AIDS knowledge and attitudes among nursing home staff.

This sampling both inspires confidence and raises concerns

In view of the tremendous publicity in the popular media about HIV infection, its modes of transmission, persons at risk, and ways of preventing contagion, the general public is already expected to be aware of the basic facts about the disease and the AIDS epidemic. Nursing home staff receive additional training on these topics and in the use of specific methods of precaution which should further increase their levels of understanding and clinical confidence. To test whether these workers believe in fact that they are sufficiently knowledgeable about HIV, and sufficiently confident in the use of precautions -- and will thus not shirk from fully caring for persons who may be HIV-positive, should the occasion arise -- we conducted an exploratory study of 120 staff members in two nursing homes.

Equal numbers of staff were selected in six categories: nurses, certified nursing assistants, laboratory technicians, and dietary, maintenance, and housekeeping workers. These categories include staff who may experience direct contact with the body fluids of nursing home residents. The staff members responded anonymously to a written questionnaire that centered on their attitudes about HIV/AIDS, how they were informed, the relative influences of different sources of information and values, and their personal preferences in giving care to residents with HIV/AIDS. The survey elicited a 100% response.

Findings

A. Information about HIV/AIDS

1. On-the-Job Training - Of the 120 respondents, only 7.5% reported receiving no on-the-job training about HIV/AIDS. This represents staff in every category. Although the majority were trained, this finding did not characterize the adequacy of that training, nor did it address the question of risk management in permitting untrained staff to function.

2. Non-Work-Related Information Sources - The popular media are the most utilized for this. Most respondents -92.5% got information about HIV/AIDS from newspapers and magazines, followed by radio and TV sources -82.5%. In descending order, other sources reported were professional journals -58.3%, professional seminars -35.8%, and churches -1.6%.

The fact that popular media overshadow professional sources of information is, in itself, not surprising. But 41.7% of the respondents reported that outside sources gave them information that they had not received in on-the-job-training.

The finding raises questions as to the completeness, accuracy, and consistency of information conveyed to the staff.

B. Other Influences on staff understanding and attitudes about HIV/AIDS.

1. Staff were asked whether they personally know someone with HIV/AIDS other than a resident in their facility. The 33.3% affirmative responses included every staff category.

2. When questioned whether religious values help them to better know their own beliefs about AIDS, 55% of staff indicated that their values in confronting AIDS and its moral overtones may be shaped or influenced by the values of their families. Staff were asked whether their beliefs about AIDS agreed with those of their immediate families. Although 35% said that there was no difference, a sizable majority -- 61.7% -- reported some difference. This suggests that formal on-the-job HIV/AIDS education does have an impact on staff understanding.

C. Perceptions of health care workers at risk

Staff were asked to rank various health care workers according to their relative degree of risk for contracting HIV from an infected resident. Responses were constant across all categories: those persons considered at greatest risk, in descending order, were: surgeons, dentists, laboratory technicians, nurses, and housekeeping, food service, and maintenance workers.

D. Staff confidence in their training and in the efficacy of precautions.

1. Despite their training, a corps of skeptics existed. Staff were asked whether training would be effective in preventing the spread of HIV in their facility. Although 88.3% said yes, 11.7% said no. Laboratory technicians were the most doubtful - 30.0% said no.

2. Posing this question another way, staff were asked whether methods of precaution would prevent the spread of HIV in their facility. Although 85.8% said yes, 14.2% were negative.

Though the negative responses to these first two questions represent a minority of the respondents, they do, however, reflect a lack of confidence sufficient to raise a concern about potential problems in staffing and morale.

3. Staff were asked whether residents with AIDS should be located in a specialized AIDS unit, housed in a separate building, or permitted to remain in integrated general care units. The majority of respondents - 65.8% - opted for integration, but a sizable minority - 28.3% - preferred a separate unit.

These choices may be better understood in the light of responses to another question. Staff were asked their views about persons with HIV/AIDS. Their responses appear in the Table.

4. The overall sympathetic attitude about the rights of persons with HIV/AIDS is reflected in the willingness of many staff to care for them. But there is a sizable minority who are not willing to do so. When asked if they would worry about caring for such residents, even with precautions, 66.7% of respondents said no, but 33.3% said yes.

