Nurse Education Today 34 (2014) 929–933
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Attitudes towards HIV/AIDS patients and empathic tendencies: A study of Turkish undergraduate nursing students Aylin Aktaş Özakgül a, Merdiye Şendir a,⁎, A. Serdar Atav b, Belkız Kızıltan c a b c
Istanbul University, Florence Nightingale Faculty of Nursing, Istanbul, Turkey Binghamton University, Decker School of Nursing, Binghamton, NY, United States Gümüşhane University, School of Health, Gümüşhane, Turkey
a r t i c l e
i n f o
Article history: Accepted 21 October 2013 Keywords: Nursing education Nursing student Human Immunodeficiency Virus (HIV) Acquired Immunodeficiency Syndrome (AIDS) Empathic tendency Attitude AAS SET
s u m m a r y Background: Studies indicate that the attitudes of nurses, nursing students, and other health care professionals towards Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) patients are affected by cultural differences and the fear of HIV/AIDS infection, resulting in both negative attitudes and reluctance to care for these patients. Empathy is critical for all health professionals in the delivery of effective care. Research indicates that as empathic tendencies develop, so do better communication skills, better attitudes, and better quality of care. Objectives: The purpose of this study was to examine the relationships among demographic factors, familiarity with HIV/AIDS, attitudes towards HIV/AIDS, and empathic tendencies in a Turkish sample of nursing students. Design and Methods: Using a non-experimental, correlational design, data on demographics, HIV/AIDS Attitude Scale (AAS) and the Scale of Empathic Tendency (SET) were collected. Participants: The study sample consisted of 614 undergraduate nursing students in two universities located in different geographic regions of Turkey. Results: The results of this study indicated that attitudes and empathic tendencies are related to knowledge and exposure to patients. As well, those students with more positive attitudes had higher empathic tendencies towards HIV/AIDS patients. Conclusions: It is important to adopt strategies to improve the empathic tendencies and attitudes of nursing students. These strategic changes would increase the quality of care provided to all patients. © 2013 Elsevier Ltd. All rights reserved.
Introduction Due to the complex physical and psychological problems presented by patients with Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), nurses should be well educated about these problems and, as with all patients; nurses should have non-discriminatory attitudes towards these patients. However, studies indicate that the attitudes of nurses/nursing students and other health care professionals towards HIV/AIDS patients are affected by both cultural differences and the fear of HIV/AIDS infection, resulting in both reluctance to care for these patients and negative attitudes towards these patients (Peate et al., 2002; Petro-Nustas et al., 2002). As HIV becomes a more and more global chronic disease, AIDS patients receive treatment and care from many different health care professionals throughout their lives and these professionals may have very different attitudes towards their patients (Pita-Fernández et al., 2004). Such diverse attitudes
⁎ Corresponding author at: Istanbul University, Florence Nightingale Faculty of Nursing, 34381 Sisli, Istanbul, Turkey. Tel.: +90 212 440 00 00x27119. E-mail addresses: [email protected] (A.A. Özakgül), [email protected] (M. Şendir), [email protected] (A.S. Atav), [email protected] (B. Kızıltan). 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.10.018
include being positive and supporting, using unsuitable isolation techniques, communicating in a minimal way, and even refusing to care for these patients (Walusimbi and Okansky, 2004). These observations make it clear that nursing students need to expand their understanding of the HIV/AIDS to provide competent and high quality care to HIV/AIDS patients (Pita-Fernández et al., 2004). The best way to understand someone is to put oneself in that person's position, to see things in their eyes, to appreciate their feelings and thoughts, and then to convey this understanding to them, namely to empathize with them (Rogers, 1983; Seymen, 2007). This potential to empathize is what is meant by empathic tendency and it is a very important skill that facilitates interpersonal relations in every part of life (Rogers, 1983). The fact that empathy helps people to feel that they are being understood means that empathic tendency is a very important skill for psychiatrists and psychologists. However, it is an also an important skill for nurses, educators, and all caring people (Seymen, 2007). Background The art and science of nursing is to help patients by establishing effective communication in order to understand the patient's needs. The efficacy of patient care is dependent upon effective communication,
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especially when dealing with specific health problems that can be aggravated by prejudicial attitudes, something that studies show occurs with AIDS patients (Tutuk et al., 2002; Röndahl et al., 2003). Empathy is one of the most basic qualifications that a nurse should develop to help to identify patient's problems. Empathic tendency is not an innate personality characteristic; it can be developed through education. One of the goals of nursing education is to improve the empathic sensitivity of students who will become health professionals in the future. Therefore, it is essential to create higher empathic tendencies in health professionals (Barrio et al., 2004; Guan et al., 2012; Mete, 2007). Studies of nursing students have determined that students with higher empathic tendency spend more time with patients and nursing programs can effectively improve the communication skills of nursing students (Öz, 1998). Determining the empathic tendencies and empathic skills of nursing students provides insight into the quality of patient care and provides opportunities to ameliorate nursing education (Akıncı and Akgün, 2011). Considering the nature of the nursing profession, empathy is critical to the delivery of effective care. Batson et al. (1997) determined that empathy allows for the development of more positive attitudes. Similarly, when the relation between empathy and student attitudes to HIV/ AIDS patients is examined in this study, it is seen that nursing students with a higher empathic tendency relate more positively to HIV/AIDS patients. Pickles et al. (2012) reported in their study that students who had negative attitudes towards HIV/AIDS patients also had little empathy for them. At the same time, Martin and Bedimo (2000) demonstrated that health professionals with higher empathic attitude show less avoidance behavior to HIV/AIDS patients. The purpose of this study is to examine in a Turkish sample of nursing students