as distinct and essential parts of the
experiential Ieaming cycle. Long (1991) describes adults initiating Ieaming
projects as independent, self-directed, and goal-oriented Ieaming experiences.

Thinking about what is accepted in our society is part of developing insight.

36

Self-Directed Learners

Self-directed Ieaming is affected by context. Rather than focusing on society
or institutions, the context for Ieaming on one's own is more easily understood in
terms of the adults life situation. Learning on one's own is the way many adults
go about acquiring new attitudes, ideas, and skills. Self-directed Ieaming may
occur by design, by chance, or by a combination of the two depending on the
interests, experiences, and actions of learners and their life circumstances
(Merriam and Cafffarella, 1991). Self-directed Ieaming is open to a range of
interpretations. At one end of the spectrum, self-directed Ieaming is thought to
occur when learners detemine goals and objectives, locate appropriate
resources, plan their Ieaming strategies, and evaluate the outcomes (Knowles,
1980 and Tough, 1990). At the other end of the spectrum, self-directed Ieaming
is thought to incorporate the notion of "critical awareness" (Brookﬁeld, 1986).
These approaches to self-directed Ieaming have in common a concern with the
psychological growth of the learner (Tennant, 1988). The process of
individualization is a hallmark of growth. As individualization proceeds, the
person becomes more separate from the world and is more independent and
self-generating. Knowles (1975) emphasized that adults learn best when
working with content that is relevant, practical, and applicable to their lives.
Young (1995) recommended "real-life" problem-solving appproaches and group
work to stimulate initiative, participation, and awareness. Learning, in terms Of

development of insight, occurs not only within formal programs but also over a

37

lifetime. Collaborative strategies recognize and value the knowledge and past
experience of all participants. Collaborative Ieaming strategies are designed to

promote active processing of information and creation of new understandings.

Reﬂection

The potential of reﬂection, as a Ieaming tool, has been recognized as a way to
integrate theory and practice. The importance of reﬂection as a key Ieaming tool
in education has been emphasized by Schon (1991). Nurses, in their everyday
practice, face unique and complex situations which are insolvable by technical
rationale alone. Two types of reﬂection are identiﬁed: reﬂection-in-action and
reﬂection-on-action. Reﬂection-in-action occurs while practising and inﬂuences
the decisions made and the care given. While a nurse is consciously aware of
the knowledge used while reﬂecting-on-action, this may not be so for reﬂection-

in-action.

Reﬂection has been deﬁned as a process of internally examining and
exploring an issue of concern, triggered by an experience which creates and
clariﬁes meaning in terms of self, and which results in a changed conceptual
perspective. Schon (1991) identiﬁes three stages of reﬂection; conscious
reﬂection, criticism, and action. The ﬁrst stage is triggered by an awareness of
uncomfortable feelings and thoughts. This arises from a realization that, in a

given situation, the knowledge one was applying was not sufﬁcient in itself to

38

explain what was happening in that unique situation. This can be an experience
of surprise or inner discomfort. The second stage involves a critical analysis of
the situation which is constructive and involves an examination of feelings and
knowledge. It may be that when an nurse initially analyzes her/his existing
knowledge and applies other knowledge, an explanation of that unique situation
may be possible. The third stage involves the development of a new perspective

on the situation. Therefore, the outcome of reﬂection is Ieaming.

Open-mindedness and motivation are important skills required to be
reﬂective. While these are not skills in themselves, they are prerequisites to
reﬂection which need to be encouraged. There are certain cognitive and
affective skills necessary to engage in reﬂection. These skills have been
identiﬁed as self-awareness, description, critical analysis, synthesis, and
evaluation. Schon (1991) suggests that it is sometimes possible through a
process of reﬂection-on-action to illuminate the knowledge used. This can be
achieved both verbally and in writing. Reﬂection, therefore, must involve the self
and must lead to a changed perspective. Reﬂection, as a Ieaming tool, is a
necessary process in professional education. If Ieaming is to occur from

practice, then, reﬂection is vital (Champion, 1991).

39

Acknowledging the Experience of Adult Learners

Adult education has its own dynamics which have been shaped by a range of
disciplinary inputs such as sociology, history, psychology, economics, and
anthropology. The connection between adult Ieaming and psychological growth
involves the individual progressing through a sequence of eight stages, the last
three of which are autonomous, individualistic and integrated stages. In these
last three stages, an adult makes commitments and choices while recognizing
the relativity of social perspectives and ambiguities and contradictions in being
an adult in a social world. As individualization proceeds, the adult becomes
more separate from the world and is more independent and self-generating.
Researchers consistently cite experience as a distinguishing characteristic of

adult Ieaming (Tennant, 1988).

The idea that the experience of adults is an important resource for Ieaming is
axiomatic. One perspective regards learners as passive receivers of attitudes,
behaviors, roles, and values that are shaped and maintained by rewards and
punishments. A second cognitive perspective on Ieaming attributes is a more
active role for learners who are seen as continually trying to understand and
make sense of their experiences. In effect, learners reconstruct their
experiences to match more closely their existing rules and categories for
understanding the world. The relationship between Ieaming and experience is
interactive rather than mechanistic. A third perspective, labeled the

psychodynamic perspective, draws attention to the emotionally-laden nature of

40

the relationship between experience and Ieaming (Tennant,1988). Both the
psychometric and cognitive structuralist traditions seem to be converging on the
view that cognitive growth occurs in the adult years and that this growth is
located in the experiences of adults in everyday life (Tennant, 1988). Usually
adults experience a range of both positive and negative consequences when
participating in lifelong Ieaming. The value that the adult places on these
consequences will determine the valence (net force of attraction and repulsion)

for the adult to participate.

"Change must not be perceived as an overnight process; it does
not happen instantaneously - it is gradual and often painstaking. "

W.W. Isaac, 1995

.41

ATTITUDE AND BEHAVIOR CHANGE

Ajzen and F ishbein (1980) assert that an individual's intention to perform any
behavior in a given situation is a function Of her or his attitude toward that
behavior or the Object of that behavior and her or his perception of the social
norms governing that behavior. Attitude is a composite variable that has both
cognitive and affective components. Cognitive components are composed of
Opinions and judgements while affective components are made up of feelings.
An opinion is an idea that an individual holds to be true and is often shared by
her or his social group. A judgement is an evaluation an individual places on an
object or situation as to whether or not it is good or bad, right or wrong. Feelings
are responses that are considered to be positive, neutral, or negative and are
expressed by affective words. Behavior or the intention to behave can best be
predicted by an individual's subjective opinions, feelings, and judgements about
the behavior or the object Of the behavior, and by the individual's opinions,
feelings, and judgements about the social norms governing this behavior

(Schuman and Johnson, 1981).

Although attitude is frequently considered as a predisposition to behavior,
periodic reviews have noted the failure Of attitude measures to predict behavior.
The certainty with which attitude judgements are made may depend upon the
degree to which an individual has developed an attitude toward the
psychological object. An individual's intention to perform any behavior in a given

situation, and eventually the behavior itself, is a function of attitude toward

42

performing the behavior in that situation, her/his perception of the norms
governing the behavior in that situation and compliance with these norms

(Sample and Warland, 1973).

Attitude Theory

There is an assumption that attitudes cause, reﬂect, or, at least, correlate
substantially with behavior. Therefore, much research attention has been
focused during the past few decades on determining the power of attitudes to
predict behaviors. In examining this research, attitudes and behaviors have
been found to be related to an extent that ranges from small to moderate in
degree in most cases (Schuman and Johnson, 1981). One model, the Ajzen-
Fishbein Model of Reasoned Action, has been used frequently to predict the
relationship to attitudes of various behaviors. More recently, this model was
shown to successfully predict student nurses' intended care behaviors with AIDS
patients (Goldenberg and Laschinger, 1991). The Ajzen-Fishbein Model of
Reasoned Action asserts that a person's intention to behave in a given situation,
and eventually the behavior itself, is a function of attitude about the behavior

and the perception of norms governing the behavior (Ajzen and F ishbein, 1980).

In order for attitudes to be better predictors of behavior, there is a need for
more precise conceptualization. Attitudes can be conceptualized in numerous

ways (Schuman and Johnson, 1981) including:

43

(a) conceptual congruence—the expectation, based on reason, that a particular
attitude and a particular behavior should go together; (b) direction—either
positive or negative; (c) intensity—subjective strength of feeling reported by the
respondent; (d) centrality—subjective importance of the issue; (e) certainty-
differentiation between clearly developed versus poorly developed, weak,
ambivalent, or nonexistent attitudes; (f) proximity—the personal versus social
focus Of the attitudes; (g) speciﬁcity—congruence of measured attitudes with
speciﬁc behavioral act; (h) committed action—actions intended or taken relevant
to the issue; and (i) crystallizatiOn-attitudes that are ﬁrmly imbedded in an
individual's belief system are resistant to change. Hence attitudinal
measurement instruments are inordinately improved by constructing items that
reﬂect the variety of attitudinal properties described above. Such items should
require thoughtful consideration on the part of respondents rather than
superﬁcial reaction. Altitudinal measurement instruments need improvement in
other ways also. Multi-item indexes must be developed to achieve high
reliability. In addition, Likert scaling, which has been shown to be the best type
Of attitudinal measurement to incorporate an internal measure of strength of
feeling, can provide greater differentiation and perhaps more appropriate

ordering of respondents.

Swanson et al., (1990) reviewed the literature from 1981 to 1989 regarding
nurses' knowledge, attitudes, and practices related to AIDS and the care of

PWAS. Thirty-two studies were reviewed. These were largely atheoretical,

44

descriptive surveys of health professionals in acute care settings, lacking a
conceptual framework upon which to base the research design, measurement,
and analysis of data. Swanson and colleagues challenged future researchers to
move beyond the use of descriptive statistics to more advanced quantitative
methods that could explore the relatiOnships among variables more fully and

could also be used to test theory.

Conceptual Foundation Of Attitudes

The conceptual foundation of mid-career nurses' attitudes about AIDS was
based on the idea that nurses' attitudes about AIDS and PWAS could best be
measured by exploring their personal and social opinions, feelings, and
judgements about these two constructs. Attitudes towards AIDS and PWAS were
conceived of as either personal or normative (social). Within each of these are
affective (feelings) and cognitive (opinions and judgements) components. These
were viewed as inﬂuencing nurses' intentions to behave towards AIDS and
PWAS and their ultimate behaviors in their nursing practice (Preston, Young,

and Koch 1992).

A survey of 731 registered nurses working in rural settings which included
acute care settings, hospitals, schools, nursing homes, clinics, community health
nurses, and educators. Findings from this study indicated that this sample of

rural nurses displayed many negative attitudes towards AIDS. Approximately

45

twenty percent (20%) also expressed an overall unwillingness to care for PWAS
as well as an unwillingness to provide specific nursing care procedures to
PWAS. In addition, many reported that their families would be upset if they were
to care for PWAS in their nursing practice. In the study of rural nurses, Preston
(1994) found that negative attitudes about AIDS were related to nurses' lower
educational levels, strong religious beliefs, and lack of experience in caring for
PWAS. Several research studies have shown that nurses with negative attitudes
towards AIDS were more anxious about caring for PWAS and were more fearful
about catching the disease. Additional research has shown that fear of AIDS on
the part of nurses has resulted in avoiding the carrying out of procedures, the
attempting of extreme precautions, the lack of regard for AIDS patients, and the
unwillingness or refusal to care for these patients leading to inferior care

(Preston,Young and Koch, 1992).

46

THE MANY FACES OF AIDS

Children and AIDS

The forecast for the HIV epidemic includes increasing numbers of infected
children who will be born to infected mothers. As the epidemic progresses,
nurses will be more frequently called on to assist women in making difﬁcult
reproductive decisions. The social ostracism is perhaps as tragic to a toddler as
are frequent bouts of illness and hospitalization. The hardest part of the disease
is fear and rejection. It is hard enough for an adult to cope with; it is impossible
to explain to a child. That's why families who have a child with AIDS go

underground.

