The views of undergraduate nursing students on caring for patients with HIV / AIDS

^ ““ The study population consisted of BCur III nursing students studying at the Medical University of Southern Africa (Medunsa). Participants were purposively selected. Focus group interviews were used as a data collection instrument. Guided by a group moderator and responding to a central research question, participants shared their views about caring for HIV/AIDS patients. Tesch’s qualitative method of data analysis, as described by Cresswell (1994:155), was used to analyse the data. Abstract: Curationis 29(3): 87-96 A qualitative, exploratory and descriptive study was conducted with the purpose of exploring and describing the views of undergraduate nursing students on caring for HIV/AIDS patients.


Introduction
The em erg en ce o f the hum an immunodeficiency virus (HIV) and its re su lta n t sy n d ro m e, the acquired immunodeficiency syndrome (AIDS), as public health concern has created ethical and legal healthcare dilemmas, which were previously unheard-of within the healthcare system.There is growing acknowledgement that many young adults regularly engage in behaviour that puts them at risk of becoming infected with HIV.Considering their ages (usually between 18 and 25 years) and sexual activities, nursing students themselves could be regarded as young adults w ho are at risk of becom ing infected with HIV.Their y outhfulness, vulnerability, lack of judgement and obvious lack of adequate know ledge ab o u t H IV /A ID S leave nursing stu d en ts w ith a feeling o f uncertainty when they have to deal with HIV/AIDS patients.Nursing students enter tertiary education with elementary knowledge of HIV/AIDS -knowledge they have obtained from sources such as primary and secondary education, society, and the media (Serlo & A avarinne 1999:468).Often it is expected of these students to care for AIDS patients from the time of entry into nursing practice.All too often they have to care for HIV/AIDS patients even before the condition is discussed in the classroom.These very early experiences of and exposure to caring for patients with HIV/AIDS lead to feelings of fear and anxiety.

Background to and significance of study
Since HIV was first described in 1983 (more than 21 years ago), millions of people have become infected worldwide.AIDS has becom e the w orld's most serious public health concern (Evian 2000:3).
It seem s that som e c o u n trie s and communities are more vulnerable to HIV infection than others.Approximately 34.3 million people are infected worldwide, and about 90% o f these infections occurred in developing or poor countries.The h ard est hit is the sub-S aharan region, where roughly two thirds of infections have occurred.South Africa, one of the developing countries in this re g io n , is am ong the co u n trie s experiencing the greatest increase in HIV infections (Health Systems Development Unit 2001:3).Young people, who intend joining the nursing profession in South A frica and those already taking up nursing, will have to face numerous challenges caused by the increasing number of HIV infected patients.
With the HIV/AIDS pandemic continuing into its th ird d ec ad e, n u rses need knowledge and skills to ensure not only safe p atien t care but also safe p ro fessio n al co n d u c t.
E ducation programmes need to focus on preparing nurses and o th e r h ealth care p ro fe ssio n a ls to e ffic ie n tly and competently care for HIV/AIDS patients without putting themselves at risk of contagion (Olayinka & Osho 1997:554).
A cco rd in g to S ie g el, L azarus, K rasnovsky, D urbin and C hesney (1991:160), several studies have assessed AIDS-related knowledge, attitudes and behaviour among high school students, as p a tte rn s o f sex u al ac tiv ity and experimentation with drugs frequently occur among this group and put them at risk of contracting the disease.Results of these studies indicated that the need for AIDS prevention is all too apparent, and that support is grow ing among ad o lesc en ts fo r A ID S ed u catio n programmes that give particular attention to emotions and anxiety relating to sexual activity.Anxiety, fear of contagion and discom fort are also experienced by undergraduate nursing students, some of whom being in the same age group as high sch o o l stu d en ts.In casual conversations, nursing students also expressed fear of becoming infected with the AIDS virus while caring for patients with HIV/AIDS.

