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The experiences of nursing students caring for persons with acquired immunodeficiency syndrome (AIDS) Negrin, Kelly Ann 1994

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THE EXPERIENCES OF NURSING STUDENTS CARING FOR PERSONS WITH ACQUIRED IMMUNODEFICIENCY SYNDROME (AIDS) A QUALITATIVE STUDY By KELLY ANN NEGRIN B.S.N., The University of British Columbia, 1990 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING in THE FACULTY OF GRADUATE STUDIES The School of Nursing We accept this thesis as conforming to the required s'feanplard THE UNIVERSITY OF BRITISH COLUMBIA April, 1994 (c) Kelly Ann Negrin, 1994 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of / LuA^lsLf) The University of British Columbia Vancouver, Canada Date DE-6 (2/88) ii ABSTRACT Acquired immunodeficiency syndrome (AIDS) is a health problem of epidemic proportion. Of all health professionals, nurses provide the majority of care to persons with AIDS (PWAs). Studies have documented that nurses hold negative attitudes toward PWAs which affect the care afforded this client population. Several studies, mostly quantitative in nature, have addressed nursing students1 attitudes toward PWAs, the findings of which indicate similar attitudes to those of nurses. Since nursing students, as students and as future nurses, will be expected to provide care to the increasing number of PWAs, a need exists for further research. Moreover, since the potential exists for inductive methods to more fully illuminate phenomena that may otherwise be difficult to convey using quantitative methods, a qualitative study was conducted of nursing students' experiences caring for PWAs. Eight students from the University of British Columbia/Vancouver General Hospital (UBC/VGH) Nursing Program, enrolled in the second through fourth years of the program, and who had cared for at least one PWAs within their course of study, participated. Direction for analysis of the audiotaped, unstructured interviews iii was taken from phenomenological methods of data analysis. Data analysis revealed that concern for personal safety was a pervasive and enduring theme throughout nursing students1 experiences caring for PWAs. Students experienced varying levels of concern for personal safety, from a heightened awareness of their clients' body fluids, to students being very scared that caring for their clients could cause their own deaths. Students described how concern for personal safety, for them, was unique to caring for PWAs due to the combined effect of the contagious, incurable, and fatal properties of AIDS. Students employed a number of mental activities, termed processing, to appraise and cope with their experiences caring for PWAs. Students also utilized a variety of deliberate and observable behaviors, termed managing, to cope with caring for this client population. The findings from this study have implications for nursing practice, education, administration, and research. iv TABLE OF CONTENTS Page ABSTRACT ii TABLE OF CONTENTS iv LIST OF FIGURES viii ACKNOWLEDGEMENTS ix CHAPTER ONE: INTRODUCTION Background and Significance of the Problem . 1 Problem Statement 4 Introduction to the Method 5 Research Question 7 Conceptual Definitions 7 Assumptions 8 Limitations to the Study 8 Summary 9 CHAPTER TWO: LITERATURE REVIEW Introduction 11 Nurses' Attitudes Toward PWAs 11 Nursing Students' Attitudes Toward PWAs . . . 22 Summary 3 4 V Page CHAPTER THREE: METHOD Introduction 3 6 Selection of Respondents 3 6 Selection Criteria 36 Recruitment Procedures 37 Sample Size 38 Data Collection 38 Data Analysis 4 0 Ethical Considerations 42 Criteria for Rigor 44 Summary 4 7 CHAPTER FOUR: FINDINGS AND INTERPRETATION Introduction 49 Conceptual Framework 49 Presentation and Interpretation of Findings . 53 Concern for Personal Safety 54 Processing 60 Analyzing 61 Comparing 62 Evaluating Self 65 Wondering 68 Judging 71 Mental Restructuring 77 Pag Categorizing 77 Rationalizing 79 Managing 80 Distancing 81 Information-seeking 85 Discussing 88 Advocating/Supporting 90 Increasing Involvement 92 Summary 94 CHAPTER FIVE: DISCUSSION OF FINDINGS Introduction 102 Concern for Personal Safety 102 Processing 108 Managing 117 Summary 124 CHAPTER SIX: SUMMARY, CONCLUSIONS, AND IMPLICATIONS FOR NURSING Summary 129 Conclusions 133 Implications for Nursing 138 Practice 138 Education 140 Administration 144 vii Page Research 14 6 REFERENCES 150 APPENDIX A: Respondent Information Letter . . . . 156 APPENDIX B: Sample Interview Questions and Probes 158 APPENDIX C: Respondent Consent Form 159 viii LIST OF FIGURES Page Figure 1. Conceptual framework for nursing students' experiences caring for PWAs 50 IX ACKNOWLEDGEMENTS I wish to thank several people whose support, in various capacities, made the preparation of this thesis attainable. To my thesis committee, Clarissa Green (chair), Alison Rice, and Dr. Joan Bottorff, thank you for your direction through the research process. Especially to Clarissa and Alison, I convey my appreciation for the way in which you gently nurtured my evolving ideas. Truly an indicator of excellence in teaching is the way in which you made me feel encouraged and enthused regardless of the nature of your feedback. To the eight nursing students who participated in my study, thank you for 'creating the windows' through which I glimpsed into your experiences caring for persons with AIDS. The powerful and intense emotions you shared will endure vividly in my mind. To three important women in my life, my mother, Marilyn, and my grandmothers, Maria and Olga, whose strength to endure adverse events in their lives, has inspired my own motivation to succeed. I also wish to acknowledge the contributions of my father, Bruno and my 'second father', Uncle Lino, whose courage and determination I emulate and whose spirits will continue to influence the unfolding of my life. Finally, to my partner and my friend, Glen, thank you. Your enduring support during my academic endeavors and, most importantly, during this past year when personal crises challenged my ability to remain focused, has rendered the accomplishment of my goal a reality. 1 CHAPTER ONE: INTRODUCTION Background and Significance of the Problem Acquired immunodeficiency syndrome (AIDS) is a health problem of epidemic proportion that has immense psychologic impact on the persons who have it and on their health care providers (Blumenfield, Smith, Milazzo, Seropian, & Wormser, 1987). Of all health professionals, nurses provide the majority of care to persons with AIDS (PWAs). An increasing body of literature indicates that nurses' attitudes toward PWAs are influenced by fears of infection; anxiety associated with a lack of information in areas of sexual behavior and drug use; and profound negative social and moral judgements toward homosexuality, intravenous (IV) drug use, and multiple sexual partners (Alexander & Fitzpatrick, 1991; Blumenfield et al., 1987; Cole & Slocumb, 1993; Flaskerud, 1991; van Servellen, Lewis, & Leake, 1988). To the extent that nurses have negative, preconceived attitudes...concerning [PWAs], these biases may interfere with the development of constructive relationships with patients, the quality and tone of nurse/patient interactions, and the psychological comfort of both patients and 2 the nurses who care for them. (Kelly, St. Lawrence, Hood, Smith, Jr., & Cook, 1988, p. 78) A few studies have addressed the attitudes of nursing students toward PWAs. Primarily quantitative in nature, these studies have identified similar attitudes as those of nurses including the right to refuse to care for PWAs, homophobia, and fear of disease transmission (Brown, Calder, & Rae, 1990; Lester & Beard, 1988; Wiley, Heath, & Acklin, 1988). Since nursing students, as future nurses, will be responsible for caring for the increasing number of AIDS patients (Synoground & Kellmer-Langan, 1991), a need exists for investigation of this experience. Rarely have inductive methods been employed to address the experiences of nursing students caring for PWAs. Many of the phenomena of nursing are complex, the meanings of which may not be fully elucidated by quantitative methods where researchers categorize concepts in a preconceived, prescriptive manner and where the use of surveys and other data collection tools to quantify phenomena may not provide adequate detail of the nature of phenomena. Further, the development of quantitative data collection tools, such as surveys and questionnaires, are based on 3 researchers' assumptions of what they believe to be the essential characteristics of phenomena and, therefore, key details about phenomena could be omitted. Because the holistic interpretations of experience derived from inductive methods could more thoroughly illuminate elements of nursing students' experiences caring for PWAs, these findings could be useful in developing a stronger knowledge base for deductive research. Further, the insights gained through an in-depth exploration of this phenomenon may be helpful to students who have not yet cared for PWAs. Similarly, these insights may also help nurse educators to be more sensitive to student needs as they care for PWAs and to develop educational strategies that foster learning to care for PWAs in a meaningful way. Caring for PWAs can elicit highly emotional reactions from health professionals. Such emotions as fear, anxiety, discomfort, embarrassment, and negative social attitudes have been documented (Flaskerud, 1992a). The researcher initially became interested in nurses' experiences caring for this client population when, as a staff nurse, she had her first experiences caring for PWAs. She confronted her feelings of fear and anxiety, feelings which had the potential to 4 influence her ability to provide quality care to these clients. The researcher's interest gained momentum when she observed other nurses expressing negative attitudes toward stigmatized client populations. These attitudes appeared to be reflected in the nurses' care of these clients. The researcher's topic was further solidified when she became a nurse educator. Although she has not had the opportunity to assign the care of PWAs to students, several of her colleagues have drawn on this population when selecting student assignments. In discussions with colleagues, the researcher wondered what these students had experienced when caring for PWAs. If caring for PWAs could evoke fear and anxiety in an experienced nurse such as herself, she was curious about the experiences of nursing students—neophytes to the practice of nursing—when confronted with caring for PWAs. Problem Statement The number of PWAs is increasing, therefore, nursing students, as students and as future nurses, will be required to care for this client population. Much of the literature indicates that nurses and nursing students alike hold negative attitudes toward 5 PWAs which influence the quality of care received by this population. Few studies have explored the experiences of nursing students caring for PWAs, and seldom have researchers employed inductive methods. Because many of the phenomena of nursing are complex and may not be fully elucidated by quantitative methods, a qualitative study of nursing students' experiences caring for PWAs must be undertaken in order to facilitate a thorough description of the phenomenon. Introduction to the Method A qualitative research design was selected as the methodological approach for this study. "Qualitative researchers tend to emphasize the dynamic, holistic, and individual aspects of the human experience and attempt to capture those aspects in their entirety, within the context of those who are experiencing them" (Polit & Hungler, 1991, p. 25). Further, Polit and Hungler state that rather than the researcher's interpretation, qualitative approaches emphasize people's interpretations of events and circumstances and "capitalize on the subjective as a means for understanding and interpretting human experience" (p. 25). 6 In qualitative research, data collection methods are loosely structured which allows respondents to express themselves and behave in naturalistic ways (Polit & Hungler, 1991). The primary data collection method chosen for this study was the unstructured interview. Direction for analysis of data was taken from phenomenological methods of analysis. The first three of Spiegelberg's (1960) steps of the phenomenological method, namely investigating particular phenomena, investigating general essences, and apprehending essential relationships among essences, provided specific direction for analysis. Phenomenological analysis necessitates that the researcher have no preconceived notions, expectations, or frameworks present to guide the analysis of data (Field & Morse, 1985). Therefore, bracketting, or "the act of suspending one's various beliefs in the reality of the natural world in order to study the essential structures of the world" (van Manen, 1992, p. 175), was undertaken by the researcher prior to the analysis of data. 7 Research Question The question that directed this research is as follows: What are the experiences of nursing students caring for persons with AIDS? Conceptual Definitions Nursing Student: An individual, without Registered Nurse status, who is currently enrolled in a nursing program leading to eligibility to write the Canadian Nurses' Association Testing Service (CNATS) examination and who has cared for at least one PWA within his/her course of study. AIDS: A syndrome widely believed to be caused by a virus called Human Immunodeficiency Virus (HIV). Characteristic of AIDS is the suppression of the immune system resulting in opportunistic infections and disease. AIDS has a spectrum of illness progression and, in its full clinical form, is invariably fatal. Carina for: Providing for the biopsychosocial needs of clients in a variety of settings through use of the nursing process. Person with AIDS: An individual in any stage of the life cycle who has a diagnosis of AIDS. 8 Assumptions A number of assumptions form the foundation of this research and are also implicit in the underpinnings of qualitative research. Two of these assumptions, which are fundamentally important to this research, deserve explicit recognition. 1. There are nursing students who have experience to report concerning caring for PWAs. 2. There will be a sufficient number of nursing student respondents to enable data saturation to occur. Limitations to the Study Several limitations were identified at the beginning of this study. 1. Willingness of respondents to participate in the study may pose a limitation. The fact that respondents are expected to consent to one to three interviews of one hour in duration may be seen as an unreasonable time commitment by some potential respondents. 2. That the researcher is a relative novice to the research process may be a limitation. In qualitative research, "the researcher serves as 9 the primary data-gathering instrument and the analysis of data occurs primarily within the reasoning processes of the researcher, [therefore] a high level of intellectual discipline is required" (Burns, 1989, p. 46). The novice researcher's abilities may affect the processes of data collection, analysis, and description of the phenomenon. 3. The results of this study only represent the experiences of nursing students in a generic, basic nursing undergraduate program and, therefore, cannot be generalized to represent the experiences of other types of nursing students. Summary This study has been designed to explore nursing students' experiences caring for PWAs. Although some quantitative research efforts have addressed the attitudes of nursing students toward PWAs, we still know little about the experience of nursing students caring for this client population. Chapter One delineated the background and significance of the research problem. In addition, the methodological perspective was introduced. Conceptual definitions, 10 underlying assumptions of the research, and limitations were also identified. In Chapter Two, entitled 'Literature Review', current literature and theory will be presented. In Chapter Three, the research method will be described. Chapter Four will be a presentation and interpretation of the findings of this study and Chapter Five will include a discussion of the findings. Finally, in Chapter Six, the researcher will present a summary, conclusions, and the study's implications for nursing practice, education, administration and research. 11 CHAPTER TWO: LITERATURE REVIEW Introduction In this chapter, the researcher will review literature in order to delineate the present state of knowledge in the area of nursing students' experiences caring for PWAs and to describe the context in which this study was derived. The selected literature is organized around both the attitudes of nurses and nursing students toward PWAs. Both quantitative and qualitative research will be reviewed. Nurses' Attitudes Toward PWAs Much of the research on attitudes toward PWAs has been quantitative in nature and has addressed the attitudes of nurses and other groups of health professionals. In a study by Blumenfield et al. (1987), surveys were distributed to all nurses at a large medical centre near New York City. A response rate of 33% was obtained on the first survey (n=107), and a repeat survey six months later achieved a 56% rate of return (n=191). Noteworthy themes arising from this study are: nurses' fear of caring for homosexual men and male prisoners because of AIDS, fear of disease transmission, the right of pregnant nurses to refuse to care for PWAs, and the intent of nurses to request a 12 transfer if they had to care for PWAs on a regular basis. A statistically significant decrease, at the second data collection point, was reported in nurses1 fear of caring for homosexual men and male prisoners which the researchers suggest may be attributable to experience and education. However, generalizability is limited due to the use of convenience sampling. This weakness aside, many of the attitudes identified in this study have also been documented by other researchers (Alexander & Fitzpatrick, 1991; Kelly et al., 1988). Alexander and Fitzpatrick (1991) used questionnaires to assess the attitudes of 13 6 nurses in a Midwest American teaching and research hospital. Although sampling strategies were not clearly described, these researchers report similar attitudes as those identified by Blumenfield et al. (1987). Both studies were conducted in major urban centres. It is possible that attitudes of health care professionals working in large urban centres—where the incidence of AIDS is higher and where the dissemination of AIDS information is likely greater—differ from the attitudes of their counterparts who are employed in more remote rural areas. 13 In another survey, Kelly et al. (1988) selected a random sample of 500 from a population of 5000 nurses residing in a U.S. state which has a moderate but increasing number of AIDS cases. Questionnaires were mailed to subjects and a 3 2.2% return rate was achieved. The method consisted of four vignettes in which the patient was depicted as either heterosexual or homosexual with either AIDS or Leukemia. Each research packet contained a vignette describing a patient and set of three inventories on which subjects were directed to record their impressions of the patient described in the vignette. The three inventories consisted of a prejudicial evaluation scale, a social interaction scale, and an interpersonal attraction inventory, each of which contained several items. Each item was rated on a seven-point Likert-type scale. Data were analyzed using multivariate and univariate analyses of variance. As in the studies by Blumenfield et al. (1987) and Alexander and Fitzpatrick (1991), negative attitudes are noted such as an unwillingness to interact in a casual fashion with the PWA and a similar attitude toward homosexuals regardless of illness. 