In a society where we have lost all respect and decency in the face of such a
fearful disease, is it any wonder that so many parents neither notify the
authorities nor any centre for disease control when they discover that their child
has AIDS? Children who have been sexually abused are becoming a high-risk
group. If we do not change our attitudes towards AIDS patients and children, we
will end up with many tragedies. As long as we discriminately ostracize children
with AIDS and their families, the families will prevent the sick children from
receiving the help they should be getting. As long as fathers fear losing their
jobs and mothers are stared at and not wanted at community functions, the sick
children will pay the price. The difference with children who suffer from AIDS is

that parents don't know what to tell their relatives and their other children. When

47

they do tell members of the family and friends, they often discover no one wants
to have much to do with them. There are many children dying of AIDS who have
no love, no hugs, no kisses, no toys, nor loving environment. They are doomed
to spend the rest of their lives in very expensive hospitals. They are neglected
and rejected Often with mothers too ill themselves to take care Of them. This is

what is happening now to these innocent children.

Recent studies have shown that women are now being blamed for the
escalating epidemic in much the same manner as male homosexuals are blamed
for the initial epidemic. But for women who risk infecting an infant, the blame
becomes more strident. HIV infected women are seen as selﬁsh, irresponsible,
or immoral if they choose to initiate or continue a pregnancy. HIV infected
women who choose to have an infant are often treated disdainfully (Chenitz,

1992).

Women and AIDS

Women constitute the fastest growing group of people with AIDS. Sexism
and stigma are a lethal combination in the HIV epidemic. When women are
seen as vectors of disease rather than as individuals with a devastating disease,
they become scapegoats (Smeltzer and Whipple, 1991). Women with AIDS
have a hard time not only facing the dread disease and all its consequences, but

worst of all, the dreadful and almost uniform rejection and isolation that the

48

diagnosis of AIDS causes. Old friends refuse to have anything to do with them
and will stop calling and visiting. The tendency for nurses to protect the privacy
of AIDS patients or PWAS, creates formidable barriers for investigators (Larson,
and Ropka, 1991). Studies done suggest the need for nurses to provide
accurate education and intervention based on specific needs of their female
clients. Nurses need to be aware that education, public policy, research, and
treatment programs have ignored the special needs of women. This can only be
done by nurses who continue to increase their knowledge about AIDS through
lifelong Ieaming (Smeltzer and Whipple, 1991). HIV infected women who are
mothers have an especially heavy burden to prepare for the care Of their
children who will be left motherless or orphaned. Hutchinson and Kurth (1991)
found that factors inﬂuencing HIV infected women about their pregnancy-related
decision-making included their desire for a child, their degree of child-
centeredness, the inﬂuence of family dynamics, religious faith, assessment of
risk, attitude toward abortion, degree of optimism, prior experience with
pregnancy, death of a child, fears related to childbearing pain, and their ability to
care for the child. They also identiﬁed a sense of isolation among these women
and found that most mothers continued with their pregnancies after HIV
diagnosis. Andrews, Williams, and Neil (1992) found that the burden of child-
care responsibilities, the guilt associated with exposing a child or children to
HIV, the pain associated with sharing the stigma of HIV/AIDS with their children,
as well as eventually abandoning their children emerged as important facets of

womens' experience of HIV/AIDS. The lifestyles of some women result in their

49

losing custody of their children. Relationships between mothers coping with
their HIV status and the children and others residing with them underscore the

need for nurses to approach HIV/AIDS as a disease affecting whole families.

Nurses need to trust that womens' reproductive decisions are based on their
personal assessments of what is best. Even if HIV prevention efforts are
successful, nurses, through care and knowledge, can be instrumental in
assuring that many levels of interventions are appropriately targeted to the goals
of preventing HIV infection in women and children (Bradley-Springer, 1994). In
a study done by Williams (1991) of women at risk, results showed that women
had very little information about new therapies and early interventions for HIV
infection. The women perceived themselves as capable of taking action to
protect themselves against AIDS in some situations but not in others. An
immediate need for drugs was one of the inﬂuencing situations. The impact of
AIDS heightened the isolation and mistrust which were characteristic of the

injection-drug-using community.

Women are often given the responsibility of health care of the family but not
the power to make decisions within the family. Only when more is known about
womens' roles, their knowledge, attitudes, and beliefs in AIDS prevention, will
strategies to empower women to protect themselves from HIV infection be
effective. Television was cited as the most common source of information about
AIDS by women in several studies. Failure of many women to follow

recommendations designed to reduce the risk for HIV infection suggests that

50

television is ineffective in promoting behaviors that would prevent HIV infection

and AIDS (Smeltzer and Whipple, 1991).

Natives and AIDS

Natives in Canada are dying twice as fast as non-natives and are receiving
less than half the medical care that other AIDS patients receive. In a study by a
Vancouver health care worker named Sanderson (1996), an AIDS co-ordinator
at St. Paul's Hospital in Vancouver, Canada, the records show that native AIDS
patients enter hospital at a later stage of the disease, have fewer hospital visits,
and shorter stays. They also live an average Of only three years after being

diagnosed HIV-positive which is half that of patients from the general population.

Prisons and AIDS

AIDS patients who are incarcerated in our prisons have no support
whatsoever (Kubler-Ross, 1990). They are kept in isolated rooms for months,
have no contact with other inmates, are never able to go outside into the fresh
. air and sunshine, and have no chance to exercise their already physically
weakened bodies. Without the use of a radio or TV, they sit all day in their small
cells isolated and unattended. They receive no special care and no chance to

talk to anyone about the deplorable condition that they are in. With a staff of

51

caregivers who are negative, vindictive, and revengeful, it is no surprise that
prison is the worst place to be if one has AIDS. AIDS patients are shUnned by
other prisoners and by corrections ofﬁcers as much as possible. Prisoners are
not routinely tested for AIDS when they enter the system. Anyone can be HIV
positive and until they become ill and are then transferred to a medical facility,
no one will ever know. The grimmest part of all is the ignorance about AIDS,
lack Of knowledge, understanding, and compassion for those who are terminally
ill and receive no treatment. Education of staff is focused on self-protection by
being equipped with goggles and rubber gloves in case of an accident or

incident involving blood or other body ﬂuids.

Contagion and Homophobia Related to AIDS

AIDS appears more contagious because it combines the powerful symbols of
the unknown, punishment and death. Evidence for this proposition appears in
research on nurses' attitudes towards AIDS and PWAS. Studies have shown a
positive relationship between fear of contagion and homophobia in nurses
(Campbell et al,, 1991; Martlndale and Barrett, 1992). In two different studies,
one-third of the nurses in one study and one-half in the other, mistrusted
information received about AIDS transmission which is an example of how fear
of the unknown makes all information suspect. PWAS can have a certain quality

Of life, the level of which is often in the hands of nurses.

52

SUMMARY

Health is multidimensional, therefore, nursing care also should be
multidimensional. That is, it should reﬂect a holistic approach to care. In
nursing, quality Of life should be viewed as the goal rather than as a variable.
Quality Of life can result if there is interaction among all members of the health
care team during all phases of the health care encounter. For the chronically ill,
de Tomyay (1991) suggests that to maintain quality Of life the emphasis should

be on continuity of care within a community setting.

Studies have documented the existence of fear of HIV in nurses. Although
fear of contagion decreases with knowledge of HIV transmission, it is not always
eliminated with education about AIDS as demonstrated by several surveys of
health care workers (Jemmott and Jemmott, 1991). Fear of HIV contagion ‘
appears to be common among nurses despite strong empirical evidence of the
low risk of occupational transmission to health care workers (Weiss, 1992).
Several independent surveys representing a total of 2,632 nurses, documented
that the majority Of respondents feared occupational exposure to HIV and greatly
overestimated the actual risk (Brenner and Kauffman, 1993). Thus the literature
seems to suggest that fear of contagion is more an emotional rather than a

cognitive reaction to the threat of AIDS.

Learning is a personal process and is intimately related to the world and

affected by it. Three factors are characteristic of present day society that affects

53

what adults want to learn. The first factor is the dramatic changes occurring in
the demographic base of our society. The second and third factors shaping the
Ieaming enterprise are economics and technology. Certain Ieaming activities
are leamer-initiated and others are society-initiated. Learning on one's own is
the way most adults go about acquiring new Skills and attitudes (Merriam and
Caffarella, 1991). Research has shown that adults are often motivated to
participate in Ieaming activities by changes in their lives. Learning, so essential
to human behavior yet so elusive to understanding, has fascinated thinkers as

far back as Plato and Aristotle.

Questions of access to Ieaming and the opportunity to Ieam have plagued
the adult Ieaming enterprise for most of the modern era and have become even
more troublesome in recent years. The gap between the better educated who
seek out lifelong Ieaming and those who do not continues to widen (Merriam and
Cafffarella, 1991). Can an employer require employees to attend educational
workshops on AIDS? In a pluralistic society such as ours, the question of who
decides what Ieaming opportunities to offer has no single answer. How strongly
one believes in a particular position is manifest in the choices one makes when
there are conﬂicting courses of action. Brandt (1990) writes that these beliefs
are translated into one's personal value system and it is this system that lies at

the heart of ethical practice.

54

Chapter 3 which follows, provides a description of the design and
methodology of the study including a description of the population survey

design, information gathering procedures, and the data analysis process.

CHAPTER 3

DESIGN AND METHODOLOGY

The intent of the study was to document the attitudes and opinions of mid-
career professionals on specific aspects of lifelong Ieaming; to increase
knowledge about AIDS and AIDS care, and assess the potential consequences

for nursing practice of PWAS.

This chapter provides detailed information about the research methodology

which was used by the researcher in the collection of the data.

Design of the Study

A survey research methodology was used to collect data. The rationale for
using survey research to achieve the purpose of the study was that the
researcher did not seek to explain relationships, to test hypotheses, or to make
predictions. Instead, the intent was to present the attitudes and opinions of mid-
career nurses on some very specific aspects of lifelong Ieaming. The plan was
to obtain the attitudes and opinions of mid-career nurses regarding their
knowledge about AlDSand AIDS care, experience with AIDS and AIDS care,
opinions of the barriers to and beneﬁts of lifelong Ieaming about AIDS and AIDS

care, and the potential consequences for nursing practice for People with AIDS.

56

57

The questions were provided in more detail in Chapter 1, and a copy of the

questionnaire was provided as Appendix 8.

Study Sample

The study sample was taken from a pool of approximately 7000 mid-career
nurses who were members of the Registered Nurses Association of Ontario and
were employed in nursing in hospitals, communities, colleges, and universities in
Ontario, Canada. As mid-career nurses tend to be members of the Registered
Nurses Association of Ontario, individuals were selected from various
membership categories offered by the Association. No attempt was made to
balance the sample size for male and female proportion or for any particular city
or rural area in Ontario. The sample size was two hundred and fifty individuals,
both males and females, who graduated from 1960 to 1980 inclusive (pre-AIDS ’
epidemic). The sample was randomly selected. The study sample was not-
stratiﬁed further because the researcher felt enough data was already obtained

for the purpose of this study.

A total of 10 surveys were returned as undeliverable making the effective
survey sample 240. Please refer to Table 1.1.1 on the following page for more

details.

58

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE 1.1.1
QUESTIONNAIRE RECORD

Location (City) Surveys Sent Undelivered Delivered Usable Returns

Total Total Total Total

Hamilton 30 0 30 18
Kingston 20 0 20 7
London 30 0 30 6
Ottawa 30 0 30 18
Peterboroug 10 2 8 4
Thunder Bay 10 0 10 8
Toronto 100 5 95 69
Windsor 20 3 17 11
TOTALS 250 10 240 141

 

 

 

 

 

 

 

F ifty-eight percent (58%) of the sample responded to the questionnaire.

 

59

SURVEY DESIGN

The primary method for collecting data from the mid-career nurses included
in the sample was a questionnaire survey. A copy of the full questionnaire can

be found in Appendix B.

The self-administered questionnaire was divided into ﬁve sections to facilitate
completion, data processing, and analysis. Each section was then sub-divided
with items ranging from eight to eighteen. The first four sections of the
questionnaire solicited knowledge, experience, attitudes/opinions of barriers to
lifelong learning and perceived benefits of lifelong Ieaming while the last section
was designed to collect demographic-type information. The rating scale was
constant throughout the four sections where knowledge, experience,
attitudes/opinions of barriers to lifelong Ieaming and perceived beneﬁts of
lifelong Ieaming were solicited.