Curationis August 2006
for patients w ith H IV /A ID S is also observed in healthcare professionals w ho have m ore k n o w led g e and ex p erien ce o f m an ag in g p atien ts.Healthcare professionals caring for HIV/ AID S p a tie n ts d e m o n stra te a considerable am ount o f burnout and frustration, as they have to deal with p rofound p h y sic a l and m ental deterioration and their own feelings of helplessness (Demmer 2000:119).These professionals are supposed to act as mentors in their practical settings and teach less experienced students the correct behaviour.Thus, their attitudes and conduct could be one reason why student nurses also have such fear and u n ce rtain ty ab o u t c o n tra c tin g the disease.
The results of this study could assist in u n d ersta n d in g the v iew s o f u n d erg rad u ate n u rsin g stu d en ts on caring for patients with HIV/AIDS and, ultimately, lead to an improvement in the quality of care given by these students to patients suffering from HIV/AIDS.

Problem statement
The high incidence of HIV infections in South A fric a and e v e r-in c re a sin g numbers of HIV/AIDS patients require a great deal of knowledge and competence in the nursing profession.Specific problems are encountered by c lin ic a l p re c e p to rs w ho su p erv ise student nurses caring for HIV/AIDS patients.The most common problems are the high rate of absenteeism and lack of interest.It seems that student nurses report sick more frequently when caring for patients with HIV/AIDS than when allocated other areas of care.Sim ilar re p o rts are also re c e iv e d from p ro fe ssio n a l n u rses su p e rv isin g students in the units.Currently limited documentation is available on the views (including opinions, beliefs and attitudes) of undergraduate nursing students on caring for patients with HIV/AIDS in South Africa.

Purpose of the study
The purpose of the study was to explore and describe the views of undergraduate nursing students on caring for patients with HIV/AIDS.

Research question
The central research question was as follows: What are the views of undergraduate nursing students on caring for patients with HIV/AIDS?

Objectives of the study
The objectives of the study were to:

Research design and method
A qualitative, exploratory and descriptive research design was used for this study.

Population and sampling
A study population involves individuals who possess certain characteristics, or a set of entities in which measurements of interest to the researcher are present (De Vos 2002:198).It refers to the entire population that m eets the sam pling criteria, i.e. the sum total of all cases that meet the definition of a unit of analysis (Brink & Wood 1989:161 ;U ys& Basson 1999:51).
The study population for this research consisted o f all th ird -y ear students studying for the baccalaureate BCur at the M edical U niversity of Southern Africa (Medunsa).BCur III students were chosen for the following reasons: • They were accessible to the researcher.

•
They were better suited to the discussions on HIV/AIDS than first-year or second-year students, as they had more knowledge and experience.

•
If issues were raised that needed their response, they would still be in the course the following year and would be readily available.Even after they had left the institution, which would be the year after, they would still use it as reference and the institution would still have their residential and postal addresses.
Sampling involves selecting a group of p eo p le, events, b eh av io u r or other elements with which to conduct the study (Burns & Grove 2001:365).It is the process of selecting a portion of the population of interest to the researcher, which conforms to a designated set of specifications (De Vos 2002:199).
BCur III nursing students were selected because they had certain characteristics in common concerning the topic, i.e. knowledge about caring for HIV/AIDS patients.A focus group interview is an effective technique for exploring the views of staff (Kitzinger 1995:299), and therefore it was appropriate to apply this technique to explore the views of these students.The services of a skilled group moderator were enlisted to facilitate the fo cu s g rou p in terv iew s and thus overcome most of the limitations of focus group interviews whilst the researcher, took the field notes.
According to De Vos (2002:311), the optimal number of participants for a focus g roup in terv iew is five to ten, but Kitzinger (1995:300) allows a number in the range of six to twelve, depending on 89

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the study's aim.Deciding on the right number of participants means striking a b alan c e betw een having enough members to generate a discussion, but not having so many people that some feel crowded out (De Vos 2002:311).In this study, two groups of six members each, both males and females, were interviewed.These numbers have shown to be suitable, as both groups generated meaningful discussions without letting individuals feel inhibited or excluded.

