PROFESSIONAL NURSES KNOWLEDGE AND UNDERSTANDING OF AIDS / HIV INFECTION NJCHAMANE and W KORTENBOUT

This study examined professional nurses’ knowledge and understanding o f AIDS/HIV infection. The sample was formed by 53 professional nurses; 27 being those that have done the AIDS counselling course (trained counsellors) and 26 who have not done the course. This sample was randomly chosen from a population of 192 professional nurses representing all departments. Questionnaires were sent to the participants andfocus group interviews formed by a group of 21 participants, were done to elicit any information that may not have been obtained through the use of a questiormaire. The results showed good knowledge o f general information which irKluded the mode of spread of infection. Lack o f knowledge in identtfication of high risk groups, symptoms, diagnostic tests and use of universal precautions in specific areas was identified.


INTRODUCTION
The study focused on the specialised hospital professional nurses' knowledge and understanding of AIDS/HIV infection.The researchers' interest was triggered by the rate of HIV infection in the hospital where the study was done.This showed a rise in the number of HTV infected patients, from 89 in 1990 to 145 in 1992, with the wards having an average of 30% of HIV infected patients.
The above picture related to HIV infection in the world which showed a tremendous growth since early eighties up to this juncture and this appears to be ±e problem for the country's health and economic system.The worlds' statistics (on HIV infected people) showed this pattern :-1990 74000-102000,1991191926 -201617,2000 an estimation of 38-110 million HIV infected people.(AIDS Bulletin;December 1992;vol 2,& AIDS Training and Information Centre. 1993.)It is realised that the professional nurses had a big role to play in the prevention of spread of infection, whose actions would be based on knowledge and understanding of AIDS/HIV infection.

RESEARCH O B JEC nV ES
The main aim of the study was to explore the knowledge held by the professional nurses in a specialised hospitd, about AIDS/HIV infection.
To estimate the number of AIDS/HFV infected patients, that the professional nurses had to deal with in each ward, so as that the intensity of exposure could be measured.

THEORETICAL FRAMEWORK
Two theories were combined to form a framework.These were:-1.COGNITIVE DISSONANCE THEORY 2. FEAR OF CONTAGION THEORY

COGNITIVE DISSONANCE
This theory assumes that people want to maintain consistency in their beliefs, attitudes, values and behaviours.If individuals confront examples of their own inconsistency in these areas they will experience psychological discomfort and be motivated to eliminate the inconsistency.(Wicklund & Brehim, 1976) FEAR OF CONTAGION This is an affective stress-response to illness.Fear of Contagion is an anxious response to the perceived threat of catching the disease.Three behaviours characterise this kind of fear;avoidance, taking extreme precautions and verbal expression of fear regarding the disease.(Meisenhelder & La Charite, 1989) Both theories clearly indicated that individuals would try by all means to maintain equilibrium or eliminate dissonance by either by avoiding the situation that causes disequilibrium or engaging in behaviours that would be directed at reducing the inconsistency.Fear of Contagion was seen to be the result of cognitive dissonance, since it is a stress-coping response.

LITERATURE RELATED TO THE STUDY
Previous studies by Akisanya & Rouse (1992) indicated that AIDS/HIV infection still appears as the most feared disease due to its incurability and its association with death and because of its prognosis.It was highhghted that fear would be worsened by lack of knowledge.Further support was from the study done in England in 1988 & 1990 which explored knowledge and attitude and revealed that nurses with limited knowledge base had judgemental and negative attitudes towards AIDS/HIV infected patients.(Eysenick, 1992 ;Akisanya & Rouse 1992) A study done in 1991 on nursing, psychology and design students to evaluate the relationship between knowledge, attitude and the rate of contact with HIV infected patients, showed no relationship between knowledge and attitude but a strong relationship between rate/degree of contact and attitude.That is then the reason for inclusion of the rate of infection in each ward, which would influence the degree of contact and exposure to HIV infected patients in this study.( Robbins et.al 1992) Bond et.al ( 1990) did a survey on experience and knowledge of conmiunity nursing staff in England and found that nurses lacked confidence in doing tasks and procedures for AIDS/HIV infected patients which included providing health education, counselling and rendering terminal care.This was related to lack of experience since most of them had less contact with HIV infected patients and as a result presented with fear.(Bond et.al, 1990;Akisanya & Rouse, 1992) METHODOLOGY This was a descriptive survey whereby questionnaires and focus group interviews were used.Questionnaires were used to collect data and in addition, focus group interviews were used to elicit information that could not be obtained through the use of a questionnaire.

SAMPLE AND SAMPLING METHOD
A sample of 60 professional nurses was drawn from a total of 192 professional nurses working in various wards/departments in a specialised hospital.Fifty percent was formed by Trained AIDS counsellors (30) and 50% was randomly selected from the rest of the professional nurses that have not done the AIDS counselling course, but work in the same setting.
Both verbal and written informed consents were obtained from the participants.These included the pilot study, focus group and questionnaire participants respectively.In the letter seeking permission, the participants' rights were explained including voluntary participation.The purpose of the study was explained.Confidentiality was assured.Participation was outside working time.Prior to conducting the study, permission was obtained from the Medical Superintendent, Chief Nursing Service Manager and Natal Provincial Administration.