A Likert scale with values from 1 to 5 was utilized for section one on the
knowledge level: 1 = Excellent

2 = Good

3=Fmr

4 = Poor

5 = No instruction on this topic
A Likert scale with values from 1 to 5 was utilized for sections two, three, and

four for experience, opinion of barriers and perceived beneﬁts:
1 = Strongly agree

2 = Agree
3 = Neutral
4 = Disagree

5 =7 Strongly Disagree

60

Participants were encouraged to add comments on the back of the survey
questionnaire. The length of the questionnaire allowed for completion of the

question in 15 - 20 minutes.

The researcher decided to construct a survey questionnaire after much
searching for an appropriate instrument. The investigator did not feel that any of
the commercially available or published instruments would have solicited the
information needed, especially since this study was not a replication of a
previous work. Much effort was put into a literature search by the researcher
who gleaned from published articles the common areas of interest, especially
those areas which were given much attention in the referenced literature. It is
the opinion of the investigator that the instrument, as constructed, was the best
tool for the topic under investigation. In the Letter of Introduction (Appendix A)

participants were assured of conﬁdentiality.

Pretest of the Survey

The survey instrument was reviewed by a selected panel of mid-career
nurses who had a wide range of experience as managers, educators and as
researchers. Twelve individuals were involved in this stage. The reviewers
were asked to evaluate the survey instrument in relation to understandability of
instructions and the clarity and completeness of the questions. The reviewers

had the additional task of completing the questionnaire as well as providing

61

feedback on clarity and understandability of the questions. Based on the
reponses and comments of the reviewers, changes were made to the draft
questionnaire. The feedback from the selected panel was very helpful in
providing suggestions for clarity and some necessary changes which were made
to the instrument before it was sent out in the ﬁnal form. The responses from the

reviewers were analyzed for effectiveness of the items.

Data Collection Procedures

The survey was addressed to two hundred and ﬁfty (250) mid-career nurses
who were current members of the Registered Nurses Association of Ontario, and
who graduated between 1960 and 1980 in the pre-AIDS epidemic. They were
also all employed in nursing in hospitals, communities, colleges and universities
in Ontario, Canada. Ontario has many large colleges and universities which
provide programs and degrees in nursing or other health related ﬁelds of study.
The researcher, being a member of the Registered Nurses Association of
Ontario, had access to a pool of approximately 7000 mid-career nurses from

which to Obtain the randomly selected individuals.

The questionnaire was sent out in the spring of 1996 to two hundred and ﬁfty
(250) randomly selected individuals from the pool with the intent of capturing the
attention of potential respondents prior to the summer holiday break. Data was

colleced over a three month period. The respondents were asked to return the

62

completed questionnaire to the researcher in the stamped, self-addressed
envelope which was provided with the survey instrument. No one wished to
provide additional information by way of a personal interview but some made
written comments on the questionnaire. A few individuals commented that they
found the survey very interesting and would be interested in the outcome of the

study.

Data Analysis

Descriptive statistics were used to analyze responses to the survey
questions. Comments and additional information provided were analyzed for
content and summarized as part of the report. The demographic information was
used for discriminant analysis using ANOVA (Analysis Of Variance).

Investigation was made into the inter-relationships of demographic variables and

the attitudinal scales.

Descriptive analysis was obtained for each statement in each section of the
questionnaire. For each attitudinal scale, a reliability analysis was performed in
order to determine the Cronbach's Coefﬁcient ALPHA (Internal Consistency of
the Scale). This provided some assurance that each item was measuring what it
was purported to measure. With a reliable scale, there is the assurance that

there is no analysis of extraneous material.

63

A factor analysis was also done to obtain a determination of whether each
scale measured only one dimension. The factor score of each scale was used
as a dependent variable for further discriminant analysis such as ANOVA and
MANOVA (Multivariable ANOVA) and multiple regression to determine group
differences such as education, experience, age etc. The data collection and
analysis from the study was extensive and required extensive data management

and statistical analysis.

The study will identify and describe attitudes which may impact on mid-career
nurses' efforts to maintain current knowledge and skills while meeting the needs
of present and future nursing practice for PWAS. The study will provide data
which could be applied to program planning for lifelong Ieaming and improved

nursing practice and care for PWAS.

64

VALIDITY AND RELIABILITY

Ensuring VALIDITY of the survey instrument was very important to this study.
The intent of each question should mean the same things to all respondents and
that responses correspond to what they are supposed to measure or determine
(Best and Khan, 1986). In this study, an attempt to assure "face" validity was
made through the panel of reviewers. Each member Of the panel of reviewers
was asked to comment on the clarity of instructions, the understood meaning or
intent of each question, and also on the coherency and completeness of the

survey as a whole.

RELIABILITY is the degree of consistency that the instrument demonstrates
(Best and Khan, 1986). It is the extent to which individuals in comparable
positions and situations will respond in similar ways. In this type of survey
design, good questions are reliable provided that there is consistency in
response in comparable situations. In other words, respondents will provide the
same answer if the questionnaire were administered at different intervals of time
in different situations. Providing consistent wording and the use of easily
understood terms goes a long way in maintaining reliability. That was another
area where the panel of reviewers provided some valuable assistance. The ﬁnal
return of useable responses was 141 of 240 assumed delivered which is ﬁfty-

eight (58%). Ten questionnaires were returned undelivered.

65

In a study of this type, the report consists of tabular presentation of the
material with explanatory text and is presented in more detail in Chapter 4 which

follows.

CHAPTER 4
ANALYSIS AND INTERPRETATION OF THE DATA

Introduction

The focus of the study is "Education for Nursing Care of AIDS Patients: A

Study Of Lifelong Learning and Mid-Career Professional Attitudes."

The purpose is to identify and describe attitudes which may impact on mid-
career professionals' efforts to maintain current knowledge and skills while
meeting the needs of present and future nursing practice of AIDS care. This
chapter reports the data collected from one hundred and forty-one (141) mid-

career nurses currently working in the province of Ontario, Canada.

Research Questions and Interpretation of Findings

The following major/primary research questions were identiﬁed because they
represented the areas of attitudes towards AIDS and AIDS care and lifelong

Ieaming.

66

67

Question 1 - What knowledge do mid-career nurses have about AIDS and

AIDS care?

The mid-career nurses agreed that their knowledge about AIDS and AIDS
care was good to fair with the exception of ﬁve issues. These issues were: the
needs of PWAS at different stages of AIDS, community resources available for
PWAS, legal and ﬁnancial needs of PWAS and their families, the quality of
education and instruction received, and the preparation of these nurses to care

for PWAS were all rated fair.

A ranking of the data showing response mean for each item of the question
regarding knowledge about AIDS and AIDS care revealed that item 1.15 (1.94)
produced the highest level of knowledge. The item receiving the lowest level of
knowledge was item 1.6 with a mean score of 3.57 followed closely by item 1.18
with a mean score of 3.50. The mid-career nurses' response to item 1.17 which
asked quality Of education and instruction received ranked poor with mean score
of 3.23. The overall response mean for the question was 2.67 and the number
of valid cases was 138. The reliability of the eighteen (18) items of this
question in the Cronbach Coefﬁcient ALPHA Internal Consistency Scale was

0.94.

68

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE 2.1.0

RESPONSE MEAN FOR EACH ITEM OF QUESTION 1

KNOWLEDGE/EDUCATION
No. Your Knomemm AIDS and AIDS Care Response

Mean

1.1 Universal Precautions procedures 2.06
1.2 Symptoms and stages of AIDS 2.68
1.3 Needs at different stgqes of AIDS 3.15
1.4 Community resources available for PWAS 3.15
1.5 Psychosocial and spiritual needs of PWAS and families 2.81
1.6 Legal and ﬁnancial needs of PWAS and families 3.57
1.7 Providing supportive care until death 2.69
1.8 Nurses' psychglggical needs (to prevent burnout) 2.67
1.9 Sources of bloodbome infections in the workplace 2.27
1.10 Primary ways of gettirﬂoodbome infections at work 2.25
1.11 Risky jobs, tasks, and work practices 2.21
1.12 Steps to be taken after an exposure incident to prevent infection 2.47
1.13 Use of Personal Protective Equipment for different tasks/situations 2.40
1.14 Limitations of Personal Protective Equipment (PPE) 2.58
1.15 Disposing of used needles and other sharp equipment 1.94
1.16 Decontaminating work areas, instruments, and equipment 2.50
1.17 Quality of education/Instruction received 3.23
1.18 Preparation to care for PWAS 3.50

 

Rating Scale - Excellent - 1; Good - 2; Fair - 3; Poor - 4;
No instruction on this topic - 5

 

69

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE 2.1.1
VALID RESPONSES, RESPONSE MEAN AND STANDARD DEVIATION
QUESTION 1
Question Valid Responses - Percent Response Standard
Items 8. Mean Devlatlon
N Values 1 . 2 3 4 ' 5
1.1 (139) 25.2 52.5 15.8 2.2 4.3 2.06 0.95
1.2(139) 7.2 31.7 48.2 11.5 1.4 2.68 0.83
1.3 Q36) 5.1 14.0 49.3 22.1 9.6 3.15 0.97
1.4 Q39) 2.9 22.3 36.0 32.4 6.5 3.15 0.93
1.5 (138) 10.1 23.9 41.3 20.3 4.3 2.81 0.97
1.6 (139) 3.6 12.2 27.3 42.4 14.4 3.57 1.00
1.7 (139) 10.8 32.4 38.8 12.2 5.8 2.69 0.99
1.8 (137) 13.9 27.7 43.8 11.7 2.9 2.67 0.97
1.9 (138) 21.0 44.2 28.3 2.2 4.3 2.27 0.98
1.10 (137) 19.7 45.3 29.2 2.2 3.6 2.25 0.94
1.11 (134) 20.9 47.0 25.4 2.2 4.5 2.21 0.97
1.12 (137) 13.1 46.7 23.4 11.7 5.1 2.47 1.03
1.13 (138) 20.6 39.0 23.5 13.2 3.7 2.40 1.08
1.14 (138L 15.9 35.5 29.7 13.8 5.1 2.58 1.11
1.15 (138) 36.2 41.3 15.9 3.6 2.9 1.94 0.98
1.16 (136) 18.4 33.8 30.1 14.7 2.9 2.50 1.04
1.17 (134) 4.5 20.9 28.4 40.3 6.0 3.23 1.01
1.18 (138) 4.3 17.4 20.3 40.6 17.4 3.50 1.10

 

 

 

 

 

 

 

 

Rating Scale - Excellent - 1; Good - 2; Fair - 3; Poor - 4;
No instruction on this topic - 5

’Reliability Coefﬁcients - ALPHA = Cronbach Coefﬁcient Alpha lntemal Consistency
of the Scale. ALPHA = 0.94.

 

70

Question 2 - What experience and education do mid-career nurses have

about AIDS and AIDS care?

The mid-career nurses were able to provide a high level of agreement on
their experience with Ale and AIDS care. The top choices are presented in
Table 2.2.0 which is a record of the Response Mean for each of the eighteen

(18) items of Question 2.

A ranking of the data showing response mean for each item of the question
regarding experience and education about AIDS and AIDS care revealed that
item 2.17 (1.98) produced the highest level of agreement that mandatory
continuing education will notmake a difference. Items 2.18 (1.92) - I regularly
pursue continuing education activities; 2.6 (1.81) - I never practice Universal
Precautions procedures; 2.12 (1.53) - protective equipment should always be
available; 2.9 (1.49) - exposure to AIDS through blood/body ﬂuids should be
reported; 2.16 (1.47) - employers should facilitate continuing education on site;
received strong agreement by respondents. The items receiving the lowest I
rating of experience/education were item 2.14 with a mean score of 3.54 and
item 2.1 with a mean score of 3.47. The overall response mean for Question 2
was 2.32 and the number of valid cases was 135. The reliability of the eighteen
(18) items of this question on the Cronbach Coefﬁcient ALPHA lntemal
Consistency Scale was 0.79. This was the lowest of all the questions. The
items 2.2 - never given care to PWAS (2.82); 2.4 - caring for PWAS has been a

negative experience (2.44); 2.6 - I never practice Universal Precautions

71

procedures (1.81); 2.7 - nursing practice should be different for PWAS (2.24); 2.8
- family members, friends, spouse/signiﬁcant other would be upset about your
caring for PWAS (2.72); 2.13 - use of protective equipment hinders performance
(2.66); 2.17 - mandatory continuing education will not make a difference (1.98);
were negatively worded in this question. Therefore, this question was not as
easy for respondents to understand, perhaps resulting in a lower reliability score

on the Cronbach Coefﬁcient ALPHA lntemal Consistency Scale of 0.79.

