RESEARCH BRIEFSHIV/AIDS Nursing Care: Instrument forMeasuring Students' Attitudes and PrecautionsKatherine Wiley, RNC, EdD; John Edwards, PhD; Patrick Smillie, BS; Linda Heath, PhD; and Marvin Acklin, PhD

Amajor challenge for nursing facul-ty is to teach and evaluate all as-pects of the HIV/AIDS curricu-

lum, including knowledge of and compli-ance with universal precautions. To ad-dress this challenge, an instrument wasdeveloped and administered in 1991 andrevised and administered again in 1993.The purpose and intended use of thisinstrument is to survey students' atti-tudes toward nursing HIV-seropositive pa-tients and document their self-reportedunderstanding of and compliance withuniversal precautions.

Several researchers have reportedstudies of health care professionals or stu-dents regarding attitudes and hehaviorsrelated to care of AIDS/HFV-infected pa-tients (Goldenberg & Laschinger, 1991;Kelly, St. Lawrence, Hood, Smith, & Cook,1988; Lawrence & Lawrence, 1989). How-ever, few researchers have published briefinstruments which were validated usingnursing students.

One such attitude instrument(Bliwise, Grade, Irish, & Ficarrotto, 1991)was developed for use in research on stu-dents in a variety of health care profes-sions, and it was validated using two dif-ferent cohorts of medical and nursing stu-dents. That instrument contains 15 itemsand has a Cronbach alpha coefficient of.86. The suhscales and Cronbach's coeffi-cients for the total scale are Fear of

Dr. Wiley is Associate Professor, Maternal ChildHealth Nursing, Dr. Edwards is Associate Pro-fessor, Mr. Smillie is a Graduate Student, and Dr.Heath IS Professor, Department of Psychology,Loyola University, Chicago, Illinois; and Dr. AcklinIS a Clinical Psychologist in Honolulu, Hawaii.

Address reprint requests to Katherine Wiley,RNC, EdD, Loyola University Chicago, 6525 NorthSheridan Road, Chicago, IL 60626.

Contagion (.65), Negative Emotions (.70),and Professional Resistance (.75). Thesecoefficients suggest good internal consis-tency. However, the Bliwise, Grade, Irish,& Ficarrotto instrument deals only withattitudes and not with universal precau-tions.

The only instrument of known mea-surement properties that addresses hothattitudes and compliance with universalprecautions is the HIV-Impact Question-naire (Wiley, Heath, Acklin, Earl, & Bar-nard, 1990). That 15-item scale was usedto survey registered nurses on three sub-scales: Precautions, Worry and Policies,Eind Job Change. Cronbach's coefficientfor the total scale was .61, and for thesubscales, .51, .76, and .76, respectively.This instrument has the advantages ofsatisfactory reliability coefficients as wellas the dual focus on attitudes and uni-versal precautions.

However, Wiley and colleagues (1990)tested their instrument with a sample ofregistered nurses, not students. The needremained, then, for an instrument to as-sess the impact of AIDS/HIV infection in-struction on student nurses' attitudes aswell as their understanding of and com-pliance with universal precautions. Thisdual focus is important in order to explorethe possibility that the primarily late ado-lescent student population would considerthemselves invulnerable (Weinstein,1984) and therefore be less likely toreport compliance with universal precau-tions. The present report describes thedevelopment, measurement propertiesand potential uses of the second revisionof the HrV-Impact Questionnaire: StudentForm for measuring nursing students'attitudes about, and precautions in,HIV/AIDS patient care.

Method

Participants—The sophomore, junior,and senior nursing classes at a mid-sized,urban CathoUc university participated inthis study after they had completed clini-cal courses for that year. About a third ofthe junior and senior classes were placed,during their sophomore year, on an AIDSunit for their initial clinical course.Because of the high mortality rate of rela-tively young persons, faculty selected stu-dents whom they believed were more psy-chosocially mature for placement on theAIDS unit.