14 In a study by van Servellen, Lewis, and Leake (1988), a survey was mailed to 3000 randomly selected California registered nurses. A response rate of 42.3% (1203) was achieved. However, only 1019 responses were analyzed since 184 nurses did not meet the study criteria. The survey, patterned after an interview schedule with open-response questions, addressed nurses' practice behaviors, knowledge, fears, and attitudes about AIDS and PWAs. The findings revealed that 24.5% of those nurses surveyed believed they were at high or moderate risk for contracting AIDS because of occupational or environmental exposure in their current work roles and 38.4% of nurses indicated 'a great deal1 to 'moderate' levels of discomfort in caring for male homosexuals with AIDS. While 23.1% of nurses indicated they would not accept a job caring for PWAs, 53.6% indicated that nurses should have the right to refuse to care for PWAs. Other researchers report similar findings as van Servellen et al. (1988) related to fear of disease transmission. Damrosch, Abbey, Warner, and Guy (1990), in their survey of registered nurses in teaching and community hospitals, also found that a sizable percentage of nurses, if given the choice, would refuse 15 to care for PWAs. Bolle (1988) also described nurses1 fear of contagion and attitudes about sexuality and alternate lifestyles as sources of stress for nurses in their care of PWAs. Reed, Wise, and Mann (1984) found, in their study of 2 67 health care providers and management from a tertiary care hospital in a large American metropolitan area, that fear of disease transmission was a significant concern. A 21-item questionnaire using a Likert scale addressed knowledge about AIDS, attitudes toward homosexuals, and experience with PWAs. When subjects were asked to rate their anxiety caring for PWAs, 31.8% reported 'some anxiety1 and 34.9% had 'quite a bit of anxiety'. When subjects were asked if they feared disease transmission, 80% of responses ranged from 'little fear' to 'quite a bit of fear'. And Turner, Gauthier, Ellison, and Greiner (1988) found, in their survey of nurses' knowledge of and attitudes toward AIDS, that 57% of subjects felt that it was unsafe to render care to PWAs without full isolation garb. Thirty-two percent of subjects also felt that infected persons should be restricted to their hospital rooms. 16 Related to attitudes about caring for homosexuals with AIDS, other PWAs, and about alternate lifestyles, other researchers report similar findings as van Servellen et al. (1988). Jemmott III, Freleicher, and Jemmott (1992) found, in their mailed survey of 496 New Jersey nurses, that subjects held negative attitudes toward IV drug users and homosexuals, and that those same nurses were more likely to report intentions to avoid AIDS client care. As well, in a survey of the knowledge, values, attitudes, and behavioral intent of Nova Scotia nurses toward AIDS and PWAs, Kerr and Horrocks (1990) found that, although 88% of subjects indicated they intended to provided care to PWAs, the quality of that care might be inadequate due, in part, to very negative attitudes toward homosexuals and PWAs. Similarly, in other surveys, negative attitudes toward PWAs and an unwillingness to provide AIDS client care are reported (Barrett, 1992; Barrick, 1988; Cole & Slocumb, 1993; Forrester & Murphy, 1992; Katz, Hass, Parisi, Astone, & McEvaddy, 1987; Kemppainen et al., 1992) . Some studies have addressed the attribute of responsibility for contracting HIV. In a study by Melby, Boore, and Murray (1992), 479 nurses in Northern 17 Ireland replied to a questionnaire related to their knowledge and attitudes about AIDS and PWAs. Results indicate that homosexuals, prostitutes, and drug-abusers were viewed as being at least partly responsible for their own illness. And Cole and Slocumb (1993), in their study of 3 67 nurses at two Southeastern New England hospitals, found that these nurses' attitudes toward PWAs differed depending on how the person acquired the disease. These researchers interpreted the results to suggest that individuals who acquired the virus without violating social norms are 'innocent victims', implying that some are more deserving of the disease than others. In a study by Bonaparte (1979), the attitudes of nurses toward culturally different people were examined. Three hundred registered nurses participated in the study. A personality questionnaire and scales measuring ego-defensiveness, open-closed mindedness, and cultural attitudes were used. Notably, the findings indicate that the more open-minded the nurse, the more positive were the attitudes toward culturally different patients. Qualitative methods have rarely been used to describe nurses' experiences caring for PWAs. However, 18 Breault and Polifroni (1992) conducted a qualitative study guided by the phenomenological approach to describe the experience of the nurse delivering care to PWAs. Sixteen nurses, each having provided care to at least two PWAs, were the respondents. Attitudes and feelings of nurses clustered into six themes: fear and risk of exposure, anger associated with personality and behavior of clients, sympathy related to lifestyles, fatigue from caring for a demanding and unappreciative group, helplessness related to the terminal nature of AIDS, and self-enhancement in the form of personal satisfaction from caring for ostracized clients. In addition to describing the attitudes and feelings of nurses, the researchers also posed three research questions that were quantitative in nature. One question addressed the amount of fear associated with caring for PWAs. On a scale of 0 (no fear) to 10 (significant fear), responses ranged from 0 to 8.5 with a mean of 3.75. Subjects described how they coped with their fears by 'not thinking about it' and by •rationalizing the risk'. It is noteworthy that fear and risk of exposure did not appear to be the most important factor in nurses' experiences in caring for PWAs. Other researchers, albeit utilizing quantitative methods, have noted fear and risk of exposure as significant factors in the care of PWAs (Alexander & Fitzpatrick, 1991; Blumenfield et al., 1987; Damrosch et al., 1990; Reed et al., 1984; Turner et al., 1988; van Servellen et al., 1988). Pickthall (1990) also utilized the phenomenological approach in a qualitative study of eight nurses' experiences caring for PWAs. Data were collected using unstructured interviews and analysis o data was guided by Spiegelberg's (1960) steps of the phenomenological method. The researcher found that these nurses experienced stress in caring for PWAs. Stressors included fear of contracting AIDS, homophobia, and caring for dying AIDS patients. The findings also indicate that these nurses utilized coping strategies such as physical and relaxation activities, talking with others, rationalization, knowledge-seeking, withdrawing, and involvement in their experiences caring for PWAs. In another qualitative study, Reutter and Northcott (1993) examined how 13 nurses coped with the risk of disease transmission while caring for PWAs. Data were collected through in-depth interviews and analyzed using the constant comparative methodology of 20 grounded theory. The findings indicate that coping with risk of disease transmission, for these nurses, involved achieving control over uncertainty by making risk meaningful. This involved the nurses finding meaning in their work. Notably, one way the nurses found meaning in their work was by accepting the patient as a person. In this study, all respondents' first encounters with AIDS involved caring for homosexual men. The researchers found that the nurses initially viewed their clients as different and had difficulty relating to them. However, nurses described how, as they got to know their clients, differences were de-emphasized and more emphasis was placed on similarities between the nurses and their clients with AIDS. As well as de-emphasizing differences, nurses coped by appreciating clients' individuality and by separating the person from the behaviors associated with alternate lifestyles that the nurses had difficulty accepting. Another important finding was the changing attributions of responsibility. As in the studies by Melby et al. (1992) and Cole and Slocumb (1993), nurses in this study attributed responsibility to clients for their disease. However, in this study, several nurses' perceptions changed after they got to 21 know their clients. Nurses began not to hold the client responsible for contracting HIV and this permitted nurses to feel closer to their clients with AIDS. In summary, the research related to nurses1 attitudes toward PWAs has been based primarily on quantitative designs which have relied extensively on questionnaires as the means for data collection. Several researchers have reported nurses' fear and anxiety about AIDS and PWAs (Alexander & Fitzpatrick, 1991; Blumenfield et al., 1987; Damrosch et al., 1990; Reed et al, 1984; Turner et al., 1988; van Servellen et al., 1988). Others report that nurses hold negative attitudes toward PWAs, especially those in stigmatized transmission groups (Alexander & Fitzpatrick, 1991; Barrett, 1992; Barrick, 1988; Blumenfield et al., 1987; Cole & Slocumb, 1993, Damrosch et al. , 1990; Forrester & Murphy, 1992; Jemmott III et al., 1992; Katz et al., 1987; Kelly et al., 1988; Kemppainen et al., 1992; Kerr & Horrocks, 1990; Melby et al., 1992; Reed et al., 1984; Turner et al., 1988; van Servellen et al., 1988). And some researchers have also addressed the attribute of responsibility for contracting HIV, reporting that nurses view some PWAs as responsible for their own 22 illness (Cole & Slocumb, 1993; Melby et al., 1992). Although the quantitative research findings provide a relatively consistent description of nurses' feelings and attitudes toward PWAs, the use of surveys and other data collection tools to quantify nurses' experiences falls short in providing a complete account of nurses' experiences in caring for PWAs. Although few in number, qualitative studies of nurses' experiences caring for PWAs provide rich descriptions of nurses' experiences in caring for this client population that extend our understanding of how nurses' fears and attitudes toward PWAs influence their practice (Breault & Polifroni, 1992; Pickthall, 1990; Reutter & Northcott, 1993). In addition, insight into the specific coping strategies that nurses use when caring for PWAs is provided. Nursing Students' Attitudes Toward PWAs Of the twelve studies which have addressed nursing students' attitudes toward PWAs, eleven have been quantitative studies (Armstrong-Esther & Hewitt, 1989; Brown et al., 1990, Eliason, 1993; Jemmott, Jemmott III, & Cruz-Collins, 1992; Lawrence & Lawrence, 1989; Lester & Beard, 1988; Mueller, Cerny, Amundson, & Waldron, 1992; Oermann & Gignac, 1991; Royse & Birge, 23 1987; Synoground & Kellmer-Langan, 1991; Wiley et al., 1988). The remaining study, by Klisch (1990), is qualitative in nature. In a survey by Lester and Beard (1988), the attitudes of a convenience sample of 177 baccalaureate students from a Midwest American university were assessed. Seventeen percent of these students had cared for PWAs and 7 0.6% had received their AIDS information from the media. Notably, students with high fear scores on the attitude questionnaire, which was developed by the researchers, typically had higher knowledge scores on the knowledge questionnaire, also developed by the researchers, and were more homophobic. Less fear was demonstrated by those students who had cared for a PWA. Forty-nine percent of this sample preferred not to care for a PWA while 3 6% believed they should not be assigned to care for a PWA. Sixty-two percent of students demonstrated more sympathy for clients who were not homosexual. Because the majority of this sample derived their AIDS information from the media, which is typically sensationalistic, this may have confounded the results. Similar to the findings of Lester and Beard (1988) related to the negative attitudes of nursing students 24 toward PWAs, Eliason (1993), in a quantitative descriptive study, identified disapproval of homosexuality among nursing students. The participants in this study were 124 baccalaureate nursing students, enrolled in a lifespan human development course, in a midwestern college in the United States. The procedure involved students watching a 60-minute videotape depicting an AIDS hospice in San Francisco and consisting of interviews with clients, family members, and significant others. All clients at the hospice were men and, although none were labelled as 'gay', some were shown with their male partners. Following the videotape, students answered open-ended questions about their desires to work in the AIDS hospice and about the attitudes and values they possessed which would render it difficult for them to work at the hospice. Data were analyzed using content analysis. Although relatively few of the students' comments could be categorized as positive, some positive comments included: a need to comfort patients, having an attitude of compassion, the fact that people need fair treatment, and that the work would be rewarding. Considerably more negative comments arose from the analysis of data. The most prevalent negative comment, 25 made by 24% of students, was the fear of contracting AIDS. Discomfort with death and dying was another negative comment as well as fear or disapproval of homosexuality. Several students indicated that there could be innocent victims of AIDS, such as people receiving blood transfusions. Negative attitudes were also expressed related to IV drug users. Other researchers have also reported nursing students' negative attitudes toward PWAs. Mueller et al. (1992) studied the attitudes of nursing students (n=110), dental hygiene students (n=51), graduate nursing students (n=36), and faculty (n=25) toward HIV. Participants were required to complete a 66-item questionnaire consisting of nine subscales. Measures of attitudes toward homosexuality, AIDS-phobia, AIDS-related work stress, social desirability, and behavioral intentions to work with PWAs, homosexuals, and IV drug users were included. Follow-up data were also collected at a second point one year later, when the beginning nursing students had completed their first year of study (n=57). Univariate and multivariate analyses of variance revealed that faculty and graduate students were positive in their attitudes and behavioral intentions. Conversely, nursing students and dental hygiene students had more negative attitudes and may have been less willing to care for PWAs. Using a descriptive-correlational design, Oermann and Gignac (1991) studied the knowledge and attitudes about AIDS among nursing students (first-year, n=27; second-year, n=46; third-year, n=4 7; and fourth-year, n=27) and faculty (n=19) at a mid-size, urban university in Canada. The researchers utilized the 'AIDS Knowledge and Attitude Assess Test'—which uses Likert scale—developed by Lawrence and Lawrence (1989). Although faculty scored higher than students on measures of knowledge, their attitudes toward PWAs were low and notably similar to the attitudes of nursing students. This finding contradicts Mueller et al. (1992), who found faculty have more positive attitudes toward PWAs than nursing students. Also a noteworthy finding of Oermann and Gignac's study is that as students progressed through program, their knowledge scores increased while their attitude scores did not improve despite experience with AIDS clients. However, attitude scores improved significantly for faculty who had experience with AIDS patients. 27 Royse and Birge (1987) also noted homophobia in their study of 161 students, including nursing students, studying for careers in health professions. The researchers found that homophobia was inversely associated with empathy for PWAs and that homophobia was a better predictor of fear of AIDS than other variables. As well, Jemmott et al. (1992) found, in their study of 153 nursing students, that students held negative attitudes toward IV drug users and homosexuals. Also, students who held more negative attitudes toward IV drug users than other students also had greater intentions to avoid caring for PWAs. Juxtaposed to the findings of Lester and Beard (1988) and Oermann and Gignac (1991), Brown et al. (1990) report a positive correlation between knowledge and attitudes. These researchers, in their study of 319 nursing students from a Saskatchewan university, found that after a one-day AIDS workshop, students gained knowledge and expressed positive changes in their attitudes toward PWAs. Knowledge and attitudes were measured by a questionnaire which addressed knowledge and fears concerning AIDS and caring for PWAs, and attitudes toward homosexuals and toward the terminally ill. Attitudes were measured on a 28 five-point Likert-type scale. Notably, students who had cared for PWAs had less positive attitudes than those students who had not provided care to clients with AIDS and no significant relationship was found between attitudes toward PWAs and homosexuality. In fact, many students had positive attitudes toward homosexuals. These researchers do acknowledge, however, that the mass media information was slower to be disseminated in this geographic location which may account for differences between their findings related to homosexuality and other studies reporting prevalent homophobic attitudes among nursing students (Eliason, 1993; Lester & Beard, 1988; Mueller et al., 1992; Royse & Birge, 1987). Lawrence and Lawrence (1989) studied the attitudes of nurses (n=60), nursing students (n=50), and liberal arts students (n=42) and found a significant increase in knowledge by nursing students after a lecture on AIDS. As well, positive changes in students' attitudes about AIDS were realized as measured by the 'AIDS Knowledge and Attitudes Assess Test' developed by the researchers. The findings indicate that nurses had more positive attitudes about AIDS, AIDS testing, human rights, and were more accepting of PWAs than nursing students. It was also found that nursing students' attitudes were more similar to those of non-nursing students than to nurses. However, the researchers do not disclose their method for sampling the nursing students. In another study, Armstrong-Esther and Hewitt (1989) compared the knowledge and perceptions of AIDS between a post-RN/BN group (n=65), enrolled in the Bachelor of Nursing program at the University of Lethbridge (Alberta), and a generic BN group (n=7 0), enrolled in baccalaureate programs in all parts of Canada. Participants were required to complete a questionnaire which addressed knowledge of symptoms, transmission modes, risk associated with sexual practices, measures of precautions when handling contaminated body fluid, and attitudes toward clinical and societal care of