E. Willingness to accept risk

1. When asked if they would be willing to work in a specialized AIDS unit, 50.0% of the respondents said no. This seems to contradict the response to the prior question, in which only 33.3% of the respondents admitted to having concerns even with precautions. However, there is a difference between a general care unit and a specialized unit. Residents with HIV/AIDS may be scattered around a general care unit, or several units, and be few and far between, thus minimizing staff exposure. Staffing assignments may even preclude a given staff member from any exposure at all. But in a specialized unit there is no escape from constant exposure. The odds of accidents and mistakes, and therefore contagion, are greater. The fear factor rises, as well.

2. In a question designed to disclose ultimate commitment, staff were asked if they would consider leaving health care if more residents with HIV/AIDS were admitted because of the growing epidemic. The professionals among the staff were most divided on this, with 50% of the nurses and laboratory technicians saying yes. Moreover, three-quarters of the CNAs said yes. The nonprofessional workers were less willing to leave.

Conclusions

Training about modes of infection of HIV, and precautionary measures, should be reviewed in the nursing home. Its content should be both comprehensive and consistent with what is reported in the popular print and broadcast media.

The management of training should be such that no worker who is at risk of exposure to HIV is permitted on the job without having completed training. This is underscored by the perceptions of nursing home respondents that nonprofessional staff are the least likely to be contaminated. Such a view imparts a false sense of security.

Improved training and monitoring may also contribute to greater confidence among workers as to the value of training and the efficacy of precautions.

The majority of respondents favored the integration of residents with AIDS on a general care unit rather than their placement in a specialized unit. This seemed preferable to all parties, perhaps because, for residents and their families, integration minimizes isolation and stigmatization.

Finally, this brief exploratory study points up the value of knowing staff perceptions, values, and attitudes. In view of the actual and potential involvement of long-term care in managing this epidemic, we suggest that each facility undertake a similar survey.

TABLE: Sample Verbatims

Lab Tech: "Working as a medical laboratory tech and with the introduction of universal precautions, AIDS inservices, media, and the assistance from infection control, I personally do not have any fear of coming into contact with AIDS patients or any bloodborne diseases.

"However, I do have some concerns about how blood and body fluids and mouth pipetting procedures were handled before AIDS education and universal precautions became mandatory."

Housekeeping Staffer: "Employees in the housekeeping department are not intimidated by the prospect of having to clean rooms where AIDS patients could be residing.

"It is the general consensus that if employees are aware of the inherent dangers of the disease and are prepared to encounter these dangers, no problem exists. If employees are supplied with the necessary equipment and products to do their jobs properly and to protect themselves, all the while following directions given by the infection control department with several inservices, there is no danger. Universal precautions are a must."

Dietary Staffer: "I have no problem preparing or serving food to AIDS patients. I have had AIDS inservices on the job, keep up with the media, follow universal precautions and protect myself with the equipment provided I can deal with this in my job.

"My family has more concerns than I do regarding working in an environment where AIDS exists."

Maintenance Staffer: "I have a wife who is a nurse. I have had several inservices on AIDS education and universal precautions. Before this I feared bringing something home to my children, but being knowledgeable about the transmission of the disease 'AIDS' I can work in an environment where AIDS patients might reside."

Nurse: "Being a nurse in the health care profession you have to be careful and cautious with everyone you treat.

"AIDS is a disease for which there is no cure, so I have to be honest and say I am concerned and somewhat afraid. However, we must remember that patients are people too, and they deserve the same care and compassion we would give someone else, without discrimination.

"Also I feel that the health care worker should be told who has AIDS, maintaining confidentiality, of course."

Attendant: 1. "Utilizing universal precautions and protecting yourself is a must when dealing with everyone, not just AIDS patients. Once you learn this you treat everyone without discrimination.

"However, I feel that on a need to know basis, and maintaining confidentiality, those at risk should be told who has AIDS. AIDS can strike anyone, rich, poor, young, old and many times, through no fault of their own, people accidently contract AIDS -- for example from tainted blood, needlesticks, etc."

2. "I have friends who have died of AIDS and I have compassion for those with AIDS."

Paul L. Selbst, PhD, is Professor and Director of the Master in Health Administration Program, Saint Joseph's College, Windham, ME. Josephine R. Alves, RN, MHSA, is Supervisor of Infection Control at the Rhode Island Veterans Home, Bristol, RI.