Demographic data for this school indi-cate that 75% of the students repwrt thatthey are Catholic; and 55% Caucasian.About 90% of these students are age 20 to23. Approximately 230 students receivedthe instrument, and 190 (83%) completed it.

Instrument—The instrument pre-sented to the students was a 28-item scalecalled the HIV-Impact Questionnaire:Student Form. It was a third revision of aninstrument (hut the second revision of thestudent form) used to survey this samepopulation in 1987 (Wiley, Heath, &Acklin, 1988). The original instrumentaddressed the concept of personal suscep-tibility (Becker, 1974), and it queried stu-dents about their perceptions of risk ofbecoming HIV-infected while givingpatient care. That 66-item pilot instru-ment used several different types ofresponse options. Students said theyfound it confusing and that they spentabout 45 minutes completing it. Only 36%returned completed questionnaires.

The first revision of the 1987 instru-ment was developed to survey a registerednurse population (Wiley, Heath, Acklin,Earl, & Barnard, 1990). For the RN survey.

230 Journai of Nursing Education

bKlKKS

15 statements were selected from the orig-inal instrument, and respondents ratedthe items using a Likert-type responsescale. The response rate to the survey was54%; 323 nurses responded. Cronbach'scoefficient for the 15-item scale was .61;three subscales were identified.

In 1991, when the 15-item registerednurse questionnaire was adapted for thestudent population, some items wererevised and others added to improve thereliability of the three subscales. Toaddress content validity of the StudentForm, one of the non-nursing authors dis-cussed the instrument with a group ofclinical nursing students. These students'comments were used to add new items andrevise other items in the 1991 and 1993instruments.

The 1991 edition of the HIV-ImpactQuestionnaire: Student Form was admin-istered to sophomores and juniors duringthe last class of the year. The responserate was 99%; 118 students responded.Recognizing that the sample size wassmall for factor analyses, the authorsexamined with caution several analyses.The best fit was a seven-factor solution ofWorry (4 items). Satisfaction (3 items).Refusal (4 items). Prevention (2 items).Precautions (3 items). Job Change (2items) and Test Results (1 item). One itemdid not load on a factor. Cronbach's coeffi-cient for the entire scale was .78.

In Spring 1993, the instrument wasrevised using the above data. Eight itemswere added, including ones about stu-dents' confidence in universal precautions.The questionnaire presented to studentshad 28 items.

At the top of the instrument, studentswere informed that HFV-seropositive bodyfluids "excluded those body fluids consid-ered to be lowly infectious, such as blood-free saliva, tears and urine." For the 28statements, students were instructed tomark one of four responses: stronglyagree, agree, disagree, and strongly disag-ree. In the statements, the phrase "HTV-seropositive patients" was used; there wasno distinction made between HTV-infectedpatients and AIDS patients. And, althoughstudents have been taught "Body Sub-stance Isolation," the term "UniversalPrecautions" was used throughout be-cause the latter term is more widely used.

Procedure—For the sophomore andjunior classes, the survey was conducted

during the last non-exam class of the year;for the senior class, it was conducted atthe end of a final exam. Students wereinformed that participation in the re-search was voluntary and that their res-ponses were anonymous. They were alsoinformed that no nursing faculty wouldsee the students' responses, and that apsychology graduate student would tabu-late the data and keep the raw data in hispossession. The consent form was "signed"by having the student choose two digitsand writing those digits in the two blankspaces provided.

Of the approximately 230 studentswho were asked to participate, 190 com-pleted the survey. The sophomore classhad the lowest response rate (80%); theresponse rate for the three classes togeth-er was 83%.

Results and Discussion

Afler tabulating the percentages ofagreement with each item, responses toapproximately half of the 28 items werereverse scored so that higher scores indi-cate a more favorable orientation towardHIV/AIDS patient care. The Table lists thereverse scored items as well as the per-cents of agreement before the items werereverse scored.