PWAs. Both groups were found to lack knowledge of key symptoms and modes of transmission. Also, while the post-RN/BN nurses were found to be more cautious in their attitudes toward caring for PWAs—advocating isolation mechanisms, AIDS testing, and quarantine—the BN group was more liberal in their attitudes toward clinical and societal care o PWAs. 30 Other studies have described the nursing student attitude that nurses should have the right to refuse to care for PWAs. Wiley et al. (1988) report that 54% of their convenience sample of 142 students believed that nurses should have this right. In another study of 87 baccalaureate students, Synoground and Kellmer-Langan (1991) report a 70% discomfort rate with caring for PWAs. Seventy-four percent of students in their study believed they have the right to refuse to care for PWAs. Conversely, using a qualitative method consisting of a semi-structured interview format with an open-ended questioning approach, Klisch (1990) reports 100% agreement among 11 nursing students, from a small private, university in the Northwest United States, that nursing students should not be permitted to refuse to care for PWAs. The overwhelming belief of these students that refusal to care for PWAs is not a right contradicts the results of many other studies (Lester & Beard, 1988; Synoground & Kellmer-Langan, 1991; Wiley et al., 1988). Another theme emerging from Klisch's (1990) study was fear and anxiety among students in the 31 pre-interaction phase of the nurse-patient relationship. Students coped with their fears by performing unnecessary tasks to delay going to meet their clients. Only one student talked to someone about these concerns. Another student was afraid to divulge the fear to anyone. In the introductory phase, intense fear of exposure and of inadequate knowledge were expressed by participants. They also described depersonalization of the client in this phase of the relationship, and, instead, only thought of the disease. Fear of contact with the client and other irrational fears were also characteristic of this phase of interaction. Distancing measures were reported, such as focusing on the technical rather than on the psychosocial aspects of care. Students believed this strategy allowed them to control their expressions of anxiety. In the working phase, students reported shifts in their feelings. They identified with their clients, especially those close to their own ages, which allowed students to drop their stereotypical perceptions and to see their clients as individuals. Anger related to the negative feelings of other staff members was also reported by students. Finally, in the termination phase, themes arose such as a feeling of 32 closeness to the clients and that the experience of caring for a PWA fostered tremendous learning. Support for Klisch's findings can be found in Tisdale's (1989) account her experience as a nursing student caring for a PWA. Like the research on nurses, the research on nursing students has also been based primarily on quantitative designs with questionnaires to measure students' fear and knowledge about AIDS and their attitudes toward AIDS and PWAs (Armstrong-Esther & Hewitt, 1989; Brown et al., 1990, Eliason, 1993; Jemmott et al., 1992; Lawrence & Lawrence, 1989; Lester & Beard, 1988; Mueller et al., 1992; Oermann & Gignac, 1991; Royse & Birge, 1987; Synoground & Kellmer-Langan, 1991; Wiley et al., 1988). Similar to the research on nurses, some studies of nursing students reported fear and anxiety associated with AIDS (Eliason, 1993; Lester & Beard, 1988). Many researchers have reported nursing students' negative attitudes toward PWAs (Eliason, 1993; Jemmott et al., 1992; Lester & Beard, 1988; Mueller et al., 1992; Oermann & Gignac, 1991; Royse & Birge, 1987). However, Armstrong-Esther & Hewitt (1989) and Brown et al. (1987) report that nursing students held positive attitudes toward homosexuals 33 with AIDS. Other studies examined nursing students' belief in the right to refuse to care for PWAs (Synoground & Kellmer-Langan, 1991; Wiley et al., 1988). Still other studies examined the relationship between knowledge of AIDS and attitudes toward PWAs. While Lester & Beard (1988) and Oermann & Gignac (1991) found a negative correlation between knowledge and attitudes, Brown et al. (1990) and Lawrence and Lawrence (1989) report a positive correlation between knowledge acquisition and attitudes toward PWAs. Despite the number of studies focusing on nursing students', the usefulness of these findings remains in question because they have been based on unsubstantiated assumptions concerning the essential characteristics of students' experiences with PWAs. For example, the surveys and attitude scales used with nursing students are very similar to those used with experienced nurses, which suggests that researchers have assumed that nursing students and experienced nurses share similar experiences in caring for PWAs. However, our incomplete understanding of students' experiences in caring for PWAs makes this assumption very tenuous. More inductive research is needed to provide detailed descriptions of the students 34 experience in learning to care for PWAs that can serve as a conceptual basis for productive quantitative research. Only one qualitative study related to nursing students' experiences with AIDS and PWAs was located (Klisch, 1990). Although the rich descriptions attest to the value of inductive methods in enhancing our understanding of nursing students' experiences with PWAs, more qualitative studies are needed with other groups of nursing students to verify and extend these findings. Summary In this chapter, a review of selected literature was presented. Much of the research on nurses' and nursing students' experiences caring for PWAs has been quantitative in nature and has relied on questionnaires for data collection. The nature of human existence is complex, however, and measures on attitude scales tell us little about the nature of the complex phenomenon of nursing students' experiences caring for PWAs. Similarly, lack of definitive findings related to the relationship of nursing students' knowledge of AIDS and attitudes toward PWAs may be due to the fact that instruments used to measure attitudes are often derived 35 from investigators' unsubstantiated a priori assumptions underlying the predominantly deductive approaches used to investigate nursing students' experiences caring for PWAs. The need for further investigation of this topic using inductive methods is in order since designs of this nature will capture the fullness of complex life experiences. Because inductive methods provide in-depth description of phenomena, they could be useful in the development of a stronger conceptual base from deductive research. 36 CHAPTER THREE: METHOD Introduction A qualitative approach was chosen for this study of nursing students' experiences caring for PWAs. In this chapter, the researcher will describe the procedures that were utilized for selection and recruitment of respondents, data collection and analysis, and the protection of human rights. Finally, the researcher will describe the criteria for rigor that were applied to this study and how potential threats to methodological rigor were managed. Selection of Respondents The purpose of qualitative research is to understand phenomena which may not be distributed evenly in a population (Field & Morse, 1985). Therefore, the sampling technique of purposive or theoretical sampling was utilized for this study (Polit & Hungler, 1991; Strauss & Corbin, 1990). In purposive sampling, respondents are chosen for their ability to illuminate the phenomenon under study. Selection Criteria Selection criteria were carefully chosen to ensure that respondents were knowledgeable about the phenomenon under study. The sampling frame was limited 37 to those nursing students, regardless of age or gender, without Registered Nurse status, who were currently enrolled in the second through fourth years of the University of British Columbia/Vancouver General Hospital (UBC/VGH) Undergraduate Nursing Program and who had cared for at least one PWA within their course of study. Respondents were also selected for their willingness to participate in one to three separate interviews of one hour in duration and for their ability to speak fluent English. Recruitment Procedures Respondents were recruited through a number of short presentations regarding the nature of the study. During the presentations to students in the second through fourth years of the nursing program, a respondent information letter was distributed to all students (see Appendix A). This letter provided interested students with the information necessary to contact the researcher. Contact was initiated by the nursing student through a telephone call at which time the nursing student's suitability for the study was determined. As well as utilizing short presentations as a means of recruiting respondents, the researcher also 38 placed advertisements on student bulletin boards as well as in the Nursing Undergraduate Society newsletter. The advertisements contained brief information regarding the nature of the study, criteria for selection of respondents, the expected time commitment of respondents, and the information necessary to contact the researcher. Sample Size When utilizing the technique of purposive sampling, the sample size cannot be predicted prior to data collection. In fact, data are collected until no new information can be obtained. Referred to as data saturation, this state is said to be reached when themes or major categories are repeated (Wilson, 1985). The researcher identified that data saturation had indeed occurred after data were collected from a total of eight respondents. Data Collection Unstructured interviews were conducted as the primary means of data collection. This type of interview is conversational and its purpose is to "elucidate respondents' perceptions of the world without imposing any of the researcher's views on them" (Polit & Hungler, 1991, p. 279). Characteristic of 39 unstructured interviews is the use of broad questions and probes presented in an informal manner to encourage respondents to explore their thoughts, feelings, and experience (see Appendix B for sample questions and probes). All interviews were audiotaped and were subsequently transcribed verbatim to facilitate data analysis. Each interview was approximately one hour in duration. Some respondents were interviewed in their homes while others requested to be interviewed in quiet settings within the School of Nursing. Initial interviews were guided by the researcher's use of broad questions and probes related to the phenomenon. After the initial interviews were conducted, the data were analyzed and the direction of subsequent interviews was planned by developing other sets of more specific questions (Field & Morse, 1985) . Second interviews with three of the eight respondents occurred six weeks after the initial interviews. Similarities among respondents' experiences were explored. As well, differences in themes were explored in order to achieve an in-depth investigation of the phenomenon under study. In the second interviews, questions were posed to respondents 40 which related more specifically to the evolving description of the phenomenon. Field notes were also maintained by the researcher as another source of data. These notes were recorded after each interview in order to document the non-verbal nuances of the interviews and the researcher's feelings during the interviews. The notes included information related to the interview settings/places and the affects of the respondents. Data Analysis Interviews were transcribed verbatim to constitute the written data. Data were analyzed according to Spiegelberg's (1960) steps of the phenomenological method. Only the first three of Spiegelberg's seven steps were utilized because "the first three steps have been accepted, at least, implicitly, and practiced by all those who have aligned themselves with the Phenomenological Movement; the later ones only by a smaller group" (p. 659). Investigating particular phenomena, the first of Spiegelberg's (1960) steps, is characterized by intuiting, analyzing, and describing phenomena. When intuiting the phenomenon, the researcher approached the data without preconceptions, thoroughly concentrating 41 on and familiarizing herself with the phenomenon. Next, analysis of the phenomenon took place, in which the researcher identified the "constituents of the [phenomenon] as well as [explored] their relations to and connections with adjacent phenomena" (p. 669). In an example of this step, the researcher identified that students' concern for personal safety was related to the contagious, incurable, and fatal properties of AIDS by exploring the relationship of students' fear and their responses to caring for clients with other contagious, incurable, and/or fatal diseases. Finally, the researcher described the phenomenon by concentrating on its decisive characteristics and essences. Investigating general essences is the second step in which the particulars are viewed as instances which represent the general (Spiegelberg, 1960). This step involved grouping elements of the phenomenon into identifying themes or categories. In an example of this step, the researcher identified the theme of 'distancing' by grouping recurring elements such as students wearing gloves excessively when providing care to PWAs, avoiding prolonged contact with PWAs, and rushing their care activities. As respondents were interviewed, the researcher identified that general essences and identifying themes were beginning to emerge after the fifth and sixth respondents were interviewed. Finally, the third step, apprehending essential relationships among essences, involved the discovery o certain essential relationships among the essences or categories. Spiegelberg (1960) states that such insight cannot be obtained by mere thinking or reasoning. Requisite to apprehending essential relationships among essences was the researcher's experience, knowledge, and intuition related to the phenomenon. In order to apprehend essential relationships, the researcher utilized her own knowledge and experience related to coping with caring for PWAs to apprehend the relationship of the various managing behaviors implemented by students in their care of PWAs. Ethical Considerations Prior to initiation of the study, the researcher obtained approval from the UBC Behavioural Sciences Screening Committee. Once approval was obtained, the researcher also obtained agency approval from the UBC/VGH School of Nursing. Memos were then sent to 43 Year-Coordinators and Course Leaders within the School of Nursing to request their permission to deliver the recruitment presentations to their classes. During the initial telephone contact, students indicated their willingness to participate in the study. Their suitability for the study was determined during the initial telephone contact and the first interviews were then scheduled. At the first interview, the information letter (see Appendix A) was reviewed and several minutes were spent reviewing the purpose of the study along with its corresponding risks and benefits. Respondent were also informed that they were free to ask questions, to refuse to answer questions, and to withdraw from the study at any time. Next, respondents signed a written consent (see Appendix C) of which they received a carbon copy. Munhall (1988) states that "because qualitative research is conducted in an ever-changing field, informed consent should be an ongoing process" (p. 156) and must be renegotiated as unexpected events unfold within the research. Therefore, Munhall states that an appropriate form of consent is 'process consent' in which respondents are continually informed and asked 44 permission as the research takes new directions. Thus, the researcher provided for process consent by re-informing respondents and audiotaping verbal consent at the beginning of, and during, each interview. Confidentiality was maintained by securing audiotapes in a locked box at the researcher's home. Once transcribed, the data were coded so that any identifying information about respondents did not appear on the transcripts. Transcripts were secured along with the audiotapes. Upon completion of the written thesis, audiotapes and transcripts were destroyed. Respondents were informed that only the researcher and two UBC professors would have access to the coded information, and that the professors would not have access to data that would allow them to identify respondents. Criteria for Rigor Sandelowski (1986) discusses four criteria which were used to ensure methodological rigor in this study: (a) credibility, (b) fittingness, (c) auditability, and (d) confirmability. A study is credible when "it presents such faithful descriptions or interpretations of a human experience that the people having that experience would 45 immediately recognize it from those descriptions or interpretations as their own" (Sandelowski, 1986, p. 30). Credibility is also achieved when others, only having read about the phenomenon, are able to recognize the phenomenon when confronted with it. A threat to credibility, says Sandelowski, is 'going native' in which the researcher-respondent relationship becomes so enmeshed that researchers have difficulty distinguishing their own experiences from those of their respondents. Maintenance of field notes enabled the researcher to document her experiences—how she was influenced by and influenced the respondents--thus assisting the researcher to separate her experiences from those of the respondents. Credibility was further enhanced by continually referring back to the original data to validate emerging themes and by asking respondents if the descriptions of the phenomenon were accurate (Reimen, 1986). Following the synthesis and integration of themes into a consistent picture of the phenomenon, the researcher conducted validation interviews with two respondents to validate the evolving description of the phenomenon. Similarly, two expert researchers were consulted regarding the accuracy of the descriptions of the phenomenon. 