72

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE 2.2.0
RESPONSE MEAN FOR EACH ITEM OF QUESTION 2
EXPERIENCE/EDUCATION
No. Your Experience with AIDS and AIDS Care Response
Mean
2.1 Frequently wen care to PWAS 3.47
. 2.2 Never glen care to PWAS 2.82
2.3 Germ for PWAS has been a positive exp_erience 2.57
2.4 Caring for PWAS has been a negative experience 2.44
2.5 I always practice Universal Precautions procedures 2.10
2.6 I never practice Universal Precautions procedures 1.81
2.7 Nursing practice should be different for PWAS 2.24
2.8 Family and friends would be upset about your caringjn PWAS 2.72
2.9 Exposure to AIDS through blood/body ﬂuids should be reported 1.49
2.10 Trusts in ofﬁcial guidelines about precautions when providinggare 2.25
2.11 Experts' estimates of the risk of HIV infection are accurate 2.63
2.12 Protective eguignent should always be available 1.53
2.13 Use Of protective equipment hinders performance (i.e. dexterity) 2.66
2.14 Use of protective equipment interferes with nurse/patient relationship 3.54
2.15 Self-directed educational programs are helpful 1.81
2.16 Employers should facilitate continuingeducation on site 1.47
2.17 Mandatory continuing education will not make a difference 1.98
2.18 I regularly pursue continuingeducation activities 1.92

 

Rating Scale - Strongly Agree - 1; Agree - 2; Neutral - 3; Disagree - 4;
Strongly Disagree - 5

 

73
TABLE 2.2.1

VALID RESPONSES, RESPONSE MEAN AND STANDARD DEVIATION
QUESTION 2

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Question \falid Responses - Percent Response Standard
Items 8. Mean Devlatlon
N Values 1 2 3 4 5
2.1 (136) 3.7 23.5 10.3 34.6 27.9 2.06 1.20
2.2 (135) 20.0 29.6 7.4 20.7 22.2 2.68 1.44
2.3 (126) 9.5 28.6 54.8 5.6 1.6 3.15 0.79
2.4 (126) 16.7 25.4 52.4 4.8 0.8 3.15 0.81
2.5 (131) 25.2 40.5 26.7 6.6 3.1 2.81 0.86
2.6 (128) 43.0 32.0 23.4 1.6 0.0 3.57 0.82
2.7 (130) 23.1 43.8 14.6 15.4 3.1 2.69 1.01
2.8 (131) 19.8 32.1 10.7 33.6 3.8 2.67 1.25
‘ 2.9 (135) 58.5 38.5 3.0 0.0 0.0 2.27 0.57
2.10 (133) 24.1 44.4 18.0 12.8 0.8 2.25 1.01
2.11 (135) 8.9 35.6 40.7 14.1 0.7 2.21 0.87
2.12 (136) 53.7 44.1 2.2 0.0 0.0 2.47 0.55
2.13 (135) 8.9 35.6 35.6 17.8 2.2 2.40 0.92
2.14 (135) 2.2 5.9 39.3 42.2 10.4 2.58 0.78
2.15 (135) 31.1 56.3 8.9 3.7 0.0 1.94 0.71
2.16 £135) 54.8 43.0 2.2 0.0 0.0 2.50 0.55
2.17 (134) 24.6 59.7 9.7 3.7 2.2 3.23 0.85
2.18 (137) 34.3 40.1 19.0 6.6 0.0 3.50 0.88

 

 

 

 

 

 

Rating Scale - Strongly Agree - 1; Agree - 2; Neutral - 3; Disagree - 4;
Strongly Disagree - 5

*Reliability Coefﬁcients - ALPHA = Cronbach Coefﬁcient Alpha lntemal Consistency
of the Scale. ALPHA = 0.79.

74
Question 3 - What attitudes/opinions are shared by mid-career nurses

about the barriers which hamper their pursuit of lifelong Ieaming activities

about AIDS and AIDS care?

The respondents of the study were able to provide a high level of agreement
on which factors negatively impacted on their attempts at lifelong Ieaming
activities. The top choices are presented in Table 2.3.0 which is a record Of the
Response Mean for each of the sixteen (16) items of Question 3. The popular
choices of the top ﬁve barriers which hamper pursuit of lifelong Ieaming about
AIDS and AIDS care were items 3.15 - accessibility of educational programs
(2.28); 3.9 - inadequate course oﬁ'erings (2.41 ); 3.1 - fear of AIDS (2.51 ); 3.3 -
fear of acquiring AIDS from patients (2.56); 3.2 - social stigma attached to AIDS
(2.60). These were chosen from the list of sixteen (16) provided. The lowest
scoring item was 3.13 - continuing education is not an expectation of employers
(3.42). The overall response mean for Question 3 was 2.89 and the number of
valid cases was 136. The reliability of the sixteen (16) items of this question on

the Cronbach Coefﬁcient ALPHA lntemal Consistency Scale was 0.88.

75

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE 2.3.0
RESPONSE MEAN FOR EACH ITEM OF QUESTION 3
OPINION OF BARRIERS
No. Lifelong LeamingActivlties by Mid-Career Nurses Response
About AIDS are Negatlvely Impacted by Mean
3.1 Fear of AIDS 2.51
3.2 Social sggma attached to AIDS 2.68
3.3 Fear of acquiringAlDS from patients 2.56
3.4 Diswst when considering the immorality of IV drug abusers 3.26
3.5 Anger re caring for PWAS who contracted the disease throughg 3.17
hi h-risk sexual behaviors
3.6 Not enough information to protect myself against AIDS in the 3.18
workplace
3.7 Religious and/or spiritual beliefs 2.94
3.8 Job workload 2.79
3.9 Inadequate course offerings 2.41
3.10 Distance from home 3.00
3.11 Personal responsibilities related to home life 2.86
3.12 Lack of money 2.91
3.13 Continuing education is not an expectation of employers 3.42
3.14 Perceiving continuingeducation to be of low personal value 3.35
3.15 Accessibility of educational programs 2.28
3.16 Low erbability of increased financial reward ( no pay increase) 2.86

 

 

 

Rating Scale - Strongly Agree - 1; Agree - 2; Neutral - 3; Disagree - 4;

Strongly Disagree - 5

 

76

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE 2.3.1
VALID RESPONSES, RESPONSE MEANS AND STANDARD DEVIATION
QUESTION 3
Question Valid Responses - Perceht Response Standard
Items 8. . Mean Devlatlon
N Values 1 2 3 4 5
3.1 (137) 11.7 11.8 16.5 3.6 5.1 2.51 1.14
3.2 (136) 57.7 52.9 48.1 25.5 27.9 2.60 1.19
3.3 (133) 4.4 7.4 9.0 24.1 22.1 2.56 1.23
3.4 (137) 19.7 18.4 15.0 35.8 35.3 3.26 1.03
3.5 (136) 6.6 9.6 11.3 10.9 9.6 3.17 1.07
3.6 (135) 4.4 31.9 14.8 36.3 12.6 3.18 1.15
3.7 (137) 3.6 40.1 19.0 29.9 7.3 2.94 1.04
3.84136) 7.4 41.9 17.6 27.9 5.1 2.79 1.05
3.9 (136) 14.7 51.5 15.4 14.7 3.7 2.41 1.01
3.104134) 3.0 35.8 25.4 29.1 6.7 3.00 1.02
311(136) 3.7 44.1 19.9 26.5 5.9 2.86 1.05
3.121136) 5.1 39.7 20.6 28.7 5.9 2.91 1.04
3.13 (135) 0.7 28.9 10.4 45.2 14.8 3.42 1.08
3.14 (135) 5.2 29.6 3.7 45.2 16.3 3.35 1.19
3.15 (136) 24.3 45.6 12.5 12.5 5.1 2.28 1.08
3.16 (136) 7.4 42.6 18.4 19.9 11.8 2.86 1.15

 

 

 

 

 

 

 

 

Rating Scale - Strongly Agree - 1; Agree - 2; Neutral - 3; Disagree - 4;

Strongly Disagree - 5

*Reliability Coefﬁcients- ALPHA= Cronbach Coefﬁcient Alpha lntemal Consistency
ofthe Scale. ALPHA= 0.88

 

77
Question 4 - What are the perceived beneﬁts by mid-career nurses in
pursuing lifelong Ieaming about AIDS and AIDS care?

What are the potential consequences for nursing practice for PWAS?

The choices for perceived beneﬁts were made from eighteen (18) items. The
top six (6) items were 4.3 - increased knowledge in caring for PWAS (1.61); 4.1 -
current information about AIDS (1.64); 4.7 - increased information to protect
against acquiring AIDS in the workplace (1.66); 4.16 - increased knowledge of
how to decrease the spread of AIDS (1.69); 4.9 - increased knowledge of
community resources (1.69); 4.18 - improved nursing practice for PWAS (1.70).
The lowest ranked item was 4.14 - increased morale (2.20). The second lowest
ranked item was 4.13 - increased level ijob satisfaction (2.16). The overall
response mean for Question 4 was 1.86 and the number of valid cases was 138.
The reliability of the eighteen (18) items of this question on the Cronbach

Coefﬁcient ALPHA lntemal Consistency Scale was 0.95.

78

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE 2.4.0
RESPONSE MEAN FOR EACH ITEM OF QUESTION 4
PERCEIVED BENEFITS
No. Lifelong Leamlngfor Mid-Career Nurses About AIDS Response
and AIDS Care Provides for... Mean
4.1 Current information about AIDS 1.64
4.2 Decreased fear of AIDS 1.75
4.3 Increased knowledge in wripgfor PWAS 1.61
4.4 Increased willingness to care for babies and women with AIDS 1.83
4.5 Increased willingness to care for homosexual and heterosexual 1.97
men with AIDS 1
4.6 Increased willinLness to care for IV dmﬂrsers with AIDS and 1.96
PWAS from blood transfusions
4.7 Increased information to protect agginst acquiring AIDS in the 1.66
work place
4.8 Increased understanding of sexuality issues 1.91
4.9 Increased knowleggm of communityresources 1.69
4.10 Increased knowledge of psychosocial and spiritual needs of 1.75
atients and families
4.11 Increased comfort level in providi_ng supportive care until death 1.76
4.12 Improved communication skills 2.02
4.13 Increased level of Eb satisfaction 2.16
4.14 Increased morale 2.20
4.15 Increased decision-makingablilty 2.00
4.16 Increased knowledge of how to decrease the spread of AIDS 1.69
4.17 Increased social acceptance of PWAS 2.07
4.18 improved nursigg practice for PWAS 1.70

 

 

 

Rating Scale - Strongly Agree - 1; Agree - 2; Neutral - 3; Disagree - 4;

Strongly Disagree - 5

 

79

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE 2.4.1
VALID RESPONSES, RESPONSE MEAN AND STANDARD DEVIATION
QUESTION 4
Questlon Valid Responses - Percent Response Standard
Items & Mean Devlatlon
Values 1 2 3 4 5
4.1 (138) 39.1 56.5 4.3 0.0 0.0 1.64 0.56
4.2 (138) 36.2 53.6 7.2 2.9 0.0 1.75 0.68
4.3 (137) 41.6 55.5 2.9 0.0 0.0 1.61 0.54
4.4 (138) 32.6 52.9 12.3 2.2 0.0 1.83 0.71
4.5 (138) 28.3 50.0 17.4 4.3 0.0 1.97 0.79
4.6 (138) 27.5 52.2 15.9 4.3 0.0 1.96 0.78
4.7(138) 37.0 59.4 3.6 0.0 0.0 1.66 0.54
4.8 (138) 29.0 55.1 11.6 4.3 0.0 1.91 0.76
4.9 (138) 34.1 63.0 2.2 0.7 0.0 1.69 0.54
410(138) 31.9 61.6 5.8 0.7 0.0 1.75 0.59
4.11 (138) 34.8 55.1 8.0 2.2 0.0 1.76 0.67
4.12 (138) 26.8 48.6 20.3 3.6 0.7 2.02 0.82
413 (138) 25.4 42.0 23.9 8.0 0.7 2.16 0.92
4.14 (138) 22.5 42.8 26.8 7.2 0.7 2.20 0.90
4.15 (138) 26.1 52.2 17.4 3.6 0.7 2.00 0.80
4.16 (138) 34.8 60.9 4.3 0.0 0.0 1.69 0.54
4.17 (138) 28.3 45.7 17.4 7.2 1.4 2.07 0.93
4.18 (138) 34.8 60.1 4.3 0.7 0.0 1.70 0.58

 

 

 

 

 

 

 

 

 

Rating Scale - Strongly Agree - 1; Agree - 2; Neutral - 3; Disagree - 4;

Strongly Disagree - 5

*Reliability Coefﬁcients - ALPHA = Cronbach Coefﬁcient Alpha lntemal Consistency
of the Scale. ALPHA = 0.95

 

80

PROFILE OF RESPONDENTS

Table 2.5.0 and Table 2.5.1 provide a summary of responses to the
demographic items as requested in Section 5 of the questionnaire. That
information has been utilized to compile a proﬁle of the individuals who
participated in the study. There were 95.7% females and 4.3% males
responding to the survey. They reported the average time spent with present *
organizations was 10.4 years and the average number Of years of experience as

a registered nurse was 22 years.