Using Factor Analysis with MaximumLikelihood Extraction and Varimax Rota-tion, the 28-item instrument was ana-lyzed, and items with low factor loadingswere deleted and the resulting 22-itemscale was analyzed. The following discus-sion reports the findings of the 22-itemscale analysis.

The seven factors of the 22-item scaleand the percent of variance accounted forare found in the Table. Although the 1993analysis included the same number of fac-tors as were found in the 1991 analysis,the best fit solution was slightly differentthan the solution foujid in the 1991 study.Both the 1991 and 1993 factor analysessuggest these five factors: Satisfaction(items 1, 12,13, 21, 22), HIV-testing (items8, 9,15, 16, 19, 20), Refusal of Assignment(items 17, 18), Precautions (items 4, 5),and Prevention (items 3,10,11). However,for the purpose of clarity, the Preventionfactor was retitled. Confidence inUniversal Precautions. In addition, the1993 analysis suggested that the WorryFactor be divided into two separate fac-

tors: I worry (items 2,7), and Others worryitems (6,14). Lastly, the Job Change factorfound in the 1991 study was deleted andone of the items formerly found in JobChange loaded on the satisfaction factor.

Cronbach's coefficients for the sevenfactors are: Satisfaction (.80), HTV-testing(.72), Knowledge/Use of Universal Pre-cautions (.75), Others Worry (.79), I Worry(.71), Confidence in Universal Precautions(.61), and Refusal of Assignment (.63).Cronbach's coefficient for the 22-itemscale was .82.

Also included in the Table are the p)er-cents of agreement with the statements.For the purpose of reporting the resultsconcisely, the authors combined the res-ponses of strongly agree and agree into a"percent of agreement" total. When read-ing these percents, the reader should keepin mind that the students may haveresponded in the manner they believedwas wanted by faculty. No measure of"social desirability" (or lying) was used.

There was 100% agreement with item4 (I understand the guidelines for univer-sal precautions), and 99%- agreement withitem 5 (I routinely follow universal pre-cautions for all patients). Also, 96%> agreedwith item 3 (On-the-job exposure to HIV-infection can be prevented if nurses useblood and body fluid precautions for allpatients) and 64% agreed with item 11 (IfI always use universal precautions, thereis virtually no chance of me becoming HFV-infected during my nursing practice).These percents of agreement suggest thatstudents have confidence in universal pre-cautions but also know that accidentalexposure can happen.

Generally speaking, the students ex-pressed satisfaction with nursing HTV-seropositive patients. Unfortunately, be-cause students were not randomly as-signed to the AIDS unit, conclusions can-not be drawn about the causal role of theAIDS unit experience in influencing theirattitudes.

In future research, larger and diversepopulations will be surveyed to enable theresearchers to analyze further the validityof this instrument. These replication stud-ies also will enable faculty elsewhere toevaluate their teaching of HFV-relatedcontent.

Although brief enough to be complet-ed in less than 15 minutes, the HIV-Impact Questionnaire: Student Form

May 1996,Vol. 35, No. 5 231

VII. REFUSAL OF ASSIGNMENT (4.5%)17.* If I were given the option, I might, under some circumstances, refuse assignment

to HIV-seropositive patients.18.* Agencies should permit nurses to refuse, under selected circumstances, assignment

to HIV-seropositive patients.

'Item recoded after percents of agreement were calculated.Cronbach alpha coefficient for total scale=.82.

Factor

Loading

.74

.75

.42

.62

.68

Percent

Agree

80%

75%

95%

20%

43%

.53

.65

.97

.67

.60

.61

.57

71%

TableResults of Factor Analyses Using Maximum Likelihood Extraction and Varimax Rotation and Percents of

Agreement with Statements

Name of Factor (Percent of Variance Accounted for)

Statements in Factor

I. SATISFACTION (22.8%)1. I find it a satisfying and rewarding experience to give direct nursing care to

HIV-seropositive patients.12. Working with HIV-seropositive patients gives me opportunities to face many

of the challenges that attracted me to nursing.13. All HIV-seropositive patients deserve the same compassionate nursing care

regardless of how they became HIV-infected.21.* If I were given the option, I would routinely refuse to be assigned to HIV-

seropositive patients.22. When I graduate, I will consider working on a unit that has a high census of

HIV-seropositive patients.