the relationships among attitudes towards HIV/AIDS, empathic tendencies, demographic factors, and familiarity with HIV/AIDS. This study is significant in two respects. First, there have been no previous studies among Turkish nursing students that examined the relationships between empathic tendencies and attitudes towards HIV/AIDS. Second, such a study would provide a baseline assessment so that educational interventions are prepared to improve empathic tendencies and attitudes with the ultimate goal of better outcomes for HIV/AIDS patients. Methods Study Design and Sample This study utilized a non-experimental correlational design. Such designs provide examination of various factors and their relationships to one another. As the very first study of its kind in the Turkish context, this design enabled the researchers to obtain baseline descriptive information as well as relationships on empathic tendencies and attitudes towards HIV/AIDS. The study population consisted of all students attending the nursing programs of two public universities in the fall semester of the 2011. These universities are located in geographic regions of Turkey that reflect different social and cultural norms. One is located in the largest city of Turkey with a cultural diversity that reflects modern life in Western Turkey. The other is located in a small city that is more conservative and reflects the more traditional lifestyle in Eastern Turkey. These diverse settings provided a sample of nursing students who are more representative of the general undergraduate nursing student population in Turkey. The study sample included a total of 614 students who voluntarily participated in the study after the disclosure of the study aim and completed data collection forms. The response rate to the questionnaire was 69.96% for the university in the large city, and 97.23% for the university in the small city with a general response rate of 76.08%. Prior to the beginning of the study, permission was granted by the institutional review boards of both schools. The purpose of the study
and the assurance of anonymity were verbally provided to potential respondents by the researchers or their assistants. In addition, students were informed of the right to refuse to participate or withdraw from the study without any consequences. They were also told that their informed consent was implied by their returned, completed questionnaires. No identifiable data were collected. Completed questionnaires were sealed in envelopes and placed in locked boxes. Instruments Research data were collected with a demographic information form, the HIV/AIDS Attitude Scale (AAS) and the Scale of Empathic Tendency (SET). Background Information Form The information form included demographic variables such as age, gender, and marital status, self-assessed knowledge and sources of information about HIV/AIDS, whether or not they had been tested for HIV, and whether or not they had cared for a patient with HIV/AIDS. Personal information such as the student's name or identification number was not included in the information form. HIV/AIDS Attitude Scale (AAS) The AAS was developed by Bliwise et al. in 1991 to determine medical and nursing students' attitudes towards people with HIV/AIDS. The AAS is a six-point Likert scale ranging from strongly disagree = 1 to strongly agree = 6. The AAS has a total of fifteen items in three subscales: Fear of Contagion (5 items), Professional Resistance (6 items), and Negative Emotions (4 items). Table 1 includes the items in each subscale of the AAS. The AAS and its subscales have documented validity and reliability in the literature. Thirteen items of the AAS are scored directly and two items (one item in the Fear of Contagion subscale and one item in the Negative Emotions subscale) are scored reversely. Items are given from one to six points for “I strongly disagree” to “I strongly agree.” The lowest possible score on the AAS is 15 points and the highest is 90. The subscales' possible scores are: Fear of Contagion = 5–30 points, Professional Resistance = 6–36 points, and Negative Emotions = 4–24 points. Higher scores on the AAS and its subscales indicate more negative attitudes towards patients with HIV/AIDS. In 2005, the AAS was adapted for the Turkish language and the validity and reliability of the Turkish version were examined by Çimen et al. (2005). In their analyses, the Turkish version of the AAS had a test retest coefficient of .82 and a Cronbach's α of .80. These validity and reliability scores are similar to, but lower than, the English version that had the test–retest coefficient of .92 and a Cronbach α of .86 (Bliwise et al., 1991). In this study, the internal consistency coefficient was found to be Cronbach α of 0.80. Scale of Empathic Tendency The Scale of Empathic Tendency (SET) was developed by Dökmen (2005) in order to measure an individual's potential of empathizing in everyday life. It is a Likert-type scale, consists of twenty questions, and points from 1 to 5 are given to each question. The questions 3, 6, 7, 8, 11, 12, 13 and 15 are reverse scored. The minimum score possible is 20; the maximum is 100. A high score shows that empathic tendency is high, and a low score shows that empathic tendency is low. The scale reliability obtained from this application is .82. The halfway through reliability of the scale among the even and odd items of the subjects of test was found to be .86 (Seymen, 2007; Dökmen, 2005). In this study, the Cronbach α for SET was 0.73. Statistical Analysis Data were analyzed by using the Statistical Package for Social Science for Windows (SPSS 21.0), licensed to Istanbul University. Frequency and
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Table 1 Summary of demographics and their relationship to AAS and SET.
n (%) School Year at university
Age Gender
Large city Small city 1st 2nd 3rd 4th 17–20 21–45 Male Female
438 (73) 176 (27) 228 (37) 163 (27) 123 (20) 100 (16) 339 (55) 275 (45) 126 (21) 488 (79)
Fear of Contagion
Negative Emotions
Professional Resistance
Total AAS
M ± SD
t/F
M ± SD
t/F
M ± SD
t/F
M ± SD
19.90 21.64 20.90 20.85 20.89 17.92 20.64 20.11 20.60 20.35
3.67⁎⁎
13.07 13.75 13.52 13.05 13.50 12.72 13.35 13.15 14.83 12.86
1.70
16.76 16.87 16.29 17.29 17.51 16.26 16.74 16.87 18.97 16.24
−18
49.73 52.27 50.71 51.20 51.91 46.90 50.73 50.12 54.40 49.44
± ± ± ± ± ± ± ± ± ±
5.43 5.27 5.55 5.10 5.40 5.15 5.37 5.51 5.72 5.36
8.61⁎⁎
1.21 .43
± ± ± ± ± ± ± ± ± ±
4.34 4.58 4.57 4.15 4.60 4.23 4.29 4.57 4.51 4.31
1.02
.57 4.43⁎⁎
± ± ± ± ± ± ± ± ± ±
7.10 6.74 7.13 6.95 6.93 6.79 6.93 7.09 7.31 6.81
1.30
.231 3.79
± ± ± ± ± ± ± ± ± ±
SET
13.64 12.50 13.29 12.92 13.74 13.34 12.81 14.03 14.17 12.97
t/F
M ± SD
2.21
70.95 70.21 70.05 70.57 71.15 72.06 69.96 71.70 68.57 71.30
3.07⁎
.55 3.56⁎⁎
± ± ± ± ± ± ± ± ± ±
t/F 8.71 9.16 9.30 9.10 8.14 8.10 9.05 8.50 9.92 8.46
.92 1.31
−2.44⁎ 3.11⁎⁎
⁎ Significant at .05. ⁎⁎ Significant at .01.