Ethical considerations
Permission to conduct the study was obtained from Medunsa and the Ethics Committee of the University of Pretoria's Faculty of Health Sciences.Consent was also obtained from participants.
The ethical principles, as set out by Polit, B eck and H ungler (2001:74), were considered.Participants were informed that participation was voluntary, that non-participation would not compromise their student status and that they had the right to withdraw at any stage of the research study without stating reasons.
Participants were not exposed to any risk or harm, as the study did not involve issues such as the adm inistration of drugs or the performance of procedures.Instead, students could benefit from participating in the study because the re searc h topic in volved a subject c o v ered in the B C ur cu rriculum .
Participants were treated as autonomous agents, capable of controlling their own activities and destinies.They were treated fairly and their privacy was maintained.P ro m ises m ade to su b jects about confidentiality were kept.The researcher ensured that no names were used and data were kept safe at all times.
The study's background, its purpose, objectives and methodology, the ethical considerations and the reporting system were explained to the participants.The explanation was follow ed up by an information leaflet that further explained what the study entailed, including the role of the participants.Participants were encouraged to ask questions in order to clarify issues.

Data analysis
Tesch's method of qualitative analysis, as interpreted by Cresswell (1994:155), was followed in order to analyse the transcribed data.
The researcher achieved a sense of the whole by listening to the audiotapes and by reading and re-reading the verbatim tran scrip tio n s.The research er read through the transcription of the first focus group interview, read through it again and underlined the themes that emerged.The researcher applied the same procedure to the second focus group interview transcription in order to identify the themes that related to the central research question.
The coding of data was performed step by step.Repetitive words, phrases and concepts were recognised as themes.
The themes were listed, and sim ilar themes were clustered together to form subcategories. From the subcategories major categories emerged.The data units w ere then g ro u p ed into them es, subcategories and categories.
Data belonging to each category were assembled and a preliminary analysis was performed.The researcher enlisted the help of an independent co-coder, and both the co-coder and the researcher completed an independent analysis.The co-coder and the researcher then held a co n sen su s m eetin g to clarify discrepancies and identify similarities (Coffey & Atkins 1996:46;Creswell 1994:154).Lincoln and Guba (1985:218)

Discussion of results and literature control
The ca te g o rie s, su b ca te g o ries and themes portraying and conveying the views of undergraduate nursing students on caring for patients with HIV/AIDS, as they emerged during the data analysis, are displayed in Table 2. Four main categories w ere identified, nam ely em o tio n s, need s, dem ands, and solutions.

Category 1: Emotions
The first c a te g o ry id e n tifie d was 'em otions'.Several themes denoting em otions o f u n d ergraduate nursing students emerged from the data and were subcategorised into 'emotions towards se lf', 'em otions tow ards HIV/AIDS patients', 'emotions towards hospital n u rsin g p e rs o n n e l' and 'em otions towards their lecturers'.

Emotions of undergraduate nursing students towards self
Within this subcategory, the themes 'fear, ignorance, guilt, hope and acceptance' emerged.Participants expressed being fearful of contracting the disease while caring for H IV /A ID S patients, and infecting other patients, or even relatives.Feelings of inadequacy and ignorance were expressed and related to their lack of knowledge about the disease.These feelings were more strongly felt when they were first-year students, especially as HIV/AIDS was not yet discussed in class.Feelings such as hope for and accep tan c e o f H IV /A ID S p atien ts developed as the course progressed and the condition was better understood.
Fear experienced by participants in connection with HIV/AIDS patients is congruent with a finding by Serlo and Aavarinne (1999:463) who stated that, w hen the co n d itio n w as p u b licly discussed, student nurses expressed many different feelings and emotions, am ong o th ers, fear, an x iety , and d isco m fo rt.T he stu d y by these re searc h ers also re v ealed that this incurable disease was poorly known and p re ju d ic e rid d en .S y n o g ro u n d and Kellmer-Langan (1991:201) indicated that student nurses expressed discom fort when caring for HIV/AIDS patients, citing inadequate preparation for dealing with these patients as one of the reasons.