II. HIV TESTING (11.2%)8.* All patients should be tested for HIV upon admission to the health care agency.9.* As soon as HIV test results are available, nurses who give direct nursing care to

a patient should be informed of that patient's HIV test results.15.* Student nurses should be tested annually for HIV infection.16.* If a student nurse tests positive for HIV, her/his faculty should be informed that

she/he is HIV-seropositive.19. An HIV-seropositive nurse who is asymptomatic should be allowed to give all

types of nursing care.20.* If a nurse is HIV-seropositive, her/his patients should be told their nurse's HIV

status if the patient asks about it.

III. KNOWLEDGE/USE OF UNIVERSAL PRECAUTIONS (8.5%)4. I understand the guidelines for universal precautions.5. I routinely follow universal precautions for all patients.

IV. OTHERS WORRY (7.3%)6.* My family and friends worry about me becoming HIV-infected during my

nursing practice.14.* Because of the AIDS risk, my family and friends are worried about me becoming

a nurse.

V.I WORRY (6.1%)2.* Because of my clinical practice, I worry about exposing my family and friends

to HIV infection.7.* Because of my clinical practice, I worry about being exposed to HIV infection.

VI. CONFIDENCE IN UNIVERSAL PRECAUTIONS (5.3%)3. On-the-job exposure to HIV infection can be prevented If nurses use blood and body

fluid precautions for all patients (called universal precautions).10. Even in busy situations, I am able to prevent my exposures through broken skin or

mucous membranes, to all blood and other infectious body fluids.11. I f l always use universal precautions, there is virtually no chance of me becoming

HIV-infected during my nursing practice.

.45

.64

.62

.34

.60

.86

.67

93%47%

54%

47%

57%

lOO"/,99%

60%

37%

45%61%

42

55

72

96%

77%

64%

46%

68%

232 Journal of Nursing Education

yields both a reliable overall score as wellas suhscale scores for several aspects ofAIDS/HIV-related teaching of nursingstudents. Included in the subscales isdocumentation about students' self-reported understanding of and compli-ance with universal precautions.

References

Becker, M. (Ed.). (1974). The health beUefmodel and personal health behavior Health

Education Monograph, 2(4), 409-419.Bliwise, N., Grade, M., Irish, T, &

Ficarrotto, T. (1991). Measuring medical andnursing students' attitudes towards AIDS.Health Psychology, 10(4), 289-295.

Goldenberg, D., & Laschinger, H. (1991).Attitudes and normative beliefs of nursing stu-dents as predictors of intended care behaviorswith AIDS patients: A test of the Ajzen-Fishbein theory of reasoned action. Journal ofNursing Education, 30, 119-126.

Kelly, J., St. Lawrence, J., Hood, H., SmithJr., S., & Cook, D. (1988). Nurses' attitudestoward AIDS. The Journal of ContinuingEducation in Nursing, 19, 78-83.

Lawrence, S., & Lawrence, R. (1989).Knowledge and attitudes about acquiredimmunodeflciency syndrome in nursing andnon-nursing groups. Journal of ProfessionalNursing, 5(2), 92-101.

Weinstein, N. (1984). Why it won't happen tome: Perceptions of risk factors and susceptibili-ty. Health Psychology, 3(5), 431-457.

Wiley, K., Heath, L., & Acklin, M. (1988).Care of AIDS patients: Student attitudes.Nursing Outlook, 36(5), 244-245.

Wiley, K., Heath, L., Acklin, M., Earl, A., &Barnard, B. (1990). Care of HIV-infectedpatients: Nurses' concerns, opinions, and precau-tions. Applied Nursing Research, 3(\), 27-33.

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