46 Fittingness is achieved when findings are able to fit into situations outside the context of the study and when the audience regards the findings as meaningful and applicable in relation to their own experiences (Guba & Lincoln, 1981). Sandelowski states that one threat to fittingness is 'elite bias' in which "respondents...are frequently the most articulate, accessible, or high-status members of their groups" (p. 32). "Holistic fallacy" (p. 32), in which data appear more congruent than they are, is another threat. By ensuring that descriptions of the data contained typical and atypical elements and by seeking out negative cases—instances where statements about data did not hold up—the researcher controlled for threats to fittingness (Sandelowski, 1986; Strauss & Corbin, 1990). Also, by presenting her findings to professional colleagues who could refute or confirm the fit of her findings with their own experiences, the researcher also controlled for threats to fittingness. Auditability is achieved when the researcher reports all the decisions involved in the transformation of data to theoretical statements (Burns, 1989) in order that another researcher is able to follow the decision trail used by the investigator 47 in the study (Sandelowski, 1986). If a study achieves auditability, other researchers should arrive at the same or comparable conclusions given the investigator's data, perspective, and situation. To achieve auditability, the researcher clearly described the data collection process and completely recorded all data. The logic for the development of categories and themes within the data was provided and decision rules were carefully recorded, dated, and cross-referenced. Finally, themes were continually compared with the raw data to ensure that theoretical statements were clearly linked to the data (Burns, 1989). Lastly, confirmability, which refers to freedom from bias in the research process, is achieved when the three criteria of credibility, fittingness, and auditability are achieved (Sandelowski, 1986). Because the researcher took appropriate action to achieve credibility, fittingness, and auditability in this study, the criterion of confirmability was also met. Summary In this chapter, the researcher described the method used for this study. Selection of respondents including selection criteria, recruitment procedures, and sample size were discussed. Data collection and 48 analysis procedures were described as well as procedures for protection of human rights. How threats to methodological rigor were managed was also discussed. 49 CHAPTER FOUR: FINDINGS AND INTERPRETATION Introduction In this chapter, the researcher will present the findings of this study in conjunction with her interpretation of the findings in order to provide an accurate description of nursing students' experiences caring for PWAs. Preceding the detailed description and interpretation of the findings, the researcher will present a conceptual framework for the phenomenon under study. For the purposes of this chapter, the terms 'student' and 'respondent' will be used interchangeably. Conceptual Framework The following framework is a conceptualization of what nursing students describe as their experiences caring for PWAs. This conceptual framework is a culmination of the researcher's investigation of the data, identification of themes within the data, and the final synthesis and integration of those themes into a accurate description of the phenomenon under study. A diagrammatic representation of the conceptual framework is presented in Figure 1. Beginning of Assignment 0 * * V 9et it ,nf*fety End of Assignment Levels of Concern for Personal Safety Figure 1. Conceptual framework for nursing students' experiences caring for PWAs o 51 Concern for personal safety is a pervasive and enduring theme throughout nursing students' experiences caring for PWAs. Concern for personal safety, within this framework, is time-limited, beginning when students first learn they are assigned to care for a PWA and concluding when their responsibilities for client care end. Varying levels of concern for personal safety exist as reflected by the grid on the left side of Figure 1. Students' levels of concern can vary from a heightened awareness of the contagious nature of their clients' body fluids, to students being very scared that caring for their clients with AIDS could cause their own deaths. In addition, levels of concern can fluctuate depending on students' involvement in those care activities where the perceived risk of contact with clients' body fluids is greater. These variations are depicted by the uneven band representing the duration of the students' assignments. Concern for personal safety is particular to caring for PWAs. Unlike caring for other clients, and more specifically dying clients, where the disease in question may be curable or of a non-contagious nature, caring for PWAs generates concern for personal 52 safety which is driven by the contagious, incurable, and fatal properties of AIDS. Various internal cognitive activities are employed by students as they care for a PWA and are triggered by their being assigned to care for PWAs and by their concern for personal safety. Termed 'processing' by the researcher, this collection of mental behaviors permeates the entire experience of caring for PWAs and, in fact, endures past the end of students' assignments. The arrows arising from processing activities reflect the influence these activities have on students' concern for personal safety. Although not depicted in Figure 1, two distinct mental activities are involved in processing. The first activity, termed 'analyzing' by the researcher, involves students considering what the experience of caring for PWAs will be like in relation to their current repertoire of experiences, knowledge, and skills and in relation to their own attitudes and values. Sub-categories of analyzing activities include: (a) comparing, (b) evaluating self, (c) wondering, and (d) judging. The second activity of processing, 'mental restructuring', involves the students mentally 53 reorganizing the thoughts and feelings that occur while they are analyzing. From mental restructuring, new personal meanings evolve for students caring for PWAs. Sub-categories of mental restructuring activities include: (a) categorizing and (b) rationalizing. Students engaged in deliberate and observable behaviors as they cared for PWAs. Termed 'managing' by the researcher, these behaviors are a product of the mental activities students undertake during processing and are related to their level of concern for personal safety and to their being assigned to care for PWAs. Like processing, managing permeates the entire experience of caring for PWAs, but unlike processing, managing behaviors, within this framework, cease with the end of the client assignment (as shown in Figure 1). Five broad categories of managing behaviors include: (a) distancing, (b) information-seeking, (c) discussing, (d) advocating/supporting, and (e) increasing involvement. Presentation and Interpretation of Findings This section of the chapter includes a detailed presentation and interpretation of the findings of this study. Concern for Personal Safety Respondents described their concern for personal safety as a pervasive and enduring theme throughout their experiences caring for PWAs. This concern for personal safety, according to them, was time-limited, beginning when they first learned they were assigned to care for a PWA and concluding when their responsibilities for client care ended. One respondent described her concern, which included initial feelings of nervousness and of being scared of contracting HIV: "I was really nervous when I first read my assignment [and] I was just kind of scared that...I might get...AIDS because of caring for them." Another respondent described her concern in terms of being scared: "I was really scared when I found out my patient was HIV positive and they were about to...change his diagnosis from just 'HIV positive' to 'full-blown AIDS'. It was a fear of danger to myself...." Yet another respondent commented on her concern in relation to safety when she remembered "taking a deep breath, or something like that, or at least metaphorically taking a deep breath...and wanting to make sure that I stayed safe" when she first learned that she was assigned to care for a PWA. 55 The level of concern that respondents described varied, from a heightened awareness of the contagious nature of their clients' body fluids, to a feeling of being very scared that caring for their clients with AIDS could cause their own deaths. Describing her level of concern as an awareness or consciousness, one respondent stated, "It didn't scare me...or anything like that because, well, things like that don't really necessarily scare me...I was just aware of it...aware more and conscious more than...I don't think I was fearful." Another respondent described the level of concern as one of being "a little scared", although her concern did not seem to affect her care of her client: I was scared in a way, but not really. I was a little scared...when you think of AIDS, you think, 'Oh, blood and body fluid precautions. Watch out. I could get it.' It triggered feelings of being scared, but it wasn't what was controlling me. My main concern was [my patient's] comfort. Those respondents who experienced higher levels of concern for personal safety also reported that this concern affected the care they provided, rendering its quality suboptimal. For example, one respondent who 56 reported being "really frightened" about contracting the HIV virus from her patient also reported that when she performed a dressing change, the client "saw how badly I was shaking and how nervous I was and he said, 'Do you want to just sit down and relax a bit?' I was very, very tense." According to students' accounts, not only were there varying levels of concern for personal safety, but individual respondents' levels of concern fluctuated. As one might expect, fluctuations depended on the students' involvement in those care activities where the perceived risk of contact with clients' body fluids was great. One respondent described her awareness of the contagious nature of her client's body fluids in the following way: "I think I wasn't really bothered because I wasn't dealing with bodily fluids at the time." However, when required to discontinue this client's IV device, she reported she "felt a little paranoid. Well, its like, 'Oh, there's...an opening." Similarly, another respondent who was discontinuing an IV device on her assigned client with AIDS noted a fluctuation in her worry by saying, "I had to discontinue his IV as well and, for some reason, I was really worried....he'd already had it heplocked [but] I 57 was terribly worried about somehow getting a needle stick...." In this instance, the fear of contracting HIV through a needle stick injury heightened this student's level of concern for her own safety. Another feature of the respondents * concern for personal safety was its reported uniqueness to caring for PWA. For the students, the contagious, incurable, and fatal nature of AIDS resulted in their concern for personal safety. One respondent described her feelings regarding discontinuing an IV for her client with AIDS in relation to her contact with clients with no known contagious bloodborne infections. At first I was a little apprehensive about caring for someone with AIDS....I just remembered when I was taking out his IV and his blood just didn't clot...he just bled and bled and bled....It's just the fact that you know that this blood's contaminated.... It just kind of crossed my mind more than it would have if somebody else had been bleeding, I think. Another respondent described how her concern for personal safety was also driven by the contagious nature of AIDS. 58 It might have been different if he had been a patient that didn't have a...transmissible disease...or if he was in there for lung cancer, I might have been a little less, I wouldn't have thought about it in my head as much. Other respondents commented on the relationship of the incurable nature of AIDS to their unique concern for their own safety. One respondent described the difference between caring for clients with curable afflictions with caring for PWAs. If the person has pneumonia, I know I wouldn't worry about anything. I know that there is a way of treating pneumonia...or other diseases, but not AIDS. Basically, there's no way out once you get it. Apparent from this comment is this student's expressed lack of concern for personal safety in the context of caring for client with pneumonia, a curable disease, juxtaposed to her expressed concern regarding the incurable nature of AIDS. As well as describing differences between caring for PWAs and clients with curable afflictions, several respondents also characterized caring for PWAs as different from caring for clients with other incurable 59 and fatal diseases. When the researcher asked about differences between caring for PWAs and persons with terminal cancer or other incurable and fatal diseases, the following response was typical: "You won't get cancer from them." This respondent differentiated AIDS from other incurable and fatal illnesses by the added contagious property of AIDS, suggesting that students' concern for safety was related to the combined effect of all three properties. Another respondent commented that "there's more of a finality when you hear that somebody's got AIDS than when you hear somebody's got cancer. With AIDS, [death] is inevitable. With cancer, it's not necessarily inevitable." This comment is representative of several students who believed that the inevitably fatal nature of AIDS was a significant component of the unique concern for personal safety students experienced while caring for PWAs. In summation, concern for personal safety was a common theme for all respondents. Despite their differing levels of concern that caring for their clients with AIDS could result in their own deaths, respondents' concern appeared to be commonly driven by the contagious, incurable, and fatal properties of AIDS. So fundamental was this concern that it 60 established the mental context in which nursing students carried out the care of their clients. That their concern essentially originated from the contagious, incurable, and fatal properties of AIDS partially accounts for the increase in respondents' concern levels when they were involved in nursing care activities where the perceived risk of contact with body fluids, and hence of contracting HIV, was great. Of importance is the indication by respondents that it was the combined effect of these properties that rendered caring for PWAs different than caring for any other client population. Processing; A collection of mental activities, which the researcher has conceptualized as 'processing', was employed by students in their care of PWAs. Students implemented processing activities in their care of PWAs in order to cope with their concerns for personal safety. Processing involved students mentally dissecting their experiences caring for PWAs and, subsequently, restructuring them to create new personal meanings. As the data revealed, processing activities were triggered by students being assigned to care for PWAs and by students' concern for personal safety. 61 Students indicated that processing activities not only permeated the entire experience of caring for PWAs, but endured past the completion of their nursing responsibilities for their assigned clients. Data also indicate that as the students mentally processed their experiences of caring for PWAs, the resultant thoughts and feelings described by students, in turn, affected their levels of concern for personal safety. Processing included two broad categories of mental activities. The first, 'analyzing', involved students mentally dissecting their experiences of caring for PWAs and examining them in relation to their own knowledge, skills, attitudes, and values. The second, 'mental restructuring', involved students reorganizing the thoughts and feelings they experienced during analyzing to create new personal meanings from their client care experiences. Data support the existence of these two distinct mental activities. Analyzing A category of mental activities within processing, which the researcher termed 'analyzing', involved students mentally dissecting their experiences caring for PWAs and examining them in relation to their own knowledge, skills, attitudes, and values. Analyzing 62 activities consisted of several distinct mental activities which students employed in their care of PWAs. These activities included: (a) comparing, (b) evaluating self, (c) wondering, and (d) judging. Comparing. A distinct mental activity within analyzing, 'comparing' involved students examining both their anticipated and evolving experiences of caring for PWAs in relation to their own repertoire of personal and professional experiences. Upon discovering that she was assigned to care for a PWA for the first time, one respondent began comparing the anticipated client care experience with past clinical experiences, drawing both similarities and differences in her comparison. I was uncertain because I had never cared for a PWA, so I didn't really know what it would be like. Um, I know what it's like to care for a patient who's bleeding, which he was, so I took that into consideration as part of his individual care and the fact that because he had AIDS and...he was bleeding, I'd have to be careful, extra careful.... But I wasn't really sure what it would be like because I'd never had a PWA. 63 Another respondent, who divulged that she was "very scared" when she became aware that she was assigned to care for a PWA, also began comparing the anticipated client care situation with past clinical experiences and personal life experiences. It was a whole new, different type of patient and I was very scared. I have not known any gay men...'gay men' still hadn't developed a face for me....I expected to encounter a queen lying there in the bed doing his Mae West impression. You know, as extreme as that sounds, I was expecting the stereotypical gay man.... By drawing similarities and differences between their present experiences with PWAs and their past clinical and personal experiences, respondents seemed to be attempting to create contexts within which to place their new experiences of caring for PWAs. As their care experiences with their clients with AIDS progressed, respondents continued comparing these experiences with past professional and personal experiences. As one respondent recounted: The fact that he was a drug user, it was just interesting to talk about that....he was just an interesting person to hear about, different 64 than the people I'd usually been caring for. I guess [it's] something I don't understand. It's totally different than...my life. As the respondent who was initially very scared of the "whole new, different type of patient" progressed through her client care experience, she began to draw similarities between herself and the client with AIDS and began to view her client as a person. It was interesting once I started talking to the fellow, I started relaxing and realizing that [AIDS] isn't just a label, this isn't just an AIDS patient. [He's] a landscape gardener and has a beautiful garden at home. He had photographs of the work he had been doing because I garden in my parents' yard....It was an interest I held. As this transcript excerpt demonstrates, the mental act of comparing affected respondents' concern for personal safety. If respondents were able to use this strategy to identify similarities between their past clinical and personal life experiences and their present experiences with PWAs, their concern for personal safety appeared to be allayed to a degree. Those respondents who continued to identify differences 65 throughout the client care experience usually had higher levels of concern for personal safety from the outset and indicated that their concern levels remained relatively constant throughout the experience. Evaluating self. Common to all respondents was the mental activity which the researcher has conceptualized as 'evaluating self. This activity was characterized by students appraising their perceived competence in delivering client care in relation to the knowledge and skill required to care for PWAs. In evaluating self, students appraised their perceived psychomotor and communication skills as well as their knowledge related to AIDS