Emotions of undergraduate nursing students towards HIV/AIDS patients
Participants expressed emotions such as pity and compassion towards HIV/AIDS patients but acknowledged that caring for these p a tie n ts w as ad v ersely influenced by the stigma attached to the disease.Participants admitted that fear of contracting the disease caused an in a b ility to n u rse w ith p assion.S tig m a tisa tio n re su ltin g in u n fa ir treatment emerged as theme from both focus group interview transcriptions.The stigm a was alw ays accom panied by discriminatory practice, while a breach of patient confidentiality surrounding HIV/ A ID S led to d iffe re n t form s o f discrimination.m edical profession has ex ten siv ely practised discrimination against people living with AIDS (PLWA).Discriminatory h o sp ital p ra c tic e s in c lu d e testin g patients for HIV without their knowledge or consent, testing p atients w ithout providing pre-test counselling (contrary to national and international guidelines), and transferring private sector patients to public hospitals when these patients are found to be HIV positive.

Emotions of undergraduate nursing students towards hospital nursing personnel
Participants expressed feelings of anger towards hospital nursing personnel, stating th at n u rsin g stu d en ts w ere expected to care for HIV/AIDS patients but were neither tim eously inform ed about the patients' HIV/AIDS status nor given proper orientation.They also expressed fru stratio n , as they w ere assigned nursing duties, such as bed bathing HIV /A IDS patients, w ithout being orientated or supervised.Peate, Suom inen, V alim aki, L ohrm an and Muinonen (2002:493) reported that, in order for educationalists to address knowledge deficiencies among student nurses, it was important to assess nurses' understanding of sexually transm itted diseases (STDs) and HIV/AIDS.This aspect especially relates to the planning o f c u rric u la .N urses need a sound understanding of the causes o f HIV/ AIDS if effective quality care were to be rendered.

Emotions of undergraduate nursing students towards lecturers
P a rtic ip a n ts ex p ressed fe e lin g s o f dissatisfaction towards lecturers.The study rev ealed th at stu d e n ts w ere dissatisfied about the lack o f support from lecturers.Students who were fearful of contracting HIV/AIDS while caring for HIV/AIDS patients felt that they did not receive adequate accom panim ent or counselling.Peate et al. (2002:492) confirmed that it was im portant to provide education about HIV/AIDS and support student nurses who were afraid of contracting the disease while performing nursing tasks.Nurse educators act as role models for n u rsin g stu d en ts.
T h e ir c lin ic a l accompaniment of students caring for patients with HIV/AIDS, their interaction with these patients, and the degree of com fort w ith w hich they clin ically supervise students caring for HIV/AIDS

Category 2: Needs
Within the second main category, three subcategories were identified, namely: 'needs id en tified w ith reference to u n d erg rad u a te n u rsin g students, healthcare professionals, and the general public'.

Needs identified with reference to undergraduate nursing students
While expressing their views on caring for patients with HIV/AIDS, nursing students identified needs relating to 'knowledge and education', 'support and counselling' and 'curriculuminnovation'.
They expressed the opinion that a module on HIV/AIDS should be included in the undergraduate nursing curriculum at firstyear level, em phasising curriculum innovation in this regard as a matter of urgency.Participants' need for curriculum innovation is supported by Petro-Nustas (2000:433) who stated that there was a need for introducing a tailor-made course on HIV/AIDS, to be offered to students as part of their study plans/curricula.This is in ac co rd a n ce w ith fin d in g s by Snowden (1997Snowden ( :1167) ) who stated that nursing education programmes should be modified to have a greater impact on HIV/ AIDS.