percentage values of the grouped variables and arithmetic means, and standard deviations of AAS and each subscale were calculated using descriptive statistics. A t-test for independent samples as well as multiple ANOVAs was utilized to determine various mean differences between groups. Relationships between the mean scores were determined by Pearson's correlation. In this study, a p-value of less than .05 was considered statistically significant. Study Limitations This study reflects the findings regarding the Turkish sample and cannot be generalized to other contexts. Results Background Characteristics and Their Relationship to AAS and SET Demographic characteristics and their relationship to AAS and SET are summarized in Table 1. Seventy-three percent of the students were from the university in the large city. Except for the fear of contagion subscale, there were no statistically significant differences between the two universities with respect to AAS and SET. For fear of contagion, students from the university in the large city had significantly better attitudes than the ones from the small city. Students' year at university was also significant only for the fear of contagion subscale. ANOVA and following post hoc t-tests revealed that seniors had significantly better scores on fear of contagion than the lower classes. Freshmen, sophomores, and juniors had similar attitudes. Age was not a significant factor in students' attitudes, except for SET. Older students (21–45) had significantly better SET scores than the younger ones. For AAS and its subscales, age was not significant. Males constituted 21% of the sample. In our analysis gender was a significant variable for negative emotions, total AAS, and SET. Males consistently had more negative attitudes than females for these
measurements. Their attitudes were not significantly different from females for fear of contagion and professional resistance. However, a mean of 20 for fear of contagion out of the best possible score of 5 indicates relatively negative attitudes for both males and females. Similarly, the overall professional resistance mean was 16.80, out of the best score of 6, indicating relatively negative attitudes for this sample. Table 2 presents the relationship between familiarity with HIV questions and their relationship to AAS and SET. There were 47 (8%) students who had cared for an HIV patient. Those who cared for an HIV patient in the past consistently had better attitudes than those who had not provided care. Furthermore, except for fear of contagion, AAS and its other subscales were significantly better for those who had provided care. Even though those who had provided care had higher scores on SET, the difference was not statistically significant. Fifty-seven students (9%) had had an HIV test. This variable did not influence students' attitudes or empathy scores. There were no statistically significant differences for any of the measures between those who had had an HIV test and those who had not. One hundred sixty-three students (41%) had tried to obtain additional information on HIV. Those who had tried to obtain more information on HIV had consistently better attitudes and higher scores on SET. Except for fear of contagion, these differences were significant for all measures.
The Relationship Between Empathic Tendency and Attitudes Towards HIV/AIDS Table 3 presents the Pearson's correlation coefficients between SET on the one hand and AAS and its subscales on the other hand. As expected, AAS and its subscales are all negatively correlated with SET. Since lower scores in AAS and its subscales mean better attitudes, a negative correlation indicates that as students' empathic tendencies increase, their attitudes towards HIV/AIDS improved. Except for fear of contagion, the total AAS, negative emotions, and professional resistance had statistically significant correlations with SET.
Table 2 Familiarity with HIV and their relationship to AAS and SET.
Provided care to an HIV patient
Yes No Have had an HIV test Yes No Tried to obtain information on HIV Yes No ⁎ Significant at .05. ⁎⁎ Significant at .01.
Fear of Contagion
Negative Emotions
Professional Resistance
Total AAS
n (%)
M ± SD
M ± SD
M ± SD
M ± SD
47 (8) 567 (92) 57(9) 548 (91) 163 (41) 239 (59)
19.19 20.50 19.86 20.45 20.16 21.06
± ± ± ± ± ±
t
t
5.52 −1.59 11.60 ± 4.06 −2.71⁎ 5.42 13.40 ± 4.42 6.18 −0.70 12.56 ± 4.20 −1.31 5.36 13.33 ± 4.43 5.43 −1.78 12.86 ± 4.21 −3.83⁎⁎ 5.42 14.39 ± 4.78
14.53 16.98 16,86 16,79 16.42 17.83
± ± ± ± ± ±
t 7.16 −2.32⁎ 6.95 7.00 0.07 7.00 6.90 −2.19⁎ 7.17
45.32 50.89 49,28 50,58 49.4 53.28
± ± ± ± ± ±
SET t
12.45 −2.76⁎ 13.36 13.53 −0.69 13.35 13.01 −3.16⁎ 13.71
M ± SD 71.34 70.69 70.82 70,73 71.06 69.83
± ± ± ± ± ±
t 11.22 .389 8.63 10.08 0.07 8.71 8.83 1.52 8.85
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Table 3 Relationship between SET and AAS and its subscales. SET
Fear of Contagion Negative Emotions Professional Resistance AAS
r
P
−.056 −.127 −.157 −.147
.166 .002⁎⁎ .000⁎⁎ .000⁎⁎
⁎⁎ Significant at .01.
Discussion Background Characteristics and Their Relationship to AAS and SET Prejudicial attitudes about HIV/AIDS are mostly based on social judgments of the behavior of infected people that are inconsistent with the social values and beliefs of the person making that judgment — behaviors most often related to socially disapproved acts like drug use and/or sexual activity. HIV infected men might be assumed to be homosexual, bisexual or having slept with a sex worker. On the other hand, women with HIV/ AIDS might be assumed to be sex workers. Even though close to 80% of the HIV/AIDS cases in Turkey are a result of heterosexual contact (Republic of Turkey Ministry of Health, 2011), aforementioned prejudices and stigmas are still strongly present. The scarcity of data about HIV transmission through non-sexual means and drug use, such as blood transfusions and contaminated needles, also supports the taboo laden assumptions about HIV/AIDS patients in Turkey (Kasapoğlu et al., 2011). In this study, nursing students from the small city had significantly more negative attitudes with respect to fear of contagion in comparison to their counterparts from the large city. This could be attributed to the fact that nursing students in rural areas are less experienced in the care of HIV/AIDS patients. In addition, their attitudes could be affected by social prejudices more prevalent in the smaller conservative residential areas of Turkey (Kasapoğlu et al., 2011). Kaya et al. (2007) investigated the knowledge and attitudes of students about HIV/AIDS and reported that 4th-year nursing students had significantly higher knowledge about both protection and infection compared to 1st-year students. In the present study, the 4th-year students had better scores than all others with respect to fear of contagion and total AAS, supporting Kaya et al.'s (2007) findings. This result can be related to the fact that both the professional knowledge and clinical experience of students increase in the latter years of nursing education (Li et al., 2008). In a study by Ayrancı (2005), females had better attitudes and knowledge than males. The findings of the present study were similar: females had significantly more positive attitudes than males, once again reflecting cultural norms in the Turkish society. Female students also had significantly higher empathic tendency scores than male students, which was supported by the results of similar studies in this field (Özcan et al., 2012). Karakaya (2001) also asserted that female nursing students had a higher empathic tendency. As well, in the study carried out by Seymen (2007) on employed nurses, female nurses were found to have a higher empathic tendency. Some researchers explain this difference to be the result of evolution and view empathy as a feminine trait because females tend to be more perceptive of emotions while males take a more rational rather than emotive approach (Boyle et al., 2010). Older students had significantly better empathic tendency scores than younger students. However, the empathic tendency of nursing students did not increase in parallel with their education year in nursing, supporting the work of Lauder et al. (2002). Contrary to this finding, previous studies conducted in Turkey by Öz (1998), Tutuk et al. (2002), and Mete (2007) reported that empathic tendency scores improved as students progressed through their nursing education. This discrepancy could be due to an age differences in student populations at the time studies were conducted.