and the care of PWAs. Data indicate that students' need to evaluate themselves originated from their concern for personal safety and that as students began to experience concern for personal safety, they began to evaluate their knowledge and skill as a means of protecting themselves. One respondent evaluated her ability to perform psychomotor skills in relation to maintaining her own safety: I was worried that I was going to do a dressing change wrong. I was worried that I was gonna be very clumsy discontinuing an IV. Um, you know, 66 the manual psychomotor skills, I didn't have the confidence in myself then. It's interesting that I didn't feel that frightened about taking care of other patients and doing dressing changes on them, but because of his different diagnosis, it seemed to make my aseptic technique and performing dressing changes properly even more important. It seems that respondents' concern for personal safety induced a stringent scrutiny of their own abilities. Interestingly, in a cyclic manner, their appraisals of their abilities, in turn, affected their concern for personal safety. One respondent who stated she was initially "a little apprehensive about caring for someone with AIDS" evaluated her knowledge and skills, stating "I knew what I could catch it from and what I couldn't and...I knew you always wear gloves anyway when you're touching anybody's blood. It's not really anything different. So I wasn't that worried." This student's favorable evaluation of her skills and knowledge related to disease transmission seemed to decrease the original concern she had for her own safety. As well as psychomotor skills, respondents also evaluated their proficiency communicating with their 67 clients and clients' families. One respondent described her evaluation of her abilities to communicate therapeutically: "I guess I was still a student that I didn't feel really confident in myself in talking to the family....I just felt really uncomfortable talking to them." Another respondent, in evaluating self, described her communication skills in this way: "I didn't have the vocabulary to construct an empathetic conversation. I didn't know how to ask the open-ended questions...." Although the nature of the students' evaluations of their communication skills did not directly affect their concern for their personal safety, unfavorable evaluations did seem to increase the discomfort students experienced when caring for PWAs. Respondents, in evaluating self, also appraised their knowledge in relation to the knowledge they anticipated would be required in their care of PWAs. One respondent described that she lacked knowledge about how a PWA might feel, stating "I didn't feel comfortable talking to [him] because...I didn't know much about how they feel...I didn't want to say something that would really hurt [him]." This 68 student's unfavorable appraisal of her knowledge seemed to increase her discomfort in caring for her client. After experiencing fear of danger to herself upon learning that she was assigned to care for a PWA, another respondent began evaluating her knowledge of AIDS and AIDS care: "My knowledge of the disease of course was a little bit beyond the layman's, but I still wasn't entirely comfortable with the...immenseness...of the disease." And after deciding that her knowledge was deficient, the same respondent stated, "I became really frightened. I was angry too....I thought that this assignment was too much for me to deal with." This student's limited knowledge seemed to threaten her sense of personal safety while caring for PWAs. Wondering. Several respondents with lower levels of concern for personal safety described their interest and curiosity surrounding their experiences with PWAs. Typically, those respondents who indicated an interest or curiosity described scenarios in which they spent prolonged periods talking with their clients. Upon learning of their assignments, students wondered what the experience would be like and wondered how they 69 would perform during the experience. As one respondent described, "I was a little scared, but not really...I was...interested in looking forward to working with that patient....I was curious...I thought it would be a real opportunity to just see how AIDS does really affect people." Students' wonder appeared to stem partially from the attention received by AIDS in the media. The same respondent stated, "I think I just wanted to see...if all the fuss is true." Students' curiosity and interest were also evident as they described their progression through their experiences, wondering about their clients' AIDS experiences and personal stories. One respondent recounted the wonder she had toward her client's AIDS experience: I was really curious about what it was like for a PWA, especially with the disease full-blown like it was for him. I was curious to hear how he felt about it and...if he'd come to terms with his dying....I just found listening to him and talking with him particularly interesting to hear his side of the story. Another student described her interest in her client's personal stories: "He gave me a glimpse into 70 a life that was completely different...like it was very interesting to me to be included in that." Several students wondered about their clients' experiences with AIDS and about their clients' personal stories also described how they continued to wonder about their clients long after their responsibilities for client care ended. As one student described: Since [my] experience less than a year ago, whenever I hear 'AIDS' or...I can just be sitting at my desk daydreaming or something and I'll think about him....I'11 go right through the whole sequence...where I walked past his room and he was looking [at me] and our eyes met and I thought, 'Oh, he's gonna probably die tonight' and he did. It had a large impact on me because I think about it a lot....One of my strongest situations, as a student, was with this man with AIDS. Another student described her enduring wonder about her client: "Every now and then, you know, something will come up that makes this particular fellow pop into my mind....I don't think I'll ever forget him...." In fact, several students commented that the impetus for their participation in this study was their continued thinking about their experiences 71 caring for their clients with AIDS. One student who remarked, "I remember his face and what room he was in and what bed he was in and what he looked like" also added about her involvement in this study, "its helped me to deal with my own baggage and get on with living." Judging. As students told their stories about caring for PWAs, the researcher identified a mental activity, termed 'judging', whereby students gauged clients' lifestyles and behaviors against their own attitudes and values. Students tended to judge their clients based on the "transmission group" (Flaskerud, 1992b, p. 321) to which the clients belonged. For example, one student described her feelings toward IV drug users: "I have nothing against how [people get] AIDS except maybe I'd feel that they deserve it if they got it from...doing drugs." This same student continued by judging IV drug users according to her own attitudes and values: Well, to me doing drugs is something very ... illegal.... I'm totally against doing drugs because I feel that...they are doing drugs just so they can feel very comfortable...and also doing drugs really increases the crime rate....I 72 probably would still give care to the IV drug user, but even if I didn't provide adequate care, I wouldn't feel as guilty.... This quote demonstrates the student's negative attitude toward IV drug users and also indicates how such an attitude might affect the care provided by the student. Another student described her attitudes toward male homosexuals. Although this student declared she was not homophobic, she acknowledged her bias against this transmission group, attributing this bias to her lack of contact with known homosexual men: "I have not known any gay men. 'Gay men' still hadn't developed a face for me. They were still the nebulas leather boys down in the West End...." This student added, "I was worried about seeing something I couldn't cope with...in terms of the stereotype." Although this student stated that her inability to build an effective therapeutic relationship with this client was multifactoral, she admitted it was due, in part, to his labels. While some students judged their clients based on the transmission groups to which they belonged, other students judged the behaviors of their clients. With reference to a male homosexual client with AIDS who was 73 not informing his partners of his HIV status, one student stated, "It probably would have been harder to give him emotional...and friendly support....When you don't like someone on a personal level...it's harder to give them effective support." Although this client was not assigned to the student but was a patient on the student's unit, the student conjectured that her judgement of this client's behavior—"his deceit"—might have affected the care she was able to provide. Some students also judged clients with regard to the amount of responsibility they believed their clients had for contracting HIV. Students indicated that clients were more or less responsible depending on the amount of control they believed their clients had over their risk of contracting HIV. One student described her feelings toward people with cancer juxtaposed to IV drug users with AIDS: "I probably would feel more sorry for people with cancer...because they have no control over this at all." In relation to IV drug users, she added, "They could help it and they could just stop using it." About male homosexuals with AIDS, this same student stated, "I don't think its [their] fault. [They] have the right to do that, but I 74 guess, in some way, they could decrease the risk by wearing a condom." While this student believed IV drug users were completely self-determining with regard to contracting HIV, she also believed male homosexuals were less at fault, although she acknowledged they could have taken actions to decrease their risk. Some students' judgements addressed the fairness of their clients contracting HIV. Like other students' judgements about their clients' responsibility for contracting HIV, 'fairness' seemed to relate to the transmission group to which students' clients belonged and to the amount of control students perceived their clients had over contracting HIV. One student who cared for a hemophiliac adolescent with AIDS described her experience: "It just felt really unfair and I felt angry that this had happened....The way he got HIV wasn't fair. Well, it's never fair, but somehow, as a representative of the health care system, it felt less fair that he got it in the process of thinking he was receiving something good." Some students did not express negative judgements. Interestingly, these students were aware of the societal prejudice that may exist toward certain clients with AIDS and credited their lack of prejudice 75 to their "open-mindedness". As one student stated, "I'm certainly not prejudiced in any respect and I had no problem with the disease per se. I found that I went in sort of with an open mind." Another student described her open-mindedness when her client with AIDS, who was an IV drug user, talked to her about his lifestyle: I think I'm a pretty open-minded person and I'm not judgemental. I find I'm quite open-minded... like when he told me those things I just thought, 'Well, that's his lifestyle and he has a reason for doing it." I didn't think, 'Oh, that was wrong. He shouldn't be doing that' or 'That's why he got AIDS'....Nothing like that came into my mind...." Students who characterized themselves as open-minded also believed they had greater success in building effective therapeutic relationships with their clients. This seems to be validated by the fact that they described scenarios within their experiences where they spent long periods of time talking with their clients. They also expressed satisfaction with the rapport they were able to build with their clients with AIDS. A student who described herself as open-minded 76 and who dedicated "quite a few hours [to] sitting and listening" to her client also stated, "in the relationship, I really felt a lot of empathy for him." Interestingly, a student, who was not able to build a rapport with her client with AIDS, identified the missing element in the relationship to be open-mindedness: I wasn't going into [the relationship] with an open mind. I was letting what I had been exposed to in the media presuppose what I was going to be seeing, what I was going to be encountering, who I was going to be talking to. Judging, then, was a mental activity in which students gauged their clients' behaviors and affiliation with certain transmission groups against their own attitudes and values. Judgements were also rendered on the amount of responsibility and control students perceived their clients had over contracting HIV. Fairness was also a judgement which related to responsibility and control. Students described how their attitudes and judgements influenced the care they gave to clients. 77 Mental Restructuring The second broad category of mental activities within processing, termed 'mental restructuring' by the researcher, involved students mentally reorganizing the thoughts and feelings they experienced while analyzing. Mental restructuring of thoughts and feelings by students produced new personal meanings of their experiences caring for PWAs. Mental restructuring consisted of two distinct mental activities which included: (a) categorizing and (b) rationalizing. Categorizing. A distinct activity within mental restructuring, 'categorizing' involved students classifying clients—often by the transmission group to which they belonged—according to their own attitudes and values. Although similarities exist between the activities of 'judging' and 'categorizing', a definite distinction must be noted. Judging involved students appraising their clients according to their own attitudes and values, an activity which, in turn, affected their levels of concern for personal safety. In juxtaposition, the use of categorizing was not motivated by students' need to appraise but was a 78 distinct activity implemented by students in order to cope with their fears of caring for PWAs. Students described how the need to categorize originated from their concern for personal safety, from their fear of the "undesirable death" that is characteristic of AIDS, and from their attitudes and values related to certain transmission groups. Although one student acknowledged that "the faces of AIDS were changing and it was no longer just 'the gay disease1", she reorganized these thoughts to allay her concern for personal safety and anxiety about her own HIV status: Because he was a gay male, it wasn't as much a priority to find out what my status was then. My fears were not as large as they would have been it if had been a heterosexual female in the bed. It was his disease because he was gay and it fit the stereotype. And with a hemophiliac patient, it was a hemophiliac's disease. He had gotten it from a blood product and that was very easy to write off...he's a hemophiliac, that's how he got it. If it had been a straight female, it would have been a completely different ball of wax. 79 This student categorized to "protect [her] mind." She described this phenomenon as "...psychic survival." It's a way of protecting my mind from worrying too much and it's not done on a conscious, malicious level. It's a defense mechanism and it's self-preservation.... It was frightening for me when I was looking at this patient. [I thought,] 'Could I be this person? What if I've been exposed myself?' Students seemed to categorize clients so that they would view them as unlike themselves to promote their own psychic survival. Rationalizing. The other unique activity within mental restructuring, termed 'rationalizing' by the researcher, involved students attempting to mitigate the degree of perceived risk in caring for PWAs. While categorizing was also implemented to mitigate the degree of risk, that activity was specifically linked to students' attitudes and values about certain transmission groups, whereas rationalizing was specifically associated with the perceived risk of providing physical care. Students' concern for their own safety caused them to reorganize the thoughts and 80 feelings they experienced while engaged in the mental activity of analyzing by drawing on their knowledge related to disease transmissibility in an attempt to allay their fears. One respondent mentally reviewed the facts about HIV transmissibility prior to taking her client's blood pressure: "I thought, 'O.K., I know I can't...get HIV from doing his blood pressure'." Another student described how she rationalized to alleviate her concern for her own safety. When the researcher asked what she thought about during her experience of caring for her client with AIDS, she replied, "Just the fact that...any fears I had were...being irrational [and], as long as I was following precautions that I should follow, then there's really nothing to be concerned about." Managing A collection of deliberate and observable behaviors, which the researcher has termed 'managing', was implemented by students as they cared for PWAs. As the data revealed, managing behaviors originated from the thoughts and feelings students experienced while processing and were related to their concern for their own safety. Unlike processing activities which endured past the end of students' responsibilities for care of 81 their clients with AIDS, managing behaviors ended when students terminated their relationships with their clients. Five distinct managing behaviors were described by students in their care of PWAs: (a) distancing, (b) information-seeking, (c) discussing, (d) advocating/supporting, and (e) increasing involvement. Distancing In telling their stories of caring for PWAs, several students described how they withdrew from their clients. 