As for the "Highest Level of Education" attained, this category showed that
29.8% of individuals reported diplomas from community colleges as their
educational level while 33.3% possessed a baccalaureate in nursing and 13.5%
a baccalaureate in "Other' category was reported. The completion of a masters
degree was reported by 14.2% of the respondents. There were 9.2% of the
respondents with doctoral degrees. One individual did not provide information

on the highest level of education attained.

81
TABLE 2.5.0

DEMOGRAPHICS OF RESPONDENTS

 

5.1 - SEXIGENDER

5.5 - AGE

 

 

135 - Female (95.7%)

0 - less than 30 years (0.0%)

 

6- Male (4.3%)

46 - between 30 - 39 (32.7%)

 

58 - between 40 - 49 (41.1%)

 

37 - between 50 - 59 (26.2%)

 

0 - more than 60 plus (0.0%)

 

 

5.2 - EDUCATION (nghest Level)

5.6 - PROFESSIONAL BACKGROUND

 

 

42 - Diploma (29.8%)

Clinical Specialty/Other TABLE 2.6.0

 

47 - Baccalaureate in Nursing (33.3%)

 

19 - Baccalaureate in Other (13.5%)

 

10 - Masters in NursinL(7.1%)

 

10 - Masters in Other (7.1%)

 

13 - Doctorate (9.2%)

 

0 - Other (0.0%)

 

 

5.3 - NURSING EDUCATION (Location)

5.7 - HOURS OF WORK

 

 

City/ProvinceICountry TABLE 2.5.1

95 - Full-time (70.9%)

 

35 - Part-time (26.1%)

 

4 - Casual (3.0%)

 

7 - Missmg (0.0%)

 

 

5.4 - EXPERIENCE As A NURSE

5.8 - YEARS WITH ORGANIZATION

 

 

141 Years (Mean average = 22 years)

0 - Less than 1 year (0)

 

 

 

141 Years (Mean averagg = 10.4 years)

 

 

82

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TABLE 2.5.1
DEMOGRAPHICS OF RESPONDENTS
NURSING EDUCATION
5.3 CITY NURSING EDUCATION
No. 89 Torontgj63.2%)
20 Hamilton (14.2%)
12 London (8.5%)
5 Ottawa (3.5%)
3 Peterborough (2.1%)
6 WIndsor (4.3%)
2 New York/Ann Arbor (1.4%)
1 Thunder Bay (0.7%)
2 Moncton (1.4%)
1 Montreal (0.7%)
5.3 PROVINCE NURSING EDUCATION
No. 136 Ontario (96.5%)
1 MichiLan (0.7%)
1 New York @.7%)
2 New Brunswick (1.4%)
1 Quebec (0.7%)
5.3 COUNTRY NURSING EDUCATION
N0. 139 Canada (98.6%)
2 USA (1.4%)

 

 

 

 

83

The location of where Nursing Education was obtained is shown in Table
2.5.1. The largest category for cities was Toronto (63.2%); followed by Hamilton
(14.2%); London, (8.5%); Ottawa (3.5%); Peterborough (2.1%); Windsor (4.3%);
New York/Ann Arbor (1 .4%); Thunder Bay (0.7%); Moncton (1 .4%) Montreal
(0.7%). As far as the provinces/states were concerned, the largest category was
Ontario (96.5%) followed by New Brunswick (1 .4%); Quebec (0.7); New York
(0.7%); Michigan (0.7%). Respondents reported having received "Nursing
Education" in Canada (98.6%) and the United States of America (1 .4%).
Twenty-nine percent (29%) reported "Other" clinical areas as
administration/nursing, education/nursing (61.3%) and research/nursing (9.7%).
One hundred and eleven (111) did not respond to the request for information in
this category, therefore not enough data was received to be meaningful for

further discussion.

TABLE 2.6.0

DEMOGRAPHICS OF RESPONSES
PROFESSIONAL BACKGROUND

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.6 CLINICAL VALID RESPONSES
AREA PERCENT
No.
11 Administration/Nursing 7.8%
27 Community Health 19.2%
14 Emergency/Occupational Health 9.9%
47 Medical/Surgical/Rehabilitation 33.3%
9 Obstetrics/Gynecology 6.4%
13 Psychiatry 9.2%
3 Research 2.1%
17 Gerontology/Chronic Care 12.1%
1 - Missing
141 - Valid Responses
5.6 OTHER VALID RESPONSES
PERCENT
No.
9 Administration/Nursing 29.0%
19 Education/Nursing 61.3%
3 Research/Nursing 9.7%
111 - Missing

131 - Valid Responses

 

 

85

The age of respondents showed 30 - 39 (32.7%); 40 - 49 (41.1%); 50 - 59
(26.2%). One individual did not respond to the question. The hours of work
reported showed full-time employment (70.9%); part-time (26.1%); casual

(3.0%), and seven did not report hours of work.

Table 2.6.0 provides a summary of "Professional Background" of
respondents. Respondents reported clinical areas as being in the following
disciplines: administration/nursing (7.8%); community health nursing (19.1%);
emergency/occupational health nursing (9.9%); medicallsurgicallrehabilitation
nursing (33.3%); obstetrical/gynecological nursing (6.4%); psychiatric nursing
(9.2%); research/nursing (2.1%); gerontological/chronic care nursing (12.1%).

One individual did not respond to the request for information.
Findings of the Study

The ﬁndings of this study showed that mid-career nurses were most fearful
about AIDS, the social stigma attached to AIDS, and of becoming infected by a
patient with AIDS. These three items would form the basis of sound educational
programming for in-house offerings. When offered in-house, there would be
opportunities for evaluation, follow-up and reinforcement. There has to be a
commitment frOm the organization not only to provide opportunities, but also to
provide quality opportunities which will be facilitated by competent and qualiﬁed

individuals.

86
The data indicated that mid-career nurses had a variety of academic
backgrounds but the skills and knowledge level desired for these individuals
should be the same regardless of their academic preparation and position within
the health care organizations or educational institutions. Mid-career nurses
need to change their perception of the pursuit Of professional development to

realize that it is an important part of their growth and that it is an expectation.

87

SUMMARY

A presentation and analysis of the data has appeared in this chapter. The
summary was comprised of issues for nursing practice which solicited the
attitudes and opinions of mid-career nurses regarding lifelong Ieaming, AIDS,
and AIDS care. Section 5 of the questionnaire provided demographic
information (Tables 2.5.0, 2.5.1, and 2.6.0) which included detailed information
on "Location of Nursing Education" and "Professional Background" including

clinical specialty.

The overwhelming message from the study sample was that attitude affected
the pursuit of lifelong Ieaming activities about AIDS. It was also learned from
the study sample that knowledge about caring for People With AIDS (PWAS)
was important for improving nursing practice for mid-career nurses. Targeted
skills for mid-career nurses should be Ieaming about the current information
concerning AIDS and AIDS care as the top priority. Educational programs
should be facilitated by employers and educational facilities to include on-site
courses, mentoring, and accessible programs offered by local educational
institutions. Personal enhancement of skills and knowledge should not be
interpreted as being of no beneﬁt to organizations and institutions. On the
contrary, the organization or institution stands to beneﬁt from the increased
knowledge of mid-career nurses about AIDS and AIDS care and the potential for

improved nursing practice for PWAS.

88

The activities of mid-career nurses with increased knowledge and skills
should also provide proof of the currency of AIDS care information. There was
no expectation that salary increases would be a natural outcome of the
increased knowledge and skills of these nurses but it could be an indirect
beneﬁt. Increased career opportunities for these nurses could also be an
indirect beneﬁt. Mid-career nurses are very aware of cost restraints but the
message was that creative ways could be found to sponsor lifelong Ieaming and
skill/knowledge development concerning AIDS and AIDS care in the ever-
changing health care system without adding to the ﬁnancial burden of the

organization or institution.

Increased knowledge was not perceived as a "nice-to-have" but as a
necessity based on the needs of a dynamic health care system. It was also
acknowledged that such values had to be embodied by the management
personnel of the health care organizations and educational institutions. The
overall message was that educational programs were high priorities for most
mid-career nurses but some respondents did not agree with this. Themes were
identiﬁed throughout the questionnaire that reﬂected the context in which the
respondents were experiencing the AIDS epidemic. They showed biases that
surfaced in attitudes towards PWAS, lack of knowledge about AIDS, fear of the
disease, and fear of acquiring the disease from PWAS. An understanding of
these themes is important because it helps to deﬁne the problems in caring for

PWAS as seen by the respondents themselves.

89

There were neutral responses to some items of the questions. These neutral
responses suggested that there was some ambivalence on the part of the
respondents. It is possible that the responses were inﬂuenced by the job
positions of respondents within a health care organization or educational

institution.

Chapter 5, which follows, provides a more detailed discussion Of the ﬁndings,

conclusions, implications and recommendations for future research.

CHAPTER 5

FINDINGS, CONCLUSIONS, IMPLICATIONS AND RECOMMENDATIONS

Mid-career professionals work in an environment that is constantly changing.
The external environment has caused the health care system to re-evaluate its
service delivery and re-direct its focus to such areas as community care and
patient-centered care. The system cannot be expected to provide new ways of
serving its clients without undergoing some changes itself. Many of these
changes have resulted in many nursing positions being eliminated for more cost-
effective service delivery models. For mid-career nurses to function effectively
in these changing environments, they must possess the skills and knowledge
which are demanded by the new health care organizations and the new external
environment. For some mid-career nurses, this would require a new
commitment to lifelong Ieaming but for the majority, the requirement might be a
shift in focus to recognize the value of non-traditional methods of lifelong

Ieaming to include how positive attitudes can be developed toward PWAS.

The purpose of the study was to identify and describe. attitudes which may
impact on mid-career professionals' efforts to maintain current knowledge and
skill while meeting the needs of present and future nursing practice for AIDS.
To facilitate the task, a questionnaire was developed and mailed to two hundred
and ﬁfty (250) mid-career nurses working in the Province of Ontario, Canada.

The source of the population and study sample were members of the Registered

90

91

Nurses Association of Ontario, 1996. It is the opinions of one hundred and forty-
one (141) respondents or 58% of delivered questionnaires which form the

results of this study. Questions were developed in order to address the main
question which was stated as follows: What are the attitudes and perceived
beneﬁts for mid-career nurses in pursuing lifelong Ieaming about AIDS and AIDS
care and what are the potential consequences for nursing practice for PWAS?
The responses have provided some answers and direction for assuring that mid-
career nurses will be equipped to provide the best nursing care possible for
PWAS in the future. Excerpts from written comments are interspersed with the

narrative.