Students who previously provided care to HIV/AIDS patients demonstrated more positive attitudes than other students. Peate et al. (2002) report similar results to this finding indicating that the experience of having provided care previously to HIV/AIDS patients reduces the fear and prejudicial attitudes. Kermode et al. (2005) reported in their study that the tendency of health care workers to volunteer to care for HIV/AIDS patients is highly related to their previous caring experience of patients with similar problems. In addition, those students who had provided care for HIV/AIDS patients had higher empathic tendencies than those who had not provided care, but not significantly. This finding is supported by Bektaş and Kulakaç (2007) who determined that empathy affected the willingness of nursing students to care for HIV/AIDS patients. Also, Pickles et al. (2012) found that among a small number of nursing students, a lower level empathic attitude was related to greater avoidance behavior to care for HIV/AIDS patients. The fact that 41% of students tried to obtain additional information on HIV indicates that the core curriculum for the students in this study was not sufficient with respect to HIV/AIDS. Those who sought more information had better attitudes than those who did not seek information. Petro-Nustas et al. (2002) carried out a comparative and intercultural study investigating the knowledge, attitude and beliefs of students about HIV/AIDS and reported that basic nursing education and in-service training ranked first among information sources of students. Similarly, Kaya et al. (2007) determined that the most important source of information was education courses for students of health schools. In the studies carried out in fields other than health sciences, the primary sources of information changed among university students. In the study by Siyez and Siyez (2009) on sexually transmitted diseases, they reported that students acquired knowledge mostly from newspapers and journals, highlighting the need for inclusion of such content in formal curricula. The Relationship Between Empathic Tendency and Attitudes Towards HIV/AIDS As expected, empathic tendencies and positive attitudes towards HIV/ AIDS are correlated. Those students who have higher scores on empathic tendencies have more positive attitudes towards HIV/AIDS. Previous studies indicated that nursing students in general have discriminatory attitudes towards HIV/AIDS infected people, and most of them experienced high anxiety and stress in the care of these patients (Röndahl et al., 2003). They avoid HIV/AIDS infected people due to the fear of contagion. It would be helpful to prepare educational manuals and introduce role model health professionals to students to motivate them to develop positive attitudes when caring for these patients. The development of positive attitudes and empathy will improve the quality of care given to HIV/AIDS patients. Conclusions Nurses constitute most of the health professionals who provide care to HIV/AIDS patients, so it is of the utmost importance for them to do so in a professional manner without any prejudice. In this study, it was found that attitudes and empathic tendencies are related to knowledge and exposure to patients. In Turkey, nursing students are rarely exposed to HIV/AIDS patients during their clinical rotations. Nurse educators need to be more cognizant of the factors that affect attitudes towards HIV/ AIDS patients when planning HIV/AIDS education for nursing students. HIV/AIDS issues and care can be included in curricula through simulation, role-playing, psychodrama, and case-scenario methods. Such methods should help students to nurture their empathic tendencies and understand the importance of empathy in their clinical practice. It is through such efforts that prejudicial attitudes can be eradicated and better patient outcomes can be achieved.
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Explanation of Contribution by Researchers
AUTHOR
ROLE IN THE MANUSCRIPT
Aylin Aktaş Özakgül, RN, PhD, Assistant Professor, Istanbul University, Florence Nightingale Faculty of Nursing, Istanbul, Turkey
Performed the data collection: urban data Performed the data analysis and interpretation Responsible for the drafting of the manuscript: outlined the manuscript, literature and references Made critical revisions to the paper for important intellectual content: revised the manuscript Provided technical or material support Responsible for the study conception and design Supervised the study: senior researcher, quality control of the work Performed the data collection: urban data together with AA Performed the data analysis and interpretation and joint the information Responsible for the drafting of the manuscript: ethical considerations and discussion Provided administrative, technical or material support Responsible for the drafting of the manuscript: outlined the manuscript, methodology, tables, results, and discussion with A. Serdar Atav Provided administrative, technical or material support Made critical revisions to the paper for important intellectual content: kept the timetable, kept the planned data included and approved the comments and the final manuscript, corresponding author Responsible for the study conception and design Provided statistical expertise: made all the statistics, prepared all the data after coding them into the SPSS statistical program Performed the data analysis, interpretation and joint the information Responsible for the drafting of the manuscript: statistical analysis section, critical overview and revision of the results Made critical revisions to the paper for important intellectual content: revised the theoretical background, study design and methods Provided administrative, technical or material support Supervised the study: senior researcher, quality control of the work Performed the data collection: rural data Performed the interpretation in local level, and joint the information into the national level Made revisions Responsible for the drafting of the manuscript: rural results, interpretation and discussion
Merdiye Şendir, RN, PhD, Associate Professor, Istanbul University, Florence Nightingale Faculty of Nursing, Istanbul, TURKEY
A. Serdar Atav, PhD, Associate Professor, Binghamton University, Decker School of Nursing, Binghamton, NY, USA
Belkız Kızıltan, RN, MSc, Research Assistant, Gümüşhane University, School of Health, Gümüşhane, Turkey
Acknowledgment We want to thank the nursing students who participated in this study. We wish to thank Nurgül Mazlum, Tuğba Torun and Mine Demir for their help with the coordination of data collection. Also, we thank Mr. Malcolm H. Gunter, for his help with editing.