'Distancing' involved students creating both physical and emotional distance between themselves and their clients with AIDS. Only those students who had higher levels of concern for their personal safety described how they distanced themselves from their clients. As these trancript exerpts demonstrate, some students physically distanced themselves from their clients with AIDS. The following example is typical: I just kind of avoided going into his room as much as possible, just kind of decreased interaction....Most of the time, I just kept my gloves on because I wasn't sure and I made sure that I washed my hands over and over again....When I started to feed [him], I just wanted to get this 82 over with as soon as possible and I kind of, you know, had a little...distance between me and the client. And I was thinking..."I just want to get this over with". Another student described how she created physical distance between herself and her client with AIDS: I realize, you know, I know you can't get AIDS through touching a person, but I wasn't comfortable touching him whereas if it had been a little old lady or a child dying of cancer in that bed, or even a person my age dying of cancer, I could hold their hand or hug them and not feel uncomfortable with that action. Students distanced themselves by avoiding opportunities for contact with their clients and by using physical barriers such as gloves excessively. Students also withdrew by creating increased physical space when they were in contact with their clients and by hurrying care activities to decrease the time spent in contact with their clients. Students with higher levels of concern for their personal safety admitted sacrificing the quality of the care they delivered to their clients with AIDS in order to create physical distance, thereby decreasing their 83 perceived risk of contracting HIV. The same student who described how she avoided going into her client's room told of her experience bathing her client: I was worried...I put my gloves on and I made sure that...I didn't touch him...with my bare hands. I had gloves on and I think, if I was washing somebody without AIDS, I would probably do a better job....I just did it really briefly just so that when I talked to my instructor I could tell her I had [bathed him]. Not only did students with higher concern levels physically distance themselves, but they also created emotional distance which affected their ability to feel empathy for their clients with AIDS. One student described how the emotional distance she created because of her fear of caring for PWAs affected her ability to build an effective therapeutic relationship with her client: I could have probably listened better and talked better, but because of the...label that was sitting there in the back of my mind and the big danger signs that kept going off...it blocked me from...relaxing and giving him the care that I am able to give patients now....He'd only been aware 84 of his HIV status for five months before this all started happening and I think he must have really needed someone to talk to and I was just too frightened to be able to sit down and listen....I couldn't be as empathetic as I wanted to be...because of my own anxieties and my inability to let him talk about his illness experience. Another student emotionally distanced herself from her client and the client's family because she stated she lacked confidence in her communication skills and lacked knowledge about "the AIDS experience" for PWAs and their families. As this student described: I didn't talk to him because I didn't feel comfortable...I didn't really know what I was going to say....I didn't know much about how they feel and...what I should say. I didn't want to say something that would really hurt them emotionally. As these transcript excerpts indicate, students distanced themselves, both physically and emotionally, because they worried about contracting HIV and because they felt inadequately prepared to provide effective emotional support to their clients. Resulting from the physical and emotional barriers erected by students 85 were client care scenarios in which suboptimal care was provided to PWAs. Information-seeking Characteristic of all of the respondents was a subset of managing behaviors termed •information-seeking'. These behaviors involved students searching for written materials or personal accounts from nurses to assist them in their care of their clients with AIDS. One student, who had a high level of concern for her own safety, described her information-seeking behaviors when she learned she had been assigned to care for a PWA: "I was just nervous that day that I just went home and started to read [to get] more information about AIDS." This student's need for more information about AIDS seemed to be fueled more by her concern for her own safety than by the usual need of students to gain information in preparation to provide comprehensive care to their clients. Another example of this same student's need for information to promote self-preservation is evident from the following transcript excerpt: "I did talk to one nurse during clinical about...what she thinks about caring for PWAs....I think she said that it wasn't that easy to get AIDS from patients, but I wasn't really 86 sure." Despite this student's information-seeking activities, she still seemed to question the accuracy of this information, rendering the effectiveness of this strategy questionable for its ability to allay fears in those students with high levels of concern for their own safety. Another student whose information-seeking behaviors seemed to be fueled by her concern for her own safety described her experience when she learned of her assignment to care for a PWA: I think I remember taking a deep breath.... that was the first thing...so what I did next was I wanted to find out everything I could about what was going on for this person....it seemed like if I knew a lot it would help....I had done reading about HIV before, but I definitely went home and did more.... Although students with lower levels of concern for their own safety also described how they searched for information during their experiences caring for their clients with AIDS, these students indicated that the impetus for information-seeking was their desire to meet the anticipated needs of their clients. As one student stated: 87 I looked up all the sort of clinical things that you need to look up, the typical drugs that are used, the typical problems as a result of this, but I was mostly familiar with most of that. I did look up considerably more about communicating with people with this sort of problem and I looked up a couple of things on how to care for dying patients. I researched more on psychological communication more than I've ever done for any other type of problem. Information-seeking behaviors were described by all students regardless of their expressed levels of concern for personal safety. However, the data indicate that while students with low levels of concern sought information in order to meet the unique needs of their clients with AIDS, students with high levels of concern were focused more on their own self-preservation than on providing quality care to their clients. Given the context that nursing students are expected to seek information in preparation for assigned client care situations, the uniqueness of the strategy of information-seeking in this study seems to be related to the motivation by some students to employ information-seeking as a means of self-preservation. 88 Discussing Prior to and during interaction with their clients with AIDS, students described how they discussed their experiences with significant others and classmates. One respondent, who was fearful of caring for her client with AIDS, chose to talk to a friend who was also a nursing student. The friend validated the respondent's fear: One of my friends was especially understanding....She never looked after somebody with AIDS, but she had the same fear as I did about caring for [PWAs]. She told me that she'd think it was scary too....So, in that way, I felt a bit better because I knew that I wasn't the only one who was scared. This respondent's fear and the resultant suboptimal care she provided to her client with AIDS were so troubling to her that she stated, "I was pretty selfish...and I felt kind of guilty." Her discussion with her classmate, who validated her feelings, seemed to comfort her during this experience. Interestingly, although this same respondent's thoughts and feelings during her experience caring for her client with AIDS were so distressing to her, she 89 specifically indicated she could not discuss her feelings with her clinical nursing instructor: It's hard to talk to your instructor about those feelings because you don't know how they would feel....They might think you're being selfish...it might give them a bad impression.... I wasn't sure how they'd react to that. That would just reflect badly on my...evaluation. Remarkably, only one student mentioned discussing her experience caring for her client with AIDS with her nursing instructor, however, the discussion took place in a post-clinical conference setting. One student, who did not discuss her feelings with anyone, admitted she "stored [her feelings] away." Interestingly, this student utilized her involvement in this study "to deal with [her] own baggage and get on with living." Discussing was a strategy utilized by students to explore their thoughts and feelings as they cared for PWAs. A strategy utilized by most students, discussing was often carried out in the company of significant others or classmates. Despite the powerful feelings described by students as they cared for PWAs, only one 90 student revealed her feelings to her nursing instructor in a post-clinical conference setting. Advocating/Supporting Advocating/supporting behaviors were characterized by students taking action when they perceived their clients1 best interests or wishes were not being met, often by other members of the health care team. Interestingly, only those students who had lower levels of concern for their own safety and who believed they had cultivated effective therapeutic relationships with their clients with AIDS described scenarios where they acted as advocates. One student, whose client was being inappropriately isolated in his private room by nursing staff, described her feelings and the resultant actions she took: My patient was on a ward that didn't really deal with AIDS patients much and I found...that this particular ward staff's attitude to him was actually abominable....The doctors would walk to the door and sort of lean in...and all the nurses that went in his room for any length of time always had a gown on and a mask and gloves on. [The nurses] were always saying, "Well, you know, he should be staying by himself". And I thought, 91 "Well, I may not be an R.N., but I really should advocate for this person".... So I spoke to my instructor, who agreed with me, and she spoke to the Head Nurse. Anyway, I did eventually get him up walking a bit out in the ward and I got him in a wheelchair with a mask on. They agreed to that....But that was the only time I know that he got out. Another student described how she supported her client's right to information about his own condition because his physician was not coming in to consult with him, despite multiple requests by nursing staff: My patient was particularly concerned because there were a lot of things he wanted to do. He knew he was dying and that it wasn't going to be long and there were a lot of things he wanted to do before he died, so he was very anxious to get out [of the hospital].... I was thinking how difficult it must be for him not to know what's going on and have to wait every day expecting to hear from the doctor....I guess I was on the patient's side rather than on the doctor's side....I made a point of leaving notes for the doctor, telling the doctor how the patient was 92 feeling, but I don't know if [the notes] were really acted on to what I thought was comfortable. Advocating/supporting, then, was described by some students to be an integral part of their experiences caring for their clients with AIDS. Further, one student viewed people's reactions to her client in the context of the social stigma of AIDS and her resultant advocacy for her client to be an important difference between caring for PWAs and clients with other non-stigmatized diseases: I think the difference is more how I see other people's reactions to patients like that....And that might change the care you give too, dealing with that kind of stigma...in that if you're more conscious of the stigma and you see other people reacting to that stigma, then, as a patient advocate, you should do something about it. Increasing Involvement The final subset of managing behaviors identified was termed 'increasing involvement1. Like advocating/supporting, increasing involvement with clients was only demonstrated by those students who had lower levels of concern for their own safety. Typically, they spent prolonged periods of time 93 providing care to their clients with AIDS. Often these prolonged periods of contact involved students attending to not only clients' physical needs but their psychosocial needs as well—needs these students anticipated would require focused attention. One student described her increasing involvement in her client's care, the motivation for which she stated was her interest and curiosity in caring for a PWA, the "sympathy" she felt for her client, and her desire to meet her client's need for comfort: "When I was helping him, my main concern was his comfort. And also I...just wanted to get in there as much as I could and do as much for him as I could." Another student described her increasing involvement in her client's care, and how she was particularly motivated by her client's psychosocial needs: I think I ended up holding his hand at one point and I think he appreciated that. I think just the fact that you're willing to sit and listen sort of shows something. I did that for quite a few hours. I think more than anything else, he just needed a listener. 94 As well as being motivated by interest and curiosity, and genuine caring for their clients, students who demonstrated increasing involvement in their clients' care were also motivated by the social stigma which surrounds AIDS and the resultant attitudes of some health care professionals. One student described her increasing involvement due to the expressed attitudes of the assigned nurse toward her client with AIDS's request for analgesia in the context of his history of IV drug use: I just felt so sorry for him, probably because of the way he was being treated. Besides the fact that he had AIDS, he wasn't getting kindness from anybody.... They weren't even going to get him something for pain....[This] might have made me have more sympathy for him and go even more out of my way....I felt it did because I felt terrible for him. Summary In this chapter, the researcher presented the findings of this study related to nursing students' experiences caring for PWAs. The findings indicate that nursing students' concern for their own safety was a predominant and enduring theme throughout their 95 experiences caring for their clients with AIDS. Students' concern for personal safety was time-limited, beginning when they first learned they were assigned to care for a PWA and concluding when their responsibilities for client care ended. In their experiences, students endured varying levels of concern for their own safety, from a heightened awareness of the contagious nature of their clients' body fluids, to worry and fear so intense that it affected the quality of care afforded these clients. Students' concern fluctuated, depending on their involvement in care activities where the perceived risk of contact with body fluids, and hence of contracting HIV, was great. Perhaps one of the most significant findings related to students' concern for personal safety was its uniqueness to caring for PWAs. For students, caring for PWAs was different than caring for clients with other illnesses in that students perceived that the care they provided to their clients with AIDS could ultimately cause their own deaths due to the contagious, incurable, and fatal properties of AIDS. Processing was a collection of mental activities employed by students to mentally dissect their experiences caring for PWAs and, subsequently, 96 restructure those experiences to create new personal meaning. Processing activities were triggered by students being assigned to care for PWAS and by their concern for their own safety. Permeating the students' entire experiences caring for PWAs, processing activities also endured past the end of students' responsibilities for the care of their clients. As students mentally processed their experiences caring for PWAs, their resultant thoughts and feelings affected their levels of concern for their personal safety. Processing activities included two categories of mental activities—analyzing and mental restructuring—each of which contained several distinct subsets of mental activities. During analyzing, students mentally dissected their experiences caring for PWAs by comparing them with past personal and professional experiences. Students, who were able to infer similarities between past and present experiences, expressed less concern for personal safety. Those students who continued to identify differences had higher initial levels of concern and their levels of concern remained relatively constant throughout their experiences. 97 When analyzing, students also evaluated themselves by appraising their perceived competence in providing nursing care in relation to the knowledge and skills required to care for PWAs. Due to their concern for their own safety, students carefully scrutinized their abilities to maintain their own safety while providing care. In light of the immense psychosocial impact of AIDS on clients and their families, students also evaluated their abilities to communicate with clients and significant others. Students whose evaluations of themselves were not favorable seemed to become more concerned for their own safety and experienced greater discomfort in caring for their clients. Suggestive of a circular process, as students became more concerned for their safety, their care was affected and, again, they evaluated that care as suboptimal. Favorable self-evaluations seemed to allay their fears. Another aspect of analyzing was wondering. Students wondered about how they would perform, what the experience of caring for a PWA would be like, and wondered about their clients' AIDS experiences and personal stories. Students who wondered were those with lower levels of concern for their own safety. 98 Students tended to wonder about their clients long after their responsibilities for client care ended. Judging, another aspect of analyzing, involved students gauging their clients' lifestyles and behaviors against their own attitudes and values. Judgements were made based on clients' affiliations with certain transmission groups, clients' behaviors, and the degree of responsibility and control students perceived their clients had for contracting HIV. If negative judgements were rendered by students, the quality of client care tended to be compromised. Students who did not pass negative judgements characterized themselves as open-minded and were able to build effective relationships with their clients with AIDS. Mental restructuring, a category of processing activities, involved students mentally reorganizing the thoughts and feelings they experienced while analyzing. During mental restructuring, students reorganized their thoughts and feelings through two distinct activities, namely categorizing and rationalizing. Categorizing involved students coping with caring for PWAs by classifying clients—often by transmission group—according to their own attitudes and values. 