CONTROLLING B U S AND CONTAMINATION OF THE STUDY
The content was valid in a sense that bias was limited.The pilot snidy was done to check if the questionnaire was clear and to ensure correct timing of participants.To avoid contamination of the main study, the pilot study participants were not included in the main study.The same applied to focus group interview participants.Both groups were selected after sampling for the selection of questionnaire participants.

CONTENT VALIDITY
The tool content was valid in a sense that it was based on the literature studied, (Eusenick, 1992;Meisehelder & La Charite, 1989) and the theoretical framework.The questions were phrased in such a way that could elicit behaviours characterising both theories, as well as actual knowledge and understanding of the disease/infection.There were open-and close-ended questions .The yes/no questions had options like "other", and the respondent had to specify the other alternative.The same applies to the agree/disagree questions which had the option of stating if "unsure/undecided".All answers were grouped, analysed and interpreted accordingly.

DATA ANALYSIS AND INTERPRETATION 1. Knowledge and Understanding in
Relation to Attitude Although this study showed good general knowledge, there was a limited knowledge base of specific information like prevention of spread of infection, use of protective clothing and the diagnostic tests available.As a result 22% respondents showed a negative attitude to HIV infected patients.When this question was counterchecked, the negative attitude increased to 43% when including those that were undecided.

Rate of Contact (Experience)
and Attitude The study revealed that almost all (95%) wards had HIV infected patients which increased the chances of contact and experience.This was looked upon as the reason for tine 78% positive attitude that initially showed in the first question that assessed attitude.The positive attitude was further shown by the focus group respondents who felt that if they could refuse to care, who then should care.This then showed a strong relationship between experience/degree of contact and attitude.

Risk of Infection when Nursing HIV
Infected Patients It was surprising to discover that some questionnaire respondents were not truthful in answering the fear question.This was discovered when they were asked to indicate the perceived risk of getting infection when nursing HIV infected patients.The results showed that 31% perceived the risk as low (less fearful), which is the actual occupational risk according to the literature (Moss,1992).The rest, 69% perceived the risk as moderate to high.This tied up with the focus group participants who perceived the risk as high and expressed fear for infected patients.See Figure 3 below:-

Knowledge and Beliefs
There was a section exploring beliefs about the use of condoms, or vaginal douche after sexual intercourse to reduce the risk of getting infection.Almost all respondents (96%), believed that vaginal douche after sexual intercourse could not reduce the risk of getting infection but use of condoms could reduce the risk; 83% of nurses knew that one antibody test could not conclusively establish sero-negativity; and 87% believed that the general appearance could not provide evidence of HIV infection.The same applied to focus group respondents who beheved that general physical appearance could not tell if a person is sero-positi ve, but with the antibody test the majority of focus group respondents did not know about the window period.

Lack of Knowledge in Universal
Precautions This was mainly marked in a section that dealt with use of universal precautions\protective clothing to prevent spreadXcontamination of infection.Both groups were equally unsure with this aspect The participants were using conflicting protective clothing for similar situations, which was a sign of uncertainty.

Knowledge Difference Between Two
Groups It was discovered that the Trained AIDS counsellors had better knowledge than the professional nurses who had not done the course.But when the differences were tested statistically, no statistical difference was noted except on knowledge of diagnostic tests whereby the Trained counsellors had better knowledge, both numerically and statistically.See diagram below, which showed the numerical difference.

CONCLUSIONS AND RECOMMENDATIONS KNOWLEDGE AND UNDERSTANDING
The general knowledge of all the professional nurses was found to be fairly high.This included knowledge of causes, predisposing factors and mode of spread.Limited knowledge was noted in specific areas like identification of highly infections body fluids, tests available to detect HIV infection of opportunistic infections.Uncertainty was seen in the use of universal precautions (protective clothing) which forms the major aspect in preventing the spread of infection in the working environment.

FEAR OF CONTAGION AND COGNITIVE DISSONANCE
The study revealed marked fear of contracting the disease irrespective of the knowledge pattern and experience.This was aggravated by the fact that the disease is incurable at this juncture.The focus group revealed the fact that the highly perceived fear is that of "knowing" that one has got HIV infection; and the participants felt that people do not die of AIDS and its complications per se but die more of " knowing" and the depression associated with this incurable monster which further lowers their immunity.It was discovered that those were the reasons for taking extreme precautions, avoidance of challenging situations and verbalisation of fear.
The nurses felt that they needed to be comfortable with themselves so as to be able to care for other individuals, but found this to be a problem with HIV infection since they lacked knowledge especially those that have not done the counselling course.As far as universal precautions are concerned, both groups were uncomfortable, as indicated by the analysis of the focus group discussions.

ATTITUDE
Although 66% of participants showed positive attitude, the rest showed a negative attitude.This was expressed in questionnaire results when people expressed the feeling that when given the chance, they would refuse to care for HIV infected patients and preferred that care be rendered on voluntary basis.The group with a positive attitude felt that if they were to refuse to render such care, who than should care for these people!RECOMMENDATIONS 1. Aids Counselling Course This progranmie increases awareness and knowledge base for professional nurse and would enable them to cope with challenges associated with HIV infection.