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Attitudes towards HIV/AIDS patients and empathic tendencies: A study of Turkish undergraduate nursing students Aylin Aktaş Özakgül a, Merdiye Şendir a,⁎, A. Serdar Atav b, Belkız Kızıltan c a b c
Istanbul University, Florence Nightingale Faculty of Nursing, Istanbul, Turkey Binghamton University, Decker School of Nursing, Binghamton, NY, United States Gümüşhane University, School of Health, Gümüşhane, Turkey
a r t i c l e
i n f o
Article history: Accepted 21 October 2013 Keywords: Nursing education Nursing student Human Immunodeficiency Virus (HIV) Acquired Immunodeficiency Syndrome (AIDS) Empathic tendency Attitude AAS SET
s u m m a r y Background: Studies indicate that the attitudes of nurses, nursing students, and other health care professionals towards Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS) patients are affected by cultural differences and the fear of HIV/AIDS infection, resulting in both negative attitudes and reluctance to care for these patients. Empathy is critical for all health professionals in the delivery of effective care. Research indicates that as empathic tendencies develop, so do better communication skills, better attitudes, and better quality of care. Objectives: The purpose of this study was to examine the relationships among demographic factors, familiarity with HIV/AIDS, attitudes towards HIV/AIDS, and empathic tendencies in a Turkish sample of nursing students. Design and Methods: Using a non-experimental, correlational design, data on demographics, HIV/AIDS Attitude Scale (AAS) and the Scale of Empathic Tendency (SET) were collected. Participants: The study sample consisted of 614 undergraduate nursing students in two universities located in different geographic regions of Turkey. Results: The results of this study indicated that attitudes and empathic tendencies are related to knowledge and exposure to patients. As well, those students with more positive attitudes had higher empathic tendencies towards HIV/AIDS patients. Conclusions: It is important to adopt strategies to improve the empathic tendencies and attitudes of nursing students. These strategic changes would increase the quality of care provided to all patients. © 2013 Elsevier Ltd. All rights reserved.
Introduction Due to the complex physical and psychological problems presented by patients with Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS), nurses should be well educated about these problems and, as with all patients; nurses should have non-discriminatory attitudes towards these patients. However, studies indicate that the attitudes of nurses/nursing students and other health care professionals towards HIV/AIDS patients are affected by both cultural differences and the fear of HIV/AIDS infection, resulting in both reluctance to care for these patients and negative attitudes towards these patients (Peate et al., 2002; Petro-Nustas et al., 2002). As HIV becomes a more and more global chronic disease, AIDS patients receive treatment and care from many different health care professionals throughout their lives and these professionals may have very different attitudes towards their patients (Pita-Fernández et al., 2004). Such diverse attitudes
⁎ Corresponding author at: Istanbul University, Florence Nightingale Faculty of Nursing, 34381 Sisli, Istanbul, Turkey. Tel.: +90 212 440 00 00x27119. E-mail addresses: [email protected] (A.A. Özakgül), [email protected] (M. Şendir), [email protected] (A.S. Atav), [email protected] (B. Kızıltan). 0260-6917/$ – see front matter © 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.nedt.2013.10.018
include being positive and supporting, using unsuitable isolation techniques, communicating in a minimal way, and even refusing to care for these patients (Walusimbi and Okansky, 2004). These observations make it clear that nursing students need to expand their understanding of the HIV/AIDS to provide competent and high quality care to HIV/AIDS patients (Pita-Fernández et al., 2004). The best way to understand someone is to put oneself in that person's position, to see things in their eyes, to appreciate their feelings and thoughts, and then to convey this understanding to them, namely to empathize with them (Rogers, 1983; Seymen, 2007). This potential to empathize is what is meant by empathic tendency and it is a very important skill that facilitates interpersonal relations in every part of life (Rogers, 1983). The fact that empathy helps people to feel that they are being understood means that empathic tendency is a very important skill for psychiatrists and psychologists. However, it is an also an important skill for nurses, educators, and all caring people (Seymen, 2007). Background The art and science of nursing is to help patients by establishing effective communication in order to understand the patient's needs. The efficacy of patient care is dependent upon effective communication,
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especially when dealing with specific health problems that can be aggravated by prejudicial attitudes, something that studies show occurs with AIDS patients (Tutuk et al., 2002; Röndahl et al., 2003). Empathy is one of the most basic qualifications that a nurse should develop to help to identify patient's problems. Empathic tendency is not an innate personality characteristic; it can be developed through education. One of the goals of nursing education is to improve the empathic sensitivity of students who will become health professionals in the future. Therefore, it is essential to create higher empathic tendencies in health professionals (Barrio et al., 2004; Guan et al., 2012; Mete, 2007). Studies of nursing students have determined that students with higher empathic tendency spend more time with patients and nursing programs can effectively improve the communication skills of nursing students (Öz, 1998). Determining the empathic tendencies and empathic skills of nursing students provides insight into the quality of patient care and provides opportunities to ameliorate nursing education (Akıncı and Akgün, 2011). Considering the nature of the nursing profession, empathy is critical to the delivery of effective care. Batson et al. (1997) determined that empathy allows for the development of more positive attitudes. Similarly, when the relation between empathy and student attitudes to HIV/ AIDS patients is examined in this study, it is seen that nursing students with a higher empathic tendency relate more positively to HIV/AIDS patients. Pickles et al. (2012) reported in their study that students who had negative attitudes towards HIV/AIDS patients also had little empathy for them. At the same time, Martin and Bedimo (2000) demonstrated that health professionals with higher empathic attitude show less avoidance behavior to HIV/AIDS patients. The purpose of this study is to examine in a Turkish sample of nursing