99 Fueled by concern for personal safety, fear of an "undesirable death", and their own attitudes and values, students categorized their clients with AIDS so that they would view them an unlike themselves and promote their own "psychic survival". Students also mentally restructured their experiences by rationalizing or mitigating the degree of perceived risk involved in providing physical care to PWAs in order to allay their fears. Managing was a collection of deliberate and observable behaviors implemented by students in their care of PWAs. Managing included: (a) distancing, (b) information-seeking, (c) discussing, (d) advocating/supporting, and (e) increasing involvement. Distancing was utilized by those students with higher levels of concern for their own safety in an attempt to create physical and emotional distance between themselves and their clients with AIDS resulting in the provision of suboptimal levels of nursing care. An opposing behavior was increasing involvement which was utilized by only those students with lower levels of concern for their own safety in their desire to meet their clients' needs through the provision of optimal care. Unlike distancing which was fueled by students' concern for their own safety, increasing involvement, was motivated by students' genuine concern for their clients' well-being, by their curiosity and interest in caring for PWAs, and by the reactions of other health care professionals to the social stigma of AIDS. Information-seeking was another managing behavior utilized by students whereby they searched for written materials or personal accounts from nurses to assist them in their care of PWAs. While all nursing students are expected to seek information in preparation for client care situations, uniquely students with higher levels of concern for their safety sought information for reasons of self-preservation. Another managing behavior utilized by most students, discussing, assisted students to explore their thoughts and feelings as they cared for PWAs. Discussing was often carried out in the company of significant others or classmates and, despite such powerful feelings described by students as they cared for their clients, only one student revealed her feelings to her nursing instructor in a post-clinical conference. Finally, advocating/supporting was a managing behavior utilized by those students with lower levels of concern for their own safety. Advocating/supporting involved students taking action when they perceived their clients' wishes or best interests were not being met, often by other members of the health care team. CHAPTER FIVE: DISCUSSION OF FINDINGS Introduction In this chapter, a discussion of the findings of this study is presented. In this discussion, the researcher will address the importance of the findings as they relate to nursing students' experiences caring for PWAs. Similar to the previous chapter, this chapter's organizing centres are the three key themes identified by the researcher, namely concern for personal safety, processing, and managing. The scope of this chapter dictates that while some of the categories within concern for personal safety, processing, and managing receive in-depth discussion, other categories receive only limited attention and are only discussed as they relate to more significant findings. As well as the literature that was discussed in Chapter Two, additional literature will be utilized by the researcher to illustrate the significance of the findings of this study. Concern for Personal Safety The findings of this study indicated that concern for personal safety was a pervasive and enduring theme throughout nursing students' experiences caring for PWAs. Just as this study revealed, Klisch (1990) also found that nursing students caring for PWAs for the first time experienced intense emotional reactions involving anxiety and fear in the pre-interaction and introductory phases of the nurse-patient relationship. However, Klisch reported that the experience forced students to confront these anxieties and fears which lead to positive experiences. That positive experiences evolved from initial reactions of intense fear is not congruent with the findings of this study. Those students who expressed high levels of concern for personal safety continued to do so throughout their experiences and expressed feelings of dissatisfaction with the quality of care they provided to PWAs. Others have also reported the initial concern for personal safety among health care providers when caring for PWAs. Flaskerud (1992c) stated that initially, upon caring for PWAs, "nurses and other health care workers have...concerns about contagion....They are in contact with the patient's body fluids, administer medications and IV fluids, change beds, bathe patients, and provide toilet care. Their concerns include fears of personal exposure..." (p. 267). And Tisdale (1989), in a personal account of an experience caring for a PWA, described initial feelings of fear upon learning of her assignment, as a nursing student, to care for a client with AIDS. That concern for personal safety was a significant finding of this study is supported by other studies where health care professionals' fear of contagion was a recurrent theme (Alexander & Fitzpatrick, 1991; Blumenfield et al., 1987; Breault and Polifroni, 1992; Eliason, 1993; Klisch, 1990; Lester & Beard, 1988; van Servellen et al., 1988), despite evidence that demonstrates that the risk of acquiring HIV infection from occupational exposure is extremely low (Gerberding, 1989; Stricof & Morse, 1986). Fear has also been identified as a source of stress experienced by nurses (Bolle, 1987; Pickthall, 1990) and other health care providers (Reed et al., 1984) in confronting PWAs. This occurred when the informants were knowledgeable about AIDS and recognized the risk to be very low (Pickthall, 1990). In the context of these studies, it is not surprising that nursing students' concern for personal safety was found, in this study, to be an enduring theme throughout their experiences caring for PWAs. An important characteristic of nursing students' concern for personal safety reflected in the findings of this study was students' varying levels of concern, from a heightened awareness of the contagious nature of their clients' body fluids, to a feeling of being very scared that caring for their clients with AIDS could cause their own deaths—an irrational fear in the context of scientific evidence that demonstrates that the risk from occupational exposure is extremely low (Gerberding, 1989; Stricof & Morse, 1986). That varying levels of concern for personal safety exist is supported by Reed et al. (1984) who studied health care providers and management from a tertiary care hospital in a large American metropolitan area. These researchers reported varying levels of anxiety and fear toward caring for PWAs. Students' concern for personal safety fluctuated depending on whether they were involved in care activities where the perceived risk of contact with body fluids, hence of contracting HIV, was great. No other studies were found which address the fluctuating nature of concern for personal safety, but it is not unrealistic to expect that these variations would occur. Perhaps the most notable finding of this study related to students• concern for personal safety was its uniqueness to caring for PWAs. For these students, the combined effect of the contagious, incurable, and fatal properties of AIDS rendered their concern particular to caring for this client population. While no studies were found which address the additive effect of these three properties, several studies have addressed, separately and in varying combinations, health care providers' concerns regarding the contagious, incurable, and fatal nature of AIDS (Blumenfield et al., 1987, Damrosch et al., 1990, Pickthall, 1990; Reed et al., 1984; van Servellen et al., 1988). Damrosch et al. (1990) concluded that critical care nurses perceived AIDS as a stigmatized disease and that "as a life-threatening, transmissible disease, AIDS reminds people of their own mortality, provoking their anxiety" (p. 395). Similarly, Blumenfield et al. (1987) found that intensive care unit (ICU) nurses had higher fear levels about AIDS than about hepatitis, a more contagious but less serious disease. These researchers speculated that the difference in fear levels may have been related to the fact that ICU staff, compared to nurses employed in other units, are more frequently exposed to body secretions and, thus, have more reason to fear a fatal viral infection. Informants in Pickthall's (1990) study were certainly aware of the higher risks associated with other infectious diseases like hepatitis, but "they [still] believed no comparison could be made because AIDS is fatal" (p. 52). And Turner, Gauthier, Ellison, and Greiner (1988) added that "the fact that AIDS is fatal and is often compared to cancer evokes the fear response that is sometimes associated with cancer" (p. 274). Finally, Beaufroy, Goldstone, and Riddell (1988) expressed the opinion that the incurable nature of AIDS also invokes the emotional reactions of nurses. Unlike Turner et al. (1988) who likened the fear response associated with the fatal nature of AIDS to people's fear of cancer, the respondents in this study suggested that caring for persons with cancer is very different from caring for PWAs since cancer is not contagious nor did respondents perceive cancer as necessarily fatal. Thus, in order to understand nursing students' experiences caring for PWAs, one must endeavor to understand the uniqueness of their concern for personal safety related to the combined effect of the contagious, incurable, and fatal properties of AIDS. Processing Processing activities were employed by students i the care of PWAs, and were triggered by their being assigned to care for PWAs and by their concern for their personal safety. Data also indicated that students' resultant thoughts and feelings from processing, in turn, affected their levels of concern for personal safety. Processing activities consisted of two main categories, namely analyzing and mental restructuring, within which existed several distinct mental activities. Analyzing, which involved students mentally dissecting their experiences caring for PWAs and examining them in relation to their own knowledge, skills, attitudes, and values, consisted of four activities, namely comparing, evaluating self, wondering, and judging. These activities are perhaps best understood in relation to Lazarus' (1966) work regarding stress, coping, and cognitive appraisal processes. Within the context of psychological stress theory, Lazarus and Folkman (1984) defined coping as "constantly changing cognitive and behavioral efforts to manage specific external and/or internal demands that are appraised as taxing or exceeding the resources of the person" (p. 141). Further, Lazarus and Folkman theorized that through cognitive appraisal processes, individuals initially appraise events as being benign, harmful, or challenging to their well-being (primary appraisal), then evaluate resources and options for managing the event (secondary appraisal). Further clarifying the notion of secondary appraisal were Lazarus and Launier (1978). These researchers said of the relationship between cognitive appraisal and coping, that "secondary appraisal, oriented as it is to possible coping resources and options, not only influences the primary appraisal process itself, mitigating or enhancing threat or the sense of harm, but it also shapes coping activity" (p. 307). Lazarus (1966) also indicated that, through a series of reappraisals, the degree of threat to the individual may be altered and that depending on certain person and situation factors influencing appraisal, similar events may be appraised differently by different individuals. The researcher's conceptualizations of comparing, evaluating self, and wondering—in which respondents examined the experience of caring for PWAs in relation to their own repertoire of personal and professional experiences, appraised their perceived competence in relation to the perceived knowledge and skill required to care for PWAs, and contemplated what the experience of caring for PWAs would be like and how they would perform, respectively—are consonant with Lazarus' (1966) conceptualization of cognitive appraisal processes. The mental activities of comparing and evaluating self were suggestive of how respondents compared their past experiences with the new experience of caring for PWAs and evaluated themselves in order to appraise the implications of caring for PWAs on their well-being (primary appraisal) and to evaluate what could be done to counter the threat to their well-being (secondary appraisal). Wondering reflects a specific kind of primary appraisal conceptualized by Lazarus (1966). Referred to as 'challenge', this kind of appraisal focuses on the potential for gain or growth in an encounter and is characterized by eagerness (Lazarus & Folkman, 1984). Like those students who wondered, expressing their interest and curiosity while caring for PWAs, the challenged person, according to Lazarus and Folkman, feels more positive, more confident, and less emotionally overwhelmed by demanding encounters. Another characteristic of cognitive appraisal which parallels the researcher's conceptualization of processing activities is Lazarus' (1966) notion of reappraisal. That reappraisals may alter the degree o threat to the individual offers support to the researcher's finding of the enduring nature of processing activities and their resultant impact on respondents' concern for personal safety. And that secondary appraisal can mitigate or enhance the sense of threat (Lazarus & Launier, 1978) also supports the researcher's finding of the ability of respondents' processing activities to affect their concern for personal safety. The final mental activity within analyzing, 'judging', involved respondents gauging clients' lifestyles and behaviors against their own attitudes and values. Respondents judged clients based on their affiliation with certain transmission groups, their behaviors, and their perceived responsibility for contracting HIV. Again, Lazarus' (1966) work related to cognitive appraisal processes and the factors that influence appraisal lends credence to the researcher's finding related to judging. Included in those person factors, which are important determinants of appraisal, are what Lazarus and Folkman (1984) termed commitments or values, and beliefs. According to Lazarus and Folkman, these variables influence appraisal by "...shaping the person's understanding of the event, and in consequence his or her emotions and coping efforts [and by] providing the basis for evaluating outcomes" (p. 55). These variables, in part, also determine the extent to which threat or challenge will be experienced. Commitments or values, and beliefs then, like the researcher's conceptualization of the mental activity of judging, influence the meaning of events—such as caring for PWAs—and determine the degree of experienced threat—or concern for personal safety. That some respondents in this study rendered negative judgements toward PWAs based on lifestyles and behaviors is also a phenomenon described in other studies of health care providers' attitudes toward PWAs (Alexander & Fitzpatrick, 1991; Blumenfield et al., 1987; Breault & Polifroni, 1992; Brown et al., 1990; Kelly et al., 1988; Kerr & Horrocks, 1990; Lawrence & Lawrence, 1989; Lester & Beard, 1988; Oermann & Gignac, 1990). It has been shown that nursing students hold negative attitudes toward IV drug users and homosexuals, and that those students who hold more negative attitudes than their peers have greater intentions to avoid caring for PWAs (Jemmott et al., 1992). Other studies have documented similar attitudes of health care professionals to stigmatized transmission groups such as homosexuals and IV drug users (Barrett, 1992; Barrick, 1988; Forrester & Murphy, 1992; Jemmott III et al., 1992; Katz et al., 1987; Mueller et al., 1992). That students expressing negative attitudes toward certain stigmatized transmission groups had higher levels of expressed concern for personal safety was another finding of this study. The association of negative attitudes with fear of AIDS is supported by Royse and Birge (1987), in their study of 161 students studying for careers in health professions. These researchers found that homophobia was inversely associated with empathy for PWAs and that homophobia was also a better predictor of fear of AIDS than several other variables. Similarly, the relationship of belief systems and fear of AIDS was also described by Grady (1989) who stated, "because AIDS is a sexually transmitted disease and often associated with homosexual activity...the fear and stigma attached to AIDS increases within some cultural belief systems" (p. 527) . That some respondents judged their clients with regard to the amount of responsibility they believed their clients had for contracting AIDS has also been documented by other researchers (Cole & Slocumb, 1993; Eliason, 1993; Melby et al. 1992; Reutter & Northcott, 1993). Melby et al.(1992), in their study of nurses in Northern Ireland, found that some nurses believed homosexuals, prostitutes, and drug-abusers were at least partly responsible for their own illness. And Cole and Slocumb (1993) found that nurses' attitudes toward PWAs differed depending on how the person acquired the disease. Individuals who acquired HIV without violating social norms were viewed as 'innocent victims'. In Eliason's (1993) study, nursing students indicated that there could be innocent victims of AIDS, such as people receiving blood transfusions. And Reutter and Northcott (1993) found that attribution of responsibility changed as nurses got to know their clients and that nurses had more difficulty accepting those clients who they perceived to be acting irresponsibly. Finally, with regard to judging, respondents who did not render negative judgements toward PWAs characterized themselves as open-minded. This finding is supported by Bonaparte (1979) in a study of nurses' attitudes toward culturally different patients. A significant finding of Bonaparte's study was that the more open-minded the nurse, the more positive were the attitudes toward culturally different patients. Mental restructuring, the second broad category of mental activities within processing, was conceptualized by the researcher as students' mental reorganization of the thoughts and feelings they experienced while analyzing. For students, this process produced new personal meanings of their experiences caring for PWAs. From students' stories, the researcher also conceptualized two distinct mental activities within mental restructuring, namely categorizing and rationalizing which were used to mitigate the degree of perceived risk in caring for PWAs. Categorizing was utilized by some students to difference themselves from their clients with AIDS which, in turn, allayed their concern for personal safety and their fears of a disease which they believed leads to an undesirable death. This kind of emotional self-preservation or coping has also been described by All (1989). In All's opinion, "people need to view AIDS victims as unlike themselves in any way to survive. The individual needs to keep the AIDS patient at arm's length both emotionally and physically (p. 163). However, Reutter and Northcott (1993) and Klisch (1990) indicate that while nurses focused on differences initially, most came to accept clients as individuals. Lazarus and Launier's (1978) work related to coping modes provides a useful context from which to further understand nursing students' use of rationalization. Lazarus and Launier described four modes of coping, one of which is called 'intrapsychic coping', in which a person cognitively regulates emotion to reduce pain, anxiety, or distress. These researchers characterized intrapsychic coping as a person's reinterpretation of a traumatic event or use of self-reassurance to lower destructive anxiety. Certainly students' stories included anecdotes in which they attempted to cope with providing physical care to their clients with AIDS by rationalizing or reassuring themselves of the relatively low risk attached to caring for PWAs in order to decrease their concern for personal safety. In her study of nurses' experiences caring for PWAs, Pickthall (1990) reported that informants typically utilized rationalization as a coping strategy by thinking logically about AIDS to decrease their fear. And Breault and Polifroni (1992) also reported that nurses coped with the fears of caring for PWAs by rationalizing the risk. Managing The data from this study revealed that nursing students implemented a number of deliberate and observable behaviors as they cared for PWAs. Termed 'managing' by the researcher, this collection of behaviors included several distinct behaviors, namely distancing, information-seeking, discussing, advocating/supporting, and increasing involvement. The 'withdrawing' behaviors reported by Pickthall (1990) in a study of nurses' experiences caring for PWAs appear to be similar to the 'distancing' behaviors identified among nursing students in this study. 