92

SUMMARY OF FINDINGS

Knowledge and Education About AIDS and AIDS Care - The responses to
Question 1 showed that mid-career nurses' knowledge about AIDS and AIDS
care was good to fair with the exception of ﬁve issues. These ﬁve issues were
all rated fair —- the needs at different stages of AIDS; legal and ﬁnancial needs of
PWAS and their families; quality of education/Instruction received, and
preparation to care for PWAS. The ﬁndings should not be surprising to anyone
who is aware of the demands of the changing health care system. The new
problem of AIDS and AIDS care demands new knowledge and skills which will
. only be possible with different values and more positive attitudes towards AIDS
and PWAS. Acquiring a positive attitude towards AIDS and PWAS means
behavioral changes for mid-career nurses.
One respondent articulated her concerns in the following:

"The nurses of my vintage are generally well-trained in basic

concepts and the principles have not changed over the years.

What has changed is equipment and technnolog y. "
Another respondent stated the following:

"I believe very strongly in continuing Ieaming and education for

everyone, particularly in this rapidly changing work environment."
The respondents agreed that the quality of education/instruction about AIDS and
AIDS care had been fair to poor.
One respondent remarked:

"My only knowledge about AIDS is gained through nursing
newsletters and public information. "

93

Another respondent commented that:

"l have never had any instruction in caring for people with AIDS. "

In a constantly changing health care environment, one must be concerned
with the abililty of mid-career nurses to meet the future requirements of the
system in terms of their skills and currency of knowledge. There was an
indication that mid-career nurses remain in the ﬁeld for long periods of time and
if that is so, there is a further assumption that skills maintenance and knowledge
currency and a positive attitude towards AIDS would be concerns to be
addressed even if the mid-career nurse did not remain with the same employer
‘ but did continue to work within the health care system. The length of time that
participants remained in health care work settings ranged from 1 to 30 years with
a mean of 10 years. There were several individuals who had been employed by
their current organization for over 25 years. Health care organizations should
not be concerned about the loss of a mid-career nurse who has received
ﬁnancial assistance for upgrading skills and knowledge about AIDS and AIDS
care. More often than not, if the individual leaves the organization, the
destination will most likely be another health care organization, hence, the
training is not lost but redeployed within the health care system.

One respondent's summary of education was:

“Education is a holistic concept — clear information, concepts,
attitudes, self-awareness, stress management etc. "

94

Because health is multidimensional, nursing care should also be
multidimensional, that is, reﬂect a holistic approach to care. Within a holistic
context, an ill person does not have an illness that must be located and
eliminated. Instead, when a person is ill, there is a collaborative effort both by
the person and the health care team to manage the illness and its effects on the
person's everyday life experiences. Therefore, quality of life should be viewed
more as an accomplishment than as a variable. Accomplishment means that the
quality of life results from the interaction of all members of the health team
during all phases of the health care encounter. The holistic approach to care
requires the return of ultimate responsibility to the patient for control over her/his
health and illness. Holistic concepts include physical, emotional, cognitive,
interactional, spiritual, and political aspects of the individual. Better
understanding by nurses Of the patient's individuality can improve the quality of

care given.

95
Experience and Education About AIDS and AIDS Care - The response to
Question 2 showed that mid-career nurses were able to provide a high level of
agreement that mandatory education will not make a difference. The issue of
mandatory lifelong Ieaming activities has generated considerable debate among
health professionals, educators and legislators. Concerns have been expressed
about cost. Mandatory continuing education has always proved to be
controversial. The literature has cited concerns about the impact and effects on
Ieamer receptivity. It has been stated that mandatory continuing education does
not necessarily ensure either utilization Of knowledge or increased competence.
Proponents of mandatory continuing education have stated that it might be the
only method of ensuring participation by the majority of practitioners in the health
ﬁeld as those most in need would be least likely to participate. Preference was
stated for self-directed educational programs and employers facilitating
continuing education on site. The 1991 study by Williams showed that
respondents preferred educational program delivery modes that were short,
intensive seminars offered as night classes.
One respondent commented that:

"I am highly committed to continuing education but have not made
AIDS my specialty and therefore my knowledge is limited. "

Another respondent stated that:

"l have been involved with self-directed Ieaming since graduation in
1969, even while unemployed. I'm disappointed that many of my
colleagues do not share my views on the importance of self-
directed learning but see that as evidence of burnout and lower
morale generally with the climate of the time':

96

Comments by other respondents:
"Professional development is the individual '8 responsibility. It may
not lead to increased ﬁnancial rewards such as a new position, but
it will deﬁnitely increase nursing knowledge and skills. "

"Training speciﬁc to the job and/or work setting is the responsibility
of the employer. "

"T he employers have a responsibility to provide inservice updates
to keep all staff on top of things. Regular changes are accepted by
most nurses and as a group we have inquiring minds regarding the
advances of medicine. "

"I am a nurse in independent practice. I am not involved with AIDS-
care in my specialty and l have not sought continuing education
about AIDS. I seek continuing education in my own specialty. "

The frequency of mid-career nurses giving care to PWAS was low. This was
the reason given for the lack Of knowledge about AIDS and PWAS by the
respondents. Considering that AIDS is a disease that is of epidemic proportions
in many parts of the world including Canada and the United States, the response
of 57% never having given care to PWAS in the province of Ontario which has
the highest number of AIDS cases in Canada was very surprising. This could be
positive or negative. Closely related to knowledge about AIDS are attitudes
towards AIDS and AIDS care. Early studies Of nurses working in hospitals found
fear of contagion related to AIDS and anxiety about providing care for PWAS.
One respondent articulated her experience in the following way:

"In 1985 we had two patients with AIDS on our unit and the staff
received very good information. Since then, we have received very

few patients with AIDS which has limited my involvement and my
need for an in-depth base. "

97

Other respondents' comments:

"As a nurse and now a pastor in a church which has no PWAS
attending, to my knowledge, I have very limited contact with
volunteers or family members of PWAS. "

"I was an AIDS Educator for the local Health Department for three
and a half years (I have since left the program). My job involved
giving care in the community to PWAS and AIDS clients and their
families as well as educational Hl V/AIDS programs to high schools,
correctional facilities, nursing students, Home Support workers,
Nursing Homes, and the general public. I left the program because
I began to seriously disagree with the way the program was
directed at the Ministerial level in Ontario. "

Another respondent expressed her experience with the following:

"I have recently attended funerals of sons of two families who are
close friends of mine. These young men in their twenties were gay.
One died alter living at home with his parents for a year and a half.
He had threatened to commit suicide as his disease progressed.
The other died last week at Casey House in Toronto, Ontario. Both
families were supportive especially toward the end. They both
were appreciative of the emotional support especially since some
of the relatives such as aunts and uncles were critical and self-
righteous. I have thought of someday doing hospice volunteering
for PWAS. "

Understanding the use of Universal Precautions is crucial for designing
educational programs to modify behavior, to reduce the risk of HIV exposure to
nurses, and to improve patient care. The respondents to this study were in
agreement about knowing what Universal Precautions were and the importance
of using these procedures in HIV/AIDS care.

One respondent stated:

"Universal Precautions and procedures should be practised by all
nurses dealing with HIV/AIDS patients. "

98

Barriers - The top three barriers were identified as social stigma attached to
AIDS, fear of acquiring AIDS from patients, and fear of AIDS. The attitudes of
mid-career nurses towards caring for PWAS are important because institutional
policies regarding expectations for treatment and care of PWAS potentially affect
all staff. Negative attitudes towards PWAs can lead to avoidance, unwillingness
to provide care, poor care, and even mistreatment Of PWAS. The respondents Of
this study expressed fear and concern about AIDS and caring for PWAS.
Response to the fear of AIDS showed 69% of mid-career nurses responded
negatively.
Only two respondents made comments about these barriers:

"Hepatitis B is also a concern for nurses or anyone in the health

care ﬁeld. Whether you have been a nurse for 30years or 5 years,

it is only in the last 5 years that we, as nurses, have been

concerned abour protective measures. "

"I don't ﬁnd dealing with or caring for AIDS patients any different

from caring for other patients with infectious diseases. Certainly

much less scary than caring for polio patients years ago. "

Inadequate course offerings and accessibility of educational programs were

also identiﬁed as barriers.
One respondent articuated her concerns in the following:

"In our locality, nurses do not have easy access to any medical

library or university. I live in a tiny village. Ongoing Ieaming may be

self-directed mainly by reading professional journals obtained by

subscription only and by work experience. "

Senge (1990) has stated that individuals cannot be expected to Ieam when

they have so little time to think and reﬂect. It would appear that having activities

99

on the job premises would assist in decreasing barriers to Ieaming activities.
The inference being that it would be easier to participate during work hours.
Loebs (1992) warned that the speed of change has so many roots in the external
environment, and that the knowledge of these changes is limited to intemal staff
only so that most organizations do .not have the capacity to provide the
necessary exposure and Ieaming to keep knowledge current. If there are going
to be Opportunities for Ieaming on the job, someone has to assume the
responsibility of ensuring that the Ieaming experiences will be beneﬁcial to the

individual and also to the organization.

In this study, the prime responsibility of lifelong Ieaming activities has been
given to employers. The facilitation by the employer could be in the form of
agreeing to be part of a secondment process. The message has to be
communicated to the employers that there is an expectation for them to share
some of the responsibilities for facilitating lifelong Ieaming activities. In the age
Of budget restraints and cost cutting, employers are less inclined to budget for

lifelong Ieaming activities for mid-career nurses as a signiﬁcant ﬁnancial outlay.

The respondents in this study also assigned responsibility to the employee.
The individual mid-career nurse has a responsibility to improve and develop her
or his knowledge and skill, hence, much of the development begins with her or
him. The information from the opinions on the facilitation role should be of
interest to educational institutions by providing them with a perspective on who

should take the lead and from whom input should be received.

100
Perceived Benefits - Mid-career nurses, in their responses, showed an
agreement that increased knowledge in caring for PWAS, current information
about AIDS, and increased information to protect against acquiring AIDS in the
work place would be beneﬁts from lifelong learning activities along with
increased knowledge of community resources. Another beneﬁt perceived was
improved nursing practice for PWAS. Overall, all eighteen (18) items were
perceived to be favorable outcomes when pursuing lifelong Ieaming activities
about AIDS and AIDS care with the exception Of two items. These two items
included increased morale and increased level of job satisfaction which rated the
lowest of perceived beneﬁts. Decreased job opportunities due to the ongoing
downsizing of health care organizations and increased work-related stress could
be reasons for the low response rate to these two questions, or, the fear of AIDS
could be the motive. A mix of both is also a possibility. Respondents provided a
high level of agreement with the skills which were identiﬁed as being needed for

the future in caring for PWAS.

With the continuing decreases in the number of nursing positions in Ontario,
mid-career nurses are forced to compete for positions either within their present
organizations or within another organization. Having current knowledge and
required skills will add value to the mid-career nurse who is forced into the
competitive job market. Roberts (1993) postulated that after the year 2000 the
deﬁnition of health will be greatly expanded. Hence, in seeking lifelong Ieaming

opportunities mid-career nurse should focus on areas of future needs that are

101

not traditionally a part of the health care curricula. This study identified some

areas of future skills as perceived by mid-career nurses.

Overall, the respondents to the survey were positive about knowledge and
skill development concerning AIDS and AIDS care. There was a strong
indication that many would like to see some form of support from the
organization but at the same time they were cogniscent of ﬁnancial restraints

faced by health care organizations.

l02

CONCLUSIONS

1. Lifelong Ieaming needs of mid-career professionals must be addressed.

The changes and needs 'of the health care system with new initiatives and
new policy directives require a co-ordinated approach that will be more
supportive of mid-career nurses in their quest for new and current knowledge
about AIDS and AIDS care. Mid-career nurses must be encouraged to develop
lifelong Ieaming skills. By taking an active role in lifelong Ieaming for
themselves and their peers, mid-career nurses can decrease the fear and stress
of caring for PWAS as well as protect themselves by routinely practicing
Universal Precautions. This will allow mid-career nurses to plan their own
development and will assist them in the development of an appreciation for
further learning. Reliance on the education and professional development staff

may be lessened.