students the relationships among attitudes towards HIV/AIDS, empathic tendencies, demographic factors, and familiarity with HIV/AIDS. This study is significant in two respects. First, there have been no previous studies among Turkish nursing students that examined the relationships between empathic tendencies and attitudes towards HIV/AIDS. Second, such a study would provide a baseline assessment so that educational interventions are prepared to improve empathic tendencies and attitudes with the ultimate goal of better outcomes for HIV/AIDS patients. Methods Study Design and Sample This study utilized a non-experimental correlational design. Such designs provide examination of various factors and their relationships to one another. As the very first study of its kind in the Turkish context, this design enabled the researchers to obtain baseline descriptive information as well as relationships on empathic tendencies and attitudes towards HIV/AIDS. The study population consisted of all students attending the nursing programs of two public universities in the fall semester of the 2011. These universities are located in geographic regions of Turkey that reflect different social and cultural norms. One is located in the largest city of Turkey with a cultural diversity that reflects modern life in Western Turkey. The other is located in a small city that is more conservative and reflects the more traditional lifestyle in Eastern Turkey. These diverse settings provided a sample of nursing students who are more representative of the general undergraduate nursing student population in Turkey. The study sample included a total of 614 students who voluntarily participated in the study after the disclosure of the study aim and completed data collection forms. The response rate to the questionnaire was 69.96% for the university in the large city, and 97.23% for the university in the small city with a general response rate of 76.08%. Prior to the beginning of the study, permission was granted by the institutional review boards of both schools. The purpose of the study
and the assurance of anonymity were verbally provided to potential respondents by the researchers or their assistants. In addition, students were informed of the right to refuse to participate or withdraw from the study without any consequences. They were also told that their informed consent was implied by their returned, completed questionnaires. No identifiable data were collected. Completed questionnaires were sealed in envelopes and placed in locked boxes. Instruments Research data were collected with a demographic information form, the HIV/AIDS Attitude Scale (AAS) and the Scale of Empathic Tendency (SET). Background Information Form The information form included demographic variables such as age, gender, and marital status, self-assessed knowledge and sources of information about HIV/AIDS, whether or not they had been tested for HIV, and whether or not they had cared for a patient with HIV/AIDS. Personal information such as the student's name or identification number was not included in the information form. HIV/AIDS Attitude Scale (AAS) The AAS was developed by Bliwise et al. in 1991 to determine medical and nursing students' attitudes towards people with HIV/AIDS. The AAS is a six-point Likert scale ranging from strongly disagree = 1 to strongly agree = 6. The AAS has a total of fifteen items in three subscales: Fear of Contagion (5 items), Professional Resistance (6 items), and Negative Emotions (4 items). Table 1 includes the items in each subscale of the AAS. The AAS and its subscales have documented validity and reliability in the literature. Thirteen items of the AAS are scored directly and two items (one item in the Fear of Contagion subscale and one item in the Negative Emotions subscale) are scored reversely. Items are given from one to six points for “I strongly disagree” to “I strongly agree.” The lowest possible score on the AAS is 15 points and the highest is 90. The subscales' possible scores are: Fear of Contagion = 5–30 points, Professional Resistance = 6–36 points, and Negative Emotions = 4–24 points. Higher scores on the AAS and its subscales indicate more negative attitudes towards patients with HIV/AIDS. In 2005, the AAS was adapted for the Turkish language and the validity and reliability of the Turkish version were examined by Çimen et al. (2005). In their analyses, the Turkish version of the AAS had a test retest coefficient of .82 and a Cronbach's α of .80. These validity and reliability scores are similar to, but lower than, the English version that had the test–retest coefficient of .92 and a Cronbach α of .86 (Bliwise et al., 1991). In this study, the internal consistency coefficient was found to be Cronbach α of 0.80. Scale of Empathic Tendency The Scale of Empathic Tendency (SET) was developed by Dökmen (2005) in order to measure an individual's potential of empathizing in everyday life. It is a Likert-type scale, consists of twenty questions, and points from 1 to 5 are given to each question. The questions 3, 6, 7, 8, 11, 12, 13 and 15 are reverse scored. The minimum score possible is 20; the maximum is 100. A high score shows that empathic tendency is high, and a low score shows that empathic tendency is low. The scale reliability obtained from this application is .82. The halfway through reliability of the scale among the even and odd items of the subjects of test was found to be .86 (Seymen, 2007; Dökmen, 2005). In this study, the Cronbach α for SET was 0.73. Statistical Analysis Data were analyzed by using the Statistical Package for Social Science for Windows (SPSS 21.0), licensed to Istanbul University. Frequency and
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Table 1 Summary of demographics and their relationship to AAS and SET.
n (%) School Year at university
Age Gender
Large city Small city 1st 2nd 3rd 4th 17–20 21–45 Male Female
438 (73) 176 (27) 228 (37) 163 (27) 123 (20) 100 (16) 339 (55) 275 (45) 126 (21) 488 (79)
Fear of Contagion
Negative Emotions
Professional Resistance
Total AAS
M ± SD
t/F
M ± SD
t/F
M ± SD
t/F
M ± SD
19.90 21.64 20.90 20.85 20.89 17.92 20.64 20.11 20.60 20.35
3.67⁎⁎
13.07 13.75 13.52 13.05 13.50 12.72 13.35 13.15 14.83 12.86
1.70
16.76 16.87 16.29 17.29 17.51 16.26 16.74 16.87 18.97 16.24
−18
49.73 52.27 50.71 51.20 51.91 46.90 50.73 50.12 54.40 49.44
± ± ± ± ± ± ± ± ± ±
5.43 5.27 5.55 5.10 5.40 5.15 5.37 5.51 5.72 5.36
8.61⁎⁎
1.21 .43
± ± ± ± ± ± ± ± ± ±
4.34 4.58 4.57 4.15 4.60 4.23 4.29 4.57 4.51 4.31
1.02
.57 4.43⁎⁎
± ± ± ± ± ± ± ± ± ±
7.10 6.74 7.13 6.95 6.93 6.79 6.93 7.09 7.31 6.81
1.30
.231 3.79
± ± ± ± ± ± ± ± ± ±
SET
13.64 12.50 13.29 12.92 13.74 13.34 12.81 14.03 14.17 12.97
t/F
M ± SD
2.21
70.95 70.21 70.05 70.57 71.15 72.06 69.96 71.70 68.57 71.30
3.07⁎
.55 3.56⁎⁎
± ± ± ± ± ± ± ± ± ±
t/F 8.71 9.16 9.30 9.10 8.14 8.10 9.05 8.50 9.92 8.46
.92 1.31
−2.44⁎ 3.11⁎⁎
⁎ Significant at .05. ⁎⁎ Significant at .01.