'Withdrawing', according to Pickthall, was characterized as a coping strategy and was utilized mainly by informants who were homophobic in order to distance themselves from clients with AIDS. Klisch (1990) also indicated that students used distancing measures to cope with their experiences caring for PWAs. Juxtaposed to distancing was 'increasing involvement', another managing behavior identified by the researcher. Increasing involvement was characterized by nursing students spending prolonged periods of time providing care to their clients with AIDS. Although there is no evidence that increasing involvement, as a means of coping, has been conceptualized in this way by other researchers, Pickthall (1990) did describe a similar coping strategy called 'involvement'. In this study of nurses' experiences caring for PWAs, nurses demonstrated involvement by sharing personal information with or seeing the patients in their non-working hours. Nurses utilized involvement primarily with those clients whom they identified with in some way. From this, one might conjecture that the nursing students in this study may have employed 'increasing involvement1 if they were able to identify with their clients with AIDS. However, students' curiousity and interest--perhaps their desire for learning about AIDS and AIDS care—was also a factor in their use of increasing involvement in their care of PWAs. Students were also motivated to increase their involvement with their clients due to their reactions to the attitudes and actions of others. This is best understood in the context of studies by Klisch (1990) and Reutter and Northcott (1993), and in the context of a personal account by Tisdale (1989). During the working phase of students' therapeutic relationships with their clients, Klisch (1990) found that some students expressed anger at the negative feelings of other members of the nursing staff. In fact, one student stated, "'I felt that he (other staff member) had never made an effort to get to know this patient as a person...'" (p. 19). Reutter and Northcott (1993) also discovered that one way nurses found meaning in their work was by accepting the patient as a person. In part, this acceptance allowed nurses to increase their involvement with clients and their families even though their work was not always valued by others. And Tisdale (1989) described how, as a nursing student, she began to see her client with AIDS as a person as their relationship progressed. It might be conjectured that the attitudes and actions of other health care providers toward the students' clients with AIDS caused respondents in this study, who were able to see their clients as persons, to react and increase their own involvement in their clients' care, perhaps to compensate for the questionable care provided by their colleagues. Another significant finding of this study was that some respondents utilized what the researcher conceptualized as 'information-seeking' in their care of their clients with AIDS. Within the context of Lazarus and Launier's (1978) notion of coping modes, further understanding of information-seeking is achieved. According to these theorists, four modes of coping exist, one of which they termed 'information seeking'. Their notion of information seeking is consonant with the researcher's conceptualization of this strategy, since Lazarus and Launier contended that information seeking "may be employed to make the person feel better by making the transaction seem more under control.... Or,...may be aimed at finding out what needs to be changed in the environment, or in the self, to manage a stressful transaction" (p. 316). Certainly respondents in this study did utilize information-seeking to cope with the perceived stressful situation of caring for a PWA. Pickthall (1990) also reported that seeking out information was a coping strategy utilized by informants in her study of nurses' experiences caring for PWAs. Termed 'knowledge-seeking' by Pickthall, this coping strategy was characterized by informants as looking for new information in order to increase their understanding. Pickthall, however, did not describe any differences in informants' motivation toward knowledge-seeking. Given the difference that appeared to exist in respondents' motivation for information-seeking, in essence the bifurcated goal of information-seeking in this study, one might conjecture that those students with lower levels of concern sought information because they were being educated into a culture of nursing which places expectations on its students to gather information prior to and during care of clients. Unique to this study, then, was that those students with higher levels of concern for their own safety, while perhaps partly motivated by the aforementioned expectations, were motivated to employ information-seeking more as a means of self-preservation. Another managing behavior found to be utilized by respondents in this study, discussing, was characterized by nursing students talking to significant others and classmates about their experiences caring for PWAs. Pickthall (1990) found 'talking with others' was a coping strategy used by nurses when caring for PWAs. It is curious, however, that the nurses in Pickthall's study only described talking to co-workers, friends, and family about their experiences. These nurses did not talk about their experiences caring for PWAs with nursing unit managers or other persons who might be perceived as having an influence on job appraisals. Similarly, nursing students in this study did not discuss their experiences with their nursing instructors and, in fact, as one might conjecture, one student did state that she purposely avoided discussing her feelings with her instructor because it might influence her evaluation. As well, only one nursing student in Klisch's (1990) study talked to someone about her fears. Another student in this same study reported a reluctance to divulge the fear to anyone. The absence of nursing instructors from students' discussing activities is noteworthy. As students told their stories in this study, the researcher noted the relative absence of nursing instructors from students' descriptions of their experiences with their clients with AIDS. It must be noted, though, that the researcher did not specifically ask students to detail the involvement of their instructors in their experiences. Yet students did not volunteer stories of instructor involvement. If instructors were indeed not part of students' experiences, it might be conjectured that they, too, may have been concerned about personal safety or had negative attitudes toward this client population which precluded their involvement in students' assignments. While Mueller et al. (1992) found faculty had positive attitudes and behavioral intentions, Oermann and Gignac (1991) did find faculty's attitudes toward PWAs to be low and also to be similar to those of nursing students. However, if instructors truly were involved in students' experiences, the fact that students described little instructor presence may suggest that students did not recognize their instructors' involvement as effective. Advocating/supporting was another managing behavior implemented by nursing students in their care of PWAs. A dearth of studies exist which have addressed health care providers' perceived need to advocate for PWAs. However, in a discussion with nurses about caring for PWAs, Bennett (1987) reported nurses' stories of advocating for PWAs with regard to code status and the right to appropriate medical care. That advocating/supporting behaviors were only described in this study by nursing students with low levels of concern for their own safety is significant. This finding suggests that only those nursing students who were relatively comfortable with caring for PWAs and who, in turn, developed positive therapeutic relationships with their clients were able to fulfill this very important nursing role. Summary In this chapter, a discussion of the findings of this study was presented. In this discussion, the researcher addressed the importance of the findings as they related to the phenomenon of nursing students' experiences caring for PWAs. Respondents in this study experienced concern for personal safety in caring for PWAs. That concern about contagion was an initial feeling of students upon caring for PWAs and that their concerns permeated the entire experience, creating the context in which their care was delivered, was supported in the literature. Also supported in the literature was the existence of varying levels of concern for personal safety. However, that respondents' concern for safety fluctuated depending on their involvement in care activities where the perceived risk of contact with body fluids, hence of contracting HIV, was great was not addressed in any other studies. Most notable regarding concern for personal safety was its uniqueness to caring for PWAs. Although several studies have addressed, separately and in varying combinations, the impact of the contagious, incurable, and fatal properties of AIDS on health care providers' fears, no other study has suggested that these three properties may have a combined effect which renders concern for personal safety unique to caring for PWAs. Processing activities, triggered by students being assigned to care for PWAs and by their concern for personal safety, included two broad categories of processing behaviors, analyzing and mental restructuring, each of which encompassed several distinct mental activities. Analyzing consisted of four activities, namely comparing, evaluating self, wondering, and judging, all of which were supported by theory related to stress, coping, and cognitive appraisal of threatening events. As well as theoretical support, the activity of judging was also supported by other research literature in which the negative attitudes of health care providers toward stigmatized transmission groups with AIDS were addressed. Support from other studies was also noted with regard to the possible inverse relationship of nursing students' attitudes toward PWAs and their fear of AIDS. Support was also found for the tendency of respondents to judge their clients on the amount of responsibility they believed the clients had for acquiring HIV. Finally, support for the fact that students who did not render negative judgements characterized themselves as open-minded was derived from research on the effects of open- and closed-mindedness on attitudes toward culturally different patients. Mental restructuring, the second broad category of process, consisted of two distinct mental activities, namely categorizing and rationalizing. Both were supported by theoretical literature on coping and by research literature on the use of rationalization by nurses to cope with caring for PWAs. Respondents used a variety of deliberate and observable behaviors as they cared for PWAs. Termed managing, these behaviors consisted of distancing, information-seeking, discussing, advocating/supporting, and increasing involvement. Although a paucity of research exists on the use of distancing and increasing involvement by health care providers in the care of PWAs, research does exist related to health care providers' intentions to refuse to care for PWAs. It is interesting to ponder the relationship of health care providers' intent to refuse to care for PWAs and nursing students' use of distancing and whether students would refuse to care for their clients if they had viewed refusal as a viable option. Also interesting is the possible relationship between students' increasing involvement with their clients and their anger at the negative attitudes and actions of other health care providers toward their clients, perhaps suggestive of a compensatory quality to increasing involvement. Another managing behavior, information-seeking, was specifically supported by theoretical and research literature on coping. Other managing behaviors, discussing and advocating/supporting, were found to be supported by research literature related to nurses' experiences caring for PWAs. The preceding discussion of findings has resulted in the explication of the findings of this study based on related literature and theory, and logical speculation by the researcher. Many of the findings and related discussion have specific implications for nursing practice, education, administration, and research. These implications will be presented in Chapter Six. CHAPTER SIX: SUMMARY, CONCLUSIONS, AND IMPLICATIONS FOR NURSING Summary As the AIDS epidemic exacts its physiologic and psychologic toll on the increasing number of PWAs, greater numbers of nurses and nursing students will be expected to deliver care to this client population. An increasing body of literature documents nurses1 negative attitudes toward PWAs, especially those PWAs affiliated with stigmatized transmission groups such as IV drug users and homosexuals. Further, the negative attitudes of nurses toward PWAs have been cited as factors affecting the quality of care received by this client population. A few studies exist which have addressed nursing students' attitudes toward PWAs in which attitudes similar to those of nurses have been reported. Rarely, however, have qualitative methods been employed to address nursing students' experiences caring for PWAs. Since nursing students, as students and as future nurses, will be expected to care for the increasing number of PWAs, the need exists for further research. In particular, in-depth explorations of the experiences of nursing students as they learn to care for PWAs is needed. Hence, the researcher employed qualitative methods to study nursing students' experiences caring for PWAs. Eight nursing students in a university undergraduate nursing program, who had cared for at least one PWA, volunteered as respondents for this study. Unstructured interviews were audiotaped and transcribed verbatim to facilitate data analysis. Direction for data analysis was taken from phenomenological methods of analysis, specifically Spiegelberg's (I960) steps of the phenomenological method. As the researcher reviewed the transcripts, general essences were identified. As essences were identified, the researcher re-interviewed selected respondents to clarify meanings and to facilitate the identification of themes. Once themes were identified, the researcher identified essential relationships among essences and integrated those relationships into a consistent description of the phenomenon of nursing students' experiences caring for PWAs. To ensure rigor, the researcher validated the description of the phenomenon with respondents and expert researchers. The findings of this study indicated that concern for personal safety was a predominant and enduring theme in nursing students' experiences caring for PWAs. 131 Concern for safety was time-limited, beginning when students first learned they were assigned to care for a PWA and concluding when their responsibilities for client care ended. Students endured varying levels of concern for personal safety from a heightened awareness of the contagious nature of their clients' body fluids, to worry and fear so intense that it affected the quality of care afforded these clients. As well, students' concern levels fluctuated with their involvement in those care activities that they perceived rendered them at risk for contracting HIV. Notably, students described their concern for personal safety as unique to caring for PWAs given the combined effect of the contagious, incurable, and fatal properties of AIDS. Processing was a collection of mental activities students employed to mentally dissect their experiences caring for PWAs and, subsequently, reorganize those experiences to create new personal meanings. Students' processing was triggered by their being assigned to care for PWAs and by their concern for their own safety. Students continued to process their experiences long after their client care responsibilities ended. Students' resultant thoughts and feelings from processing, in turn, affected their levels of concern for personal safety. Processing was comprised of two broad categories of mental activities, namely analyzing and mental restructuring. In analyzing their experiences, students compared their past personal and professional experiences with the experience of caring for a PWA. They also evaluated their own abilities to provide nursing care in relation to the knowledge and skills they anticipated would be required in the provision of AIDS care. Further, in analyzing, students wondered about how they would perform, what the experience of caring for a PWA would be like, and about their clients' AIDS experiences and personal stories. Finally, while analyzing, students judged their clients in relation to their affiliated transmission groups, risk behaviors, and degree of responsibility for contracting HIV. Students who did not render negative judgements characterized themselves as open-minded. The other broad category of processing was mental restructuring. This category of mental activities was characterized by students categorizing their clients as unlike themselves to promote their own 'psychic survival' as they provided care to their clients with 133 AIDS. Students also used rationalizing to mitigate the degree of perceived risk in providing AIDS care. Five deliberate and observable behaviors were conceptualized by the researcher as managing. Managing, which appears to be comparable to what other researchers have conceptualized as coping (Lazarus, 1966; Pickthall, 1990), was characterized by students physically and emotionally distancing themselves from their clients with AIDS. Typically, distancing behaviors were utilized only by those students with higher levels of concern for personal safety. Students also sought AIDS information from literature and other personnel providing care to PWAs. In addition, discussing their experiences with peers and significant others was employed by students to manage their experiences. Advocating/supporting and increasing involvement with their clients with AIDS were other managing behaviors used typically by those students with lower levels of