2. Attitudes towards AIDS and PWAS must be addressed.

The negative attitudes of mid-career nurses towards AIDS and the fear of
AIDS, the social stigma attached to AIDS, and the fear of acquiring AIDS from
patients need to be changed in order to improve nursing care to PWAS.
Negative attitudes have been reported by nurses on a variety Of survey
questionnaires. A survey of New England hospital nurses uncovered both AIDS

phobia and homophobia among these nurses and determined that these two

103

types of attitudes were significantly correlated. Positive attitudes towards
required knowledge and skills need to be developed in mid-career nurses

concerning AIDS and AIDS care.

Attitudes are recognized as an important inﬂuence on behavior. Therefore, in
order to improve the quality of the holistic care, including psychosocial support
and education that mid-career nurses should be providing to PWAS and their
signiﬁcant others, opportunities must be provided for positive attitude
development towards AIDS related issues. Turner (1990) warned that, failure to
combine the elements of knowledge and opportunity for attitudinal examination
and modiﬁcation of behavior may result in a nurse who, though knowledgeable,
is immobilized by personal feelings and is poorly prepared to deliver quality

care.

3. Performance appraisal systems for mid-career professionals should

emphasize professional development.

This will assist mid-career nurses to plan for their own professional
development but the performance appraisals must be done on a regular basis, at
least annually, by the employer. During a performance appraisal, among other
things, the nurse is provided with a conﬁdential summary of her/his strengths,
areas for improvement, and strategies for obtaining additional knowledge and

skill.

104
4. Partnerships should be pursued between health care organizations and

academic institutions for mid-career professionals to be more actively

involved in program delivery.

This will assist in the further development of mid-career nurses while also
providing performance appraisals where that is a regular occurrence. Part of
this facilitation is the inclusion of personal growth activities. There is much to be
gained from involvement in program delivery. It adds depth and value to mid-

career nurses' experiences.

5. A system should be organized to allow academic faculty to spend time

in health care organizations for their own professional development.

This will facilitate the building of a relationship which will provide input into
the initial and continuing education of mid-career nurses. It would also provide
partnerships for mid-career nurses' development and other collaborative
endeavours. The pursuit of professional development is an important part Of an

educator's growth and should be an expectation.

105

6. Professional development must be considered an organizational

expectation for its mid-career professionals.

The organization must have policies to support mid-career nurses'
professional development and recognize its value to the organization. This will
send a strong positive message to the mid-career nurses who, in turn, will be
more motivated to pursue professional development. Lifelong Ieaming
continually improves nursing practice regardless Of position, role, or experience.
Whether nurses are involved in direct nursing care, education, administration, or

research, nursing practice can always be improved.

7. Nursing education programs need to be established consisting of two

components: quality control and quality improvement.

The quality control component of nursing education programs involves setting
and following certain requirements for registration and maintenance of practice.
Quality control works to ensure that quality care is being provided by

appropriately prepared individuals.

Quality improvement methods for nursing education programs need to
consider both individuals and the systems in which they function in order to
identify potential problems and ﬁnd ways to prevent them from occurring. Each

mid-career nurse would be responsible for possessing and continually acquiring

106

current knowledge relevant to nursing practice. Nursing education programs
that include these quality assurance components would help mid-career nurses
to engage in lifelong Ieaming to include self-directed Ieaming for the purpose of

continually improving their nursing practice.

8. Collaborative Ieaming strategies need to be addressed.

Learning models can range from simply "depositing" material into individuals'
minds to collaborative approaches in which educators and students are active
co-leamers. Collaborative Ieaming strategies capitalize on individual ways Of
Ieaming through self-reﬂection and through interaction with others (Young,
1995). To Ieam "actively" means "to process" information rather than "to
receive" input passively. Effective Ieaming experiences encourage active
involvement, questioning, and processing of information. Creating personal
knowledge means to increase understanding. Personal understandings evolve
as new information is considered. Personal understandings are shaped by our
perceptions and our choices. Since to Ieam is to change, effective Ieaming

experiences will enable personal understandings to evolve (Young, 1995).

Tough (1990) described adult Ieaming projects as independent, self-directed,
and goal-oriented Ieaming experiences. Learning occurs over a lifetime, not
only within formal programs. Collaborative Ieaming strategies recognize and

value the knowledge and past experience of all participants. Learners work with

107

others to create shared meanings and develop understandings. Co-leamers
create shared Ieaming experiences. The goal of the experience is to deepen
understandings, create shared meaning, and develop insight through reﬂection
and interaction (Young, 1995). Collaborative Ieaming strategies are designed to
promote active processing of information and creation of new understandings.
These Ieaming strategies can be applied as we progress through our lives

building our personal knowledge and reﬂecting on our experiences.

9. The teaching and mentoring function is integral to good nursing care.

Through this, mid-career nurses take what is foreign and fearful to the patient
and make it familiar and thus less frightening. Understanding can change as
perceptions and perspectives change. Attentions can be refocused to "see"
what was previously unnoticed. Personally meaningful Ieaming enables the
individual to perceive the world differently and to see things that were not seen
before. Time and content are carefully structured so that the Ieamer can work

with the teacher/mentor on well-deﬁned, planned activities.

10. Professional support groups for nurses must be formed in Canada.

Professional support groups can be valuable in improving the attitudes and

behaviors of nurses by increasing communication, decreasing isolation,

108

increasing self-esteem, and enhancing morale through peer support. The
understanding of information, advice, and insight offered by support groups can
be very beneﬁcial. Support groups can provide encouragement to work together
in order to provide emotional support for each other. The mutual process
between one individual and another is a powerful energy presence that

promotes conﬁdence, patience, and perseverance.

109

IMPLICATIONS
What do the ﬁndings suggest for the health care system regarding mid-career
nurses' professional development? The ﬁndings showed that there was a need
for attitude change and the development of skills which would improve nursing
practice for PWAS. These changes cannot be done in isolation because the
health care system has structures, values, and procedures which demand

examination and change.

Implications for Mid-Career Professionals

All mid-career nurses, regardless of their location or professional
backgrounds, need to be prepared to deal with HIV/AIDS either through direct
patient care or educational efforts. More and more people with AIDS or PWAS
are returning to their families of origin for support and care as their disease
progresses so that in the future, most hospitals and community health agencies

throughout our country will be serving PWAS.

Less negative attitudes towards AIDS and PWAS will only result from lifelong
Ieaming and understanding. It is encouraging that affective educational
experiences have been shown to have a signiﬁcant effect towards positive
attitude change. Such experiences offer opportunities for mid-career nurses to
express their anxieties, in either a general or personal way, and examine the

causes of these anxieties to determine if they are founded or unfounded.

110

Fear of contagious diseases is not always eliminated with education as
demonStrated in several surveys of health care workers (Jemmott and Jemmott,
1991). Thus, the literature seems to suggest that fear of contagion is more an
emotional than a cognitive reaction to the threat of AIDS. Lack of knowledge
about HIV transmission is a logical predictor of fear of contagion. Several
studies showed the relationship between classes about AIDS and decreased
fear (Campbell et al,, 1991). Lower levels of fear are also associated with more
accurate scores of knowledge of transmission (F icarrotto et al., 1991). Mid-
career nurses need to ﬁnd a balance so as to avoid becoming overly committed
or dysfunctionally detached. Other studies showed that nurses who personally
knew individuals with HIV or had experience working with PWAS were
signiﬁcantly less fearful (Anderson and Kimber, 1991; Campbell et al., 1991,
Rafﬁn et al., 1993). The more people can identify with a known person with
AIDS, the less symbolic meaning is applied to the disease. Homophobia and
fear of the unknown may both represent fears of being out of control. Fear of the
unknown or the element of mystery threatens one's sense of control over
external factors. Both concepts may possibly indicate that the most frightening

aspect of any disease is the lack of control people feel concerning it.

111

Implications for Health Care Organizations

Organizations need to re-evaluate their values regarding the importance of
lifelong Ieaming activities. Greater importance has to be placed on the services
which are being Offered or should be Offered. It must be perceived as an integral
part of the organization and not as an area of budget reserve so that in times of
difﬁculty, of organizational restructuring and down-sizing, the lifelong Ieaming
activities should be given an enhanced role especially in preparing surviving
mid-career nurses for expanded and/or new roles. Education services within
health care organizations need to be kept centralized to avoid fragmentation and
compartmentalization of lifelong Ieaming activities for mid-career nurses. With a
centralized service, there will be greater ﬂexibility in meeting needs, both urgent

and non-urgent, in a timely manner.

Implications for Educational Institutions

Providers of education should seek out opportunities for alliances and
partnerships for lifelong Ieaming offerings. There needs to be a higher level of
co-operation between academic faculty and health care organizations in the
delivery of educational programs. Utilizing the resource of knowledgeable staff
in teaching roles will enhance the theoretical offerings. Academic faculty will be

well advised to spend time in the health care environment as part of their own

112

lifelong Ieaming. The increased interaction will also provide some partnership

for improving educational programs offered.

Implications for Education and Health Care Beyond the Year 2000

The forces driving change for education and health care will be economic,
demographic, environmental, social, technological, and political. Together,
these can be regrouped according to the major elements of globalization,

empowerment, technology and the economy.

Globalization refers to the holistic perspective, the ability to see the big
picture, bridge cultural gaps, and take a broad approach to education, Ieaming
and problem solving. With globalization, communication and transportation
technologies will facilitate movement of ideas, capital, and people across ﬁxed

boundaﬁes.

Empowerment will support a new leadership paradigm for the 21 st century.
The emphasis will be on continuous quality improvement, team Ieaming, more
problem-solving to reduce conﬂicts, and a more collaborative approach to health

care issues.

Technology will provide an expanded information capacity, user-friendly
accessibility, ﬂexible communication techniques. Health promotion will be

enhanced as health professionals use technology to accelerate patient Ieaming.

113

The development of integrated technological systems will create a continuum of

health care that will link a patient's home, the doctor's ofﬁce and the hospital.

Economics will be a concern due to soaring health care costs. Alternate

ways to decrease health care costs will need to be developed.

Consumers and health professionals will be affected by emerging trends in
the way health care is delivered. Some of these trends are multi-skilled workers,
health information specialists, and a new type of leadership that focuses less on
managing knowledge and more on harnessing creative energies to manage the
total health care organization. This type of leadership will view Change as an
Opportunity for innovation requiring imagination and creative experimentation.
There will be an increased ability to study outcomes of health care given by
professionals, organizations, institutions, and countries. Therapies and
treatments given to individuals will be evaluated and then the consumer will be
able to seek out speciﬁc health care professionals who establish and maintain .
effective outcomes and high standards of care. There will also be an increased
demand for effective methods of measuring resources and describing health

care processes being developed and used around the globe.

114

RECOMMENDATIONS FOR FURTHER STUDY

Education for health care professionals has to be Changed in order to meet
the health care needs of the future. Education is essential in order to keep pace
with the rapid changes in the health care system and practice. Learning will
have to be a lifelong process for all nurses. With new consumer demands,
rapidly growing information resources, and high technology, specialized nursing
courses will be commonplace. New curriculum and more collaboration between
academic and practice areas will help the design and delivery of educational
programs and nurses in academic settings will assume duties related to their
area of expertise. There will be more specialization throughout the profession
resulting in the need for more specialized educational programs. Education
programs will have to teach nurses how to be independent learners and be
capable of applying the facts and knowledge they have Ieamed. Advanced
educational preparation will be a necessity. With changing health care needs
and resources, education must prepare nurses to keep one step ahead of the

trends.