percentage values of the grouped variables and arithmetic means, and standard deviations of AAS and each subscale were calculated using descriptive statistics. A t-test for independent samples as well as multiple ANOVAs was utilized to determine various mean differences between groups. Relationships between the mean scores were determined by Pearson's correlation. In this study, a p-value of less than .05 was considered statistically significant. Study Limitations This study reflects the findings regarding the Turkish sample and cannot be generalized to other contexts. Results Background Characteristics and Their Relationship to AAS and SET Demographic characteristics and their relationship to AAS and SET are summarized in Table 1. Seventy-three percent of the students were from the university in the large city. Except for the fear of contagion subscale, there were no statistically significant differences between the two universities with respect to AAS and SET. For fear of contagion, students from the university in the large city had significantly better attitudes than the ones from the small city. Students' year at university was also significant only for the fear of contagion subscale. ANOVA and following post hoc t-tests revealed that seniors had significantly better scores on fear of contagion than the lower classes. Freshmen, sophomores, and juniors had similar attitudes. Age was not a significant factor in students' attitudes, except for SET. Older students (21–45) had significantly better SET scores than the younger ones. For AAS and its subscales, age was not significant. Males constituted 21% of the sample. In our analysis gender was a significant variable for negative emotions, total AAS, and SET. Males consistently had more negative attitudes than females for these
measurements. Their attitudes were not significantly different from females for fear of contagion and professional resistance. However, a mean of 20 for fear of contagion out of the best possible score of 5 indicates relatively negative attitudes for both males and females. Similarly, the overall professional resistance mean was 16.80, out of the best score of 6, indicating relatively negative attitudes for this sample. Table 2 presents the relationship between familiarity with HIV questions and their relationship to AAS and SET. There were 47 (8%) students who had cared for an HIV patient. Those who cared for an HIV patient in the past consistently had better attitudes than those who had not provided care. Furthermore, except for fear of contagion, AAS and its other subscales were significantly better for those who had provided care. Even though those who had provided care had higher scores on SET, the difference was not statistically significant. Fifty-seven students (9%) had had an HIV test. This variable did not influence students' attitudes or empathy scores. There were no statistically significant differences for any of the measures between those who had had an HIV test and those who had not. One hundred sixty-three students (41%) had tried to obtain additional information on HIV. Those who had tried to obtain more information on HIV had consistently better attitudes and higher scores on SET. Except for fear of contagion, these differences were significant for all measures.
The Relationship Between Empathic Tendency and Attitudes Towards HIV/AIDS Table 3 presents the Pearson's correlation coefficients between SET on the one hand and AAS and its subscales on the other hand. As expected, AAS and its subscales are all negatively correlated with SET. Since lower scores in AAS and its subscales mean better attitudes, a negative correlation indicates that as students' empathic tendencies increase, their attitudes towards HIV/AIDS improved. Except for fear of contagion, the total AAS, negative emotions, and professional resistance had statistically significant correlations with SET.
Table 2 Familiarity with HIV and their relationship to AAS and SET.
Provided care to an HIV patient
Yes No Have had an HIV test Yes No Tried to obtain information on HIV Yes No ⁎ Significant at .05. ⁎⁎ Significant at .01.
Fear of Contagion
Negative Emotions
Professional Resistance
Total AAS
n (%)
M ± SD
M ± SD
M ± SD
M ± SD
47 (8) 567 (92) 57(9) 548 (91) 163 (41) 239 (59)
19.19 20.50 19.86 20.45 20.16 21.06
± ± ± ± ± ±
t
t
5.52 −1.59 11.60 ± 4.06 −2.71⁎ 5.42 13.40 ± 4.42 6.18 −0.70 12.56 ± 4.20 −1.31 5.36 13.33 ± 4.43 5.43 −1.78 12.86 ± 4.21 −3.83⁎⁎ 5.42 14.39 ± 4.78
14.53 16.98 16,86 16,79 16.42 17.83
± ± ± ± ± ±
t 7.16 −2.32⁎ 6.95 7.00 0.07 7.00 6.90 −2.19⁎ 7.17
45.32 50.89 49,28 50,58 49.4 53.28
± ± ± ± ± ±
SET t
12.45 −2.76⁎ 13.36 13.53 −0.69 13.35 13.01 −3.16⁎ 13.71
M ± SD 71.34 70.69 70.82 70,73 71.06 69.83
± ± ± ± ± ±
t 11.22 .389 8.63 10.08 0.07 8.71 8.83 1.52 8.85
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Table 3 Relationship between SET and AAS and its subscales. SET
Fear of Contagion Negative Emotions Professional Resistance AAS
r
P
−.056 −.127 −.157 −.147
.166 .002⁎⁎ .000⁎⁎ .000⁎⁎
⁎⁎ Significant at .01.
Discussion Background Characteristics and Their Relationship to AAS and SET Prejudicial attitudes about HIV/AIDS are mostly based on social judgments of the behavior of infected people that are inconsistent with the social values and beliefs of the person making that judgment — behaviors most often related to socially disapproved acts like drug use and/or sexual activity. HIV infected men might be assumed to be homosexual, bisexual or having slept with a sex worker. On the other hand, women with HIV/ AIDS might be assumed to be sex workers. Even though close to 80% of the HIV/AIDS cases in Turkey are a result of heterosexual contact (Republic of Turkey Ministry of Health, 2011), aforementioned prejudices and stigmas are still strongly present. The scarcity of data about HIV transmission through non-sexual means and drug use, such as blood transfusions and contaminated needles, also supports the taboo laden assumptions about HIV/AIDS patients in Turkey (Kasapoğlu et al., 2011). In this study, nursing students from the small city had significantly more negative attitudes with respect to fear of contagion in comparison to their counterparts from the large city. This could be attributed to the fact that nursing students in rural areas are less experienced in the care of HIV/AIDS patients. In addition, their attitudes could be affected by social prejudices more prevalent in the smaller conservative residential areas of Turkey (Kasapoğlu et al., 2011). Kaya et al. (2007) investigated the knowledge and attitudes of students about HIV/AIDS and reported that 4th-year nursing students had significantly higher knowledge about both protection and infection compared to 1st-year students. In the present study, the 4th-year students had better scores than all others with respect to fear of contagion and total AAS, supporting Kaya et al.'s (2007) findings. This result can be related to the fact that both the professional knowledge and clinical experience of students increase in the latter years of nursing education (Li et al., 2008). In a study by Ayrancı (2005), females had better attitudes and knowledge than males. The findings of the present study were similar: females had significantly more positive attitudes than males, once again reflecting cultural norms in the Turkish society. Female students also had significantly higher empathic tendency scores than male students, which was supported by the results of similar studies in this field (Özcan et al., 2012). Karakaya (2001) also asserted that female nursing students had a higher empathic tendency. As well, in the study carried out by Seymen (2007) on employed nurses, female nurses were found to have a higher empathic tendency. Some researchers explain this difference to be the result of evolution and view empathy as a feminine trait because females tend to be more perceptive of emotions while males take a more rational rather than emotive approach (Boyle et al., 2010). Older students had significantly better empathic tendency scores than younger students. However, the empathic tendency of nursing students did not increase in parallel with their education year in nursing, supporting the work of Lauder et al. (2002). Contrary to this finding, previous studies conducted in Turkey by Öz (1998), Tutuk et al. (2002), and Mete (2007) reported that empathic tendency scores improved as students progressed through their nursing education. This discrepancy could be due to an age differences in student populations at the time studies were conducted.