Needs identified with reference to healthcare professionals
Within the subcategory 'needs identified w ith re fere n ce to h e a lth c a re professionals', the themes 'knowledge and e d u c a tio n ' and 're d u c in g stigmatisation' were identified during the coding process.Participants expressed the need for healthcare professionals to be educated about HIV/AIDS, because these professionals did not have the m ost recent in fo rm atio n ab o u t the disease and w ere u nab le to clearly explain or m otivate nursing actions towards HIV/AIDS patients, causing confusion am ong nursin g stu d en ts.A ccording to the participants, health professionals should take ac tio n to reduce the stigma associated with HIV/ A ID S and, in o rd e r fo r th ese professionals to change their negative h ttp :// w w w .iss u e s in m e d ic a le th ic s .or g / 123ed0.html)attested to these facts, stating that, in public hospitals, patients with HIV infection were referred to the STD wards, regardless of the source of infection, denied emergency treatment, or were isolated, thus making their HIV status known.
Needs identified with reference to the public 'K n o w led g e and e d u c a tio n ' and 'support' were identified as themes within this subcategory.Participants in d ic a te d th at know ledge o f and ed u catio n about H IV /A ID S should extend to the general public, communities included, as most HIV/AIDS patients receive home-based care.Knowledge and education would empower the public to better support HIV/AIDS patients and their fam ilies.As expressed by the participants, support could take the form of active involvement in church and com m unity organisations caring for 93 Curationis August 2006 these p a tien ts.A ccording to the p a rtic ip a n ts, the S outh A frican g o v ernm ent should take a g reater responsibility for educating the public and ensuring community support for HIV/AIDS patients and their families.
The need for a general public that is knowledgeable about HIV/AIDS and supportive of HIV/AIDS patients and the government's responsibility in this regard were also em phasised in a study by Uwakwe (2000:423) about systemised HIV/AIDS education for student nurses.U w akw e stated that the relativ e reluctance of Nigerian healthcare workers to treat HIV/AIDS patients was not only attributable to erroneous attitudes and beliefs, but also due to a shortage of health supplies, such as syringes and gloves, that were needed to comply with u n iv ersa l p re cau tio n s.H ealth departm ents or health m inistries are resp o n sib le fo r p ro v id in g health ed u catio n and su p p ly in g adequate health resources, including facilities and supplies.
Category 3: Demands P a rtic ip a n ts d irec ted dem ands at healthcare professionals, lecturers and the government.
Demands directed at healthcare professionals 'Recognition of student status' emerged as them e u n d er th is subcategory.Participants indicated that they did not wish to be regarded as additional staff members in the wards but as student nurses.In addition, they dem anded freedom of expression in clinical practice, especially when caring for HIV/AIDS patients.Participants explained that the non-communicative practice of referring the patient to the doctor every time the patient requests information about her/ his condition was a barrier towards the successful delivery of care.Furthermore, participants argued that nurses, including student nurses, who attended to the patient by staying at her/his bedside most o f the tim e, should be given some freedom of expression to be able to deal with the patient's health issues.
Research by Arhin and Johnson-Mallard (2003:121-2), describing students' needs for independence and self-expression, supports the demand for recognition of student status expressed by participants in this study.Arhin and Johnson-Mallard described the majority of students in classrooms of colleges and universities today as 'products of a generation of latchkey kids', who grew up with daycare, television and computers as surrogate p aren ts and the p ro life ra tio n o f technology, the Internet and cellphones, w hich m ade them independent and re so u rce co n d itio n ed .
S tudents, therefore, are a challenge for educators, and need to be encouraged, and given alternative forms of self-expression.

Demands directed at lecturers
U nder this su b category, the them e 'clinical accompaniment' emerged, as alm ost all p articipants in the study strongly urged more intensive clinical accompaniment by lecturers, especially in the first study year when they were unsure and fearful of patients infected with the AIDS virus.The quality of clinical acco m p an im en t o f stu d e n ts is an important dimension of the education or learning programme.Clinical preceptors/ mentors are responsible for ensuring students' compliance with the clinical outcom es o f the p ro g ram m e, in accordance with requirements laid down by the nursing education institution and the South African Nursing Council (Tsele & Muller 2000:33).