Clearly, more research needs to be conducted to deten'nine those factors that
inﬂuence the quality of care that mid-career nurses give to PWAS with a larger
population of mid-career nurses in both rural and urban settings. In addition,
future research involving mid-career nurses in other geographical locations and
settings is encouraged in order to determine similarities and differences

concerning frequency of and inﬂuences upon AIDS attitudes of mid-career

115

nurses throughout the country. Due to the voluntary response rate and speciﬁcs
of this study sample, the ﬁndings cannot be generalized to other nursing
populations. The relationship between AIDS related attitudes and actual nursing
behaviors also needs to be explored.
It is hoped that through educational efforts, more mid-career nurses will express
the attitude of one respondent in the study:

'I am not afraid of AIDS and nursing allows me to show the patients

with AIDS that they are not alone and not everyone fears them. "

Strategies for attitudes Change, such as gaining more information and
experience and more interaction with others, including PWAS, should be offered.
Mid-career nurses also need to develop better advocacy skills so that they can
advocate tor better resources for themselves and their patients in ﬁghting AIDS.
Attitude Changes cannot occur without proper education in the schools of
nursing curricula for lifelong Ieaming at all levels and in health care
organizations.

Critical thinking is an important strategy for change. Thinking critically about
the way things are and reﬂecting on "accepted practice" leads to change. The
"widely accepted" may become the "unaccepted" such as racism, ageism,
gender stereotyping, and different lifestyles. First comes awareness, then
comes planning and working together to create the desired change. Today,
more than ever, we need to examine issues in the social context, explore ways

to manage change, and Ieam how to Ieam.

116

Enabling partnerships are important for collaborative Ieaming strategies.
Education and students must come together as co-leamers to build on each
other's strengths and share responsibility for learning. Co-leamers work
together to investigate issues, collect information, reﬂect on events, explore
different viewspoints, consider other perspectives and participate in dialogue.
CO-leamers create shared Ieaming experiences. The goal of this experience is
to deepen understandings, create shared meaning, and develop insight through

critical thinking, reﬂection, and interaction.

Educators of mid-career nurses must be able to provide appropriate cognitive
and affective Ieaming experiences that will best meet the needs of this group of
nurses they are teaching. Therefore, it is recommended that educators assess
nurses' attitudes in these areas in order to better plan, implement, and evaluate
educational programs about AIDS as part of the lifelong Ieaming for mid—career
nurses. Attitudes expressed by nurses' family members should also be explored
and ways to improve communication with signiﬁcant others about their AIDS
anxieties should be taught. Workshops might even be provided for the nurses'

families.

All lifelong Ieaming courses/programs aimed at decreasing fear need to
incorporate an effective intervention to promote identiﬁcation with those at risk
for AIDS. Examples of such teaching strategies include psychodrama, personal
~ journals, structured controversy, and incorporating people with AIDS into

educational sessions. Adequate knowledge of transmission and extended

117

contact with a person with AIDS appear to be two most effective interventions for

decreasing the fear of HIV/AIDS exposure.

In addition to focusing on individual behavioral changes, AIDS service
programs must acknowledge the social context of AIDS which includes the
response of the community to the epidemic and the relationship between the
individual and the community. By taking an active role in the community
organizations and speaking out against discrimination towards persons at risk
for AIDS, mid-career nurses can decrease the public stigma of AIDS. Mid-career
nurses can be advocates for the inclusion of PWAS concerns in the development

Of public health policy and education.

Mid-career nurses are in a unique position to provide holistic care, education
and counseling, to coordinate services, and to conduct and disseminate
knowledge about HIV and AIDS. They can also provide leadership as advocates
through professional and political action. Mid-career nurses are traditionally I
concerned about health prevention and about making health care accessible to

all members of society.

As mid-career nurses struggle with what they feel and what they need to do,
they also struggle to protect themselves from feeling ovenrvhelmed. These
ﬁndings can serve as a basis for mid-career nurses who work with PWAS to
achieve and maintain a functional level Of involvement in the needs of PWAS.
The focus of the study was to identify and describe lifelong Ieaming and

attitudes which may impact on mid-career nurses' efforts to maintain current

1 18

knowledge and skills while meeting the needs Of present and future nursing
practice for AIDS care. Health care organizations are "re-organizing",
"downsizing", and "re-engineering" jobs in an effort to cope with decreased
funding and at the same time to try and satisfy client and patient needs and
expectations. These activities have caused the health care environment to be
one of constant change with demands of current knowledge of health care and
related issues. Identiﬁcation Of the issues faced by mid-career nurses in their
pursuit of lifelong Ieaming activities will help to provide insight into the needs of
the present and future health care system regarding the necessary skills and
knowledge. Without a clear identiﬁcation of the needs of PWAS, current
knowledge about AIDS and AIDS care, and positive attitudes towards PWAS,
mid-career nurses will not be equipped to provide good-quality nursing care to
People With AIDS.

"There is still much to be learned about Ieaming that takes place in

adulthood. "
Merriam and Caffarella, 1991

APPENDICES

APPENDIX A

119

APPENDIX A

LETTER OF INTRODUCTION

248 The Klngsway North
lslington, Ontario
M9A 3T5

April 2, 1996

Dear Colleague:

The problems of caring for people with AIDS has become of great concern to
nurses. This questionnaire has been developed for use as a tool to solicit the
opinions of mid-career nurses on the topic Of Lifelong Learning.

The health environment is constantly changing and some mid-career nurses
might wonder how they can maintain the knowledge and skills required to meet
future needs of the health care system. Lifelong Learning could be the way to
maintain currency.

The information you provide will be used to help improve educational programs
for nurses and nursing care of people with AIDS.

You may be assured of complete conﬁdentiality.

Completing and returning the questionnaire will indicate your voluntary
agreement to participate in this study.

Thank you for your kind assistance.

Sincerely,

Gail Skomschek
BScN., MSc., PhD Candidate

mﬂ
Enclosure

APPENDIX B

120

APPENDIX B

LIFELONG LEARNING

LIFELONG LEARNING
QUESTIONNAIRE

 

121

APPENDIX B

LIFELONG LEARNING

Rating Scale
Excellent - 1; Good - 2; Fair - 3; Poor - 4; No instruction on this topic - 5

Using the rating scale provided please indicate your level of knowledge of the
following statements '

1. KNOWLEDGE/EDUCATION

 

No. Your-Knowledge about AIDS and AIDS Care 1 2 3 4

 

 

1.1 Universal Precautions Procedures

 

1.2 Symptoms and staggof AIDS

 

1.3 Needs at different stﬂes of AIDS

 

1.4 CommurﬂI resources available for PWAS

 

1.5 Psychosocial and spiritual needs of PWAS and families

 

1.6 Legal and ﬁnancial needs of PWAS and families

 

1.7 Providingﬂrpportive care until death

 

1.8 Nurses' psymrﬂpgical needs (to prevent burnout)

 

1.9 Sources of bloodbome infections in the workplace

 

1.10 Primary ways of gettingbloodbome infections at work

 

1.11 Risky jobs, tasks and work practices

 

Steps that should be taken after an exposure incident in
1.12 order to prevent infection

 

Use of Personal Protective Equipment (PPE) required
1.13 for different tasks or situations

 

1.14 Limitations of Personal Protective Equipment

 

1.15 Disposing of used needles and other sharps

 

Decontaminaﬁng work areas, instruments and
1.16 equipment

 

1.17 Quality of education/Instruction received

 

 

 

 

 

 

1.18 Preparation to care for PWAS

 

 

 

122

APPENDIX B

LIFELONG LEARNING

Rating Scale
Strongly Agree - 1; Agree - 2; Neutral - 3; Disagree - 4; Strongly Disagree - 5

Using the rating scale provided please indicate your level of
agreement/disagreement with the following statements

2. EXPERIENCE/EDUCATION

 

No. Your Experience with AIDS and AIDS Care 1 2 3

 

 

2.1 Frequently given care to PWAS

 

2.2 Never given care to PWAS

 

2.3 Caring for PWAS has been a positive experience

 

.4 Caringﬂr PWAS has been a negative experience

 

2.5 l alwags practice Universal Precautions procedures

 

2.6 I never practice Universal Precautions procedures

 

2.7 Nursing practice should be different for PWAS

 

Family members, friends, spouse/signiﬁcant other would be
2.8 upset about your caring for PWAS

 

Exposure to AIDS through blood and body ﬂuids in the
29 workplace should be reported

 

Trust should be placed in ofﬁcial guidelines about what
2.10 precautions should be taken when providinﬁare

 

2.11 Experts' estimates of the risk of HIV infection are accurate

 

2.12 Protective equipment should always be available

 

Use of protective equipment hinders performance (hinders
2.13 dexterity)

 

Use of protective equipment interferes with the
2.14 nurse/patient relationship

 

2.15 Self-directed educational proggams are helpful

 

2.16 Employers should facilitate continuirngeducation on site

 

2.17 MandatorLcontinuirngeducation will not make a difference

 

 

 

 

 

 

2.18 l regularlypursue mntinuingpducation activities

 

 

 

 

123

APPENDIX B

LIFELONG LEARNING

Rating Scale
Strongly Agree - 1; Agree - 2; Neutral - 3; Disagree - 4; Strongly Disagree - 5

Using the rating scale provided please indicate your level of
agreement/disagreement with the following statements

3. OPINIONS OF BARRIERS

 

Lifelong Learning Activities by Mid-Career Nurses about ,
AIDS are Negatively Impacted by , 1 2 3

 

 

3.1 Fear of AIDS

 

3.2 Social stigmg attached to AIDS

 

3.3 Fear of acquiring AIDS from patients

 

3.4 Disgst when consideriryg the immorality of IV druLabusers

 

Anger about caring for a person with AIDS who contracted
3.5 the disease through high-risk sexual behaviors

 

Not enough information to protect myself against AIDS in
3.6 the workplace

 

3.7 Religious/spiritual beliefs

 

3.8 Job workload

 

3.9 Inadequate course offering

 

3.10 Distance from home

 

3.11 Personal responsibilities related to home life

 

3.12 Lack of money

 

3.13 Continuing education is not an expectation of employers

 

3.14 Perceiviggcontinuigg education to be of low personal value

 

3.15 Accessibility of educational prgrams

 

Low probability of increased ﬁnancial reward (no pay
3.16 increases)

 

 

 

 

 

 

 

 

 

124

APPENDIX B

LIFELONG LEARNING

Ratlng Scale
Strongly Agree - 1; Agree - 2; Neutral - 3; Disagree - 4; Strongly Disagree - 5

Using the rating scale provided please indicate your level of
agreement/disagreement with the following statements

4. PERCEWED BENEFITS

 

Lifelong Learning for Mid-Career Nurses about AIDS and I
No. ‘ w , AIDS Care Provides for * ‘ ' w 1 2 3 4

 

 

4.1 Current information about AIDS

 

4.2 Decreased fear of AIDS

 

4.3 Increased knowledgin caring for PWAS

 

Increased willingness to care for babies and women with
4.4 AIDS

 

Increased willingness to care for homosexual and
4.5 heterosexual men with AIDS

 

Increased willingness to care for IV drug users with AIDS
4.6 and PWAS from blood transfusions

 

Increased information to protect against acquiring AIDS
4.7 in the work place

 

4.8 Increased understanding of sexuality issues

 

4.9 Increased knowlegge of community resources

 

Increased knowledge of psychosocial and spiritual needs
4.10 of patients and families

 

Increased comfort level in providing supportive care until
4.11 death

 

4.12 Improved communication skills

 

4.13 Increased level of job satisfaction

 

4.14 Increased morale

 

4.15 Increased decision-making ability

 

Increased knowledge of how to decrease the spread of
4.16 AIDS

 

4.17 Increased social acceptance of PWAS

 

 

 

 

 

 

 

4.18 Improved nursing practice for PWAS

 

 

 

125

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPENDIX B
LIFELONG LEARNING
5. DEMOGRAPHICS
No. Seleender No. Age
5.1 Female 5.5 less than 30
Male 30 - 39
40 - 49
50 - 59
60 plus
5.2 Education (Highest Level) 5.6 Professional Backgound
Diploma Clinical Specialty
Baccalaureate (Nursing)
Baccalaureate (Other)
Masters (NursingL Other
Masters (Other)
Doctorate
Other
'53 Nursing Education (Location) '57 Hours of Work
City Full-time
Province Part-time
Country _ Casual
5.4 Experience as an RN 5.8 Years with Ogganization
Years ~ Less than one (1)
Number of Years

 

 

 

 

 

THANK YOU FOR YOUR TIME AND EFFORT IN COMPLETING THIS SURVEY
PLEASE ADD ANY FURTHER COMMENTS YOU MAY HAVE ON THE BACK

 

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