Students who previously provided care to HIV/AIDS patients demonstrated more positive attitudes than other students. Peate et al. (2002) report similar results to this finding indicating that the experience of having provided care previously to HIV/AIDS patients reduces the fear and prejudicial attitudes. Kermode et al. (2005) reported in their study that the tendency of health care workers to volunteer to care for HIV/AIDS patients is highly related to their previous caring experience of patients with similar problems. In addition, those students who had provided care for HIV/AIDS patients had higher empathic tendencies than those who had not provided care, but not significantly. This finding is supported by Bektaş and Kulakaç (2007) who determined that empathy affected the willingness of nursing students to care for HIV/AIDS patients. Also, Pickles et al. (2012) found that among a small number of nursing students, a lower level empathic attitude was related to greater avoidance behavior to care for HIV/AIDS patients. The fact that 41% of students tried to obtain additional information on HIV indicates that the core curriculum for the students in this study was not sufficient with respect to HIV/AIDS. Those who sought more information had better attitudes than those who did not seek information. Petro-Nustas et al. (2002) carried out a comparative and intercultural study investigating the knowledge, attitude and beliefs of students about HIV/AIDS and reported that basic nursing education and in-service training ranked first among information sources of students. Similarly, Kaya et al. (2007) determined that the most important source of information was education courses for students of health schools. In the studies carried out in fields other than health sciences, the primary sources of information changed among university students. In the study by Siyez and Siyez (2009) on sexually transmitted diseases, they reported that students acquired knowledge mostly from newspapers and journals, highlighting the need for inclusion of such content in formal curricula. The Relationship Between Empathic Tendency and Attitudes Towards HIV/AIDS As expected, empathic tendencies and positive attitudes towards HIV/ AIDS are correlated. Those students who have higher scores on empathic tendencies have more positive attitudes towards HIV/AIDS. Previous studies indicated that nursing students in general have discriminatory attitudes towards HIV/AIDS infected people, and most of them experienced high anxiety and stress in the care of these patients (Röndahl et al., 2003). They avoid HIV/AIDS infected people due to the fear of contagion. It would be helpful to prepare educational manuals and introduce role model health professionals to students to motivate them to develop positive attitudes when caring for these patients. The development of positive attitudes and empathy will improve the quality of care given to HIV/AIDS patients. Conclusions Nurses constitute most of the health professionals who provide care to HIV/AIDS patients, so it is of the utmost importance for them to do so in a professional manner without any prejudice. In this study, it was found that attitudes and empathic tendencies are related to knowledge and exposure to patients. In Turkey, nursing students are rarely exposed to HIV/AIDS patients during their clinical rotations. Nurse educators need to be more cognizant of the factors that affect attitudes towards HIV/ AIDS patients when planning HIV/AIDS education for nursing students. HIV/AIDS issues and care can be included in curricula through simulation, role-playing, psychodrama, and case-scenario methods. Such methods should help students to nurture their empathic tendencies and understand the importance of empathy in their clinical practice. It is through such efforts that prejudicial attitudes can be eradicated and better patient outcomes can be achieved.
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Explanation of Contribution by Researchers
AUTHOR
ROLE IN THE MANUSCRIPT
Aylin Aktaş Özakgül, RN, PhD, Assistant Professor, Istanbul University, Florence Nightingale Faculty of Nursing, Istanbul, Turkey
Performed the data collection: urban data Performed the data analysis and interpretation Responsible for the drafting of the manuscript: outlined the manuscript, literature and references Made critical revisions to the paper for important intellectual content: revised the manuscript Provided technical or material support Responsible for the study conception and design Supervised the study: senior researcher, quality control of the work Performed the data collection: urban data together with AA Performed the data analysis and interpretation and joint the information Responsible for the drafting of the manuscript: ethical considerations and discussion Provided administrative, technical or material support Responsible for the drafting of the manuscript: outlined the manuscript, methodology, tables, results, and discussion with A. Serdar Atav Provided administrative, technical or material support Made critical revisions to the paper for important intellectual content: kept the timetable, kept the planned data included and approved the comments and the final manuscript, corresponding author Responsible for the study conception and design Provided statistical expertise: made all the statistics, prepared all the data after coding them into the SPSS statistical program Performed the data analysis, interpretation and joint the information Responsible for the drafting of the manuscript: statistical analysis section, critical overview and revision of the results Made critical revisions to the paper for important intellectual content: revised the theoretical background, study design and methods Provided administrative, technical or material support Supervised the study: senior researcher, quality control of the work Performed the data collection: rural data Performed the interpretation in local level, and joint the information into the national level Made revisions Responsible for the drafting of the manuscript: rural results, interpretation and discussion
Merdiye Şendir, RN, PhD, Associate Professor, Istanbul University, Florence Nightingale Faculty of Nursing, Istanbul, TURKEY
A. Serdar Atav, PhD, Associate Professor, Binghamton University, Decker School of Nursing, Binghamton, NY, USA
Belkız Kızıltan, RN, MSc, Research Assistant, Gümüşhane University, School of Health, Gümüşhane, Turkey
Acknowledgment We want to thank the nursing students who participated in this study. We wish to thank Nurgül Mazlum, Tuğba Torun and Mine Demir for their help with the coordination of data collection. Also, we thank Mr. Malcolm H. Gunter, for his help with editing.
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