Demands directed at government
Participants expressed the importance of a n tire tro v ira l th era p y d e liv e ry by g o v ern m en t.De M artin o , Tovo, Balducci, Galli, Gabiano, Rezza andPezzotti (2000: 2871-2) confirm the im portance of antiretroviral therapy, stating that since the introduction of combined antiretroviral therapy in Italy, mortality rates in adults with HIV Type 1 infection have decreased.

Category 4: Solutions
Within the final category 'solutions', three subcategories emerged, namely: 'solutions involving u ndergraduate nursing students', 'solutions involving HIV/AIDS p atien ts', and 'solutions involving communities and government'.

Solutions involving undergraduate nursing students
'Students participating in prevention campaigns' emerged as theme within this subcategory.P a rtic ip a n ts fe lt that student nurses should actively rally com m unity support fo r H IV /A ID S patients and their families.On the o rg an isatio n A dvocates for Youth's homepage, My Voice Counts (2005: http://www.advocatesforyouth.org/youth/advocacy/m yvoicecounts/ g lo b alh iv /), it is stated th at under U g an d a's su ccessful ABC strategy (Abstinence, Be faithful, use Condoms), everyone was encouraged to adopt abstinence, if appropriate, be faithful to one partner, and use condoms.Contrary to th is, u n d er the US P re s id e n t's Emergency Plan for AIDS Relief, these messages were separated and directed at different groups -abstinence was intended for only young people; be faithful, for only married couples; and use condoms, for only sex workers and others who were considered being at great risk of contracting the disease.

Solutions involving HIV/AIDS patients
Within this subcategory, two themes emerged, namely 'universality of care' and 'patients' rights'.
Participants argued that patients should not be treated differently because of their HIV/AIDS status.They proposed that h ea lth c are p ro fe s s io n a ls sh o u ld reorientate themselves towards applying a holistic healthcare strategy, as opposed to following a purely physical healthcare approach.In this study, HIV /A IDS patients were seen as having rights equal to all other patients, as stipulated by the Patients' Bill of Rights.
The proverb 'actions speak louder than words' is especially applicable to crosscultural com m unication (W illiam s & Davis 2004:58).W illiam s and Davis em phasise the im portance o f crosscultural non-verbal communication and state that nurses have to be extra careful when caring for patien ts o f diverse cultures.This applies to South African nurses, as South Africa is a multicultural country.W hatever caring m odality is used, nurses should ensure that their strategies o f caring are u n iv ersally acceptable to the recipients o f care.

Solutions involving communities and government
The discussions of participants focused on reducing stigm a and in cre asin g support for HIV/AIDS patients and their families.In this study, government was seen as having a re sp o n sib ility , in partnership with communities, to reduce the stigma attached to HIV/AIDS.This could be accomplished by implementing aw areness p ro g ram m e s am ong communities that patients with HI V/AIDS are like all other patients with chronic diseases.Uys and Cameron (2003:81) indicate that a holistic continuum of HIV prevention, support and care structures is needed to prevent the stigmatisation, discrimination and trauma associated with HIV/AIDS.Informal social structures made up of family, friends and neighbours often offer care and support to individuals in their own homes, that is, community-based hom e care.H ow ever, h o m e-b a sed caregivers need additional support from outside their immediate circle.

Recommendations
The follow ing recom m endations are based on the above fin d in g s and problems identified in the study.
were used to establish the trustw orthiness of the study.These strateg ie s in clu d e cred ib ility , tra n sfe ra b ility , d ep e n d ab ility , and confirmability.(SeeTablel.) Jesani, Kalantri, Thomas and S rin iv asan (2003: h ttp :// w w w .is s u e s in m e d ic a le th ic s .or g / 123ed0.html)are in agreement with the findings above, in d icatin g that the 90 Curationis August 2006

Table 2 : Summary of categories, subcategories and themes
ConclusionHIV infection and AIDS are having considerable effects on the healthcare system in South Africa.It is important that student nurses should be supported in caring for HIV/AIDS patients.This study will help educationalists plan and implement programmes that are sensitive to the needs of not only students, but also HIV/AIDS patients and their families, thereby improving the quality of care provided for HIV/AIDS patients and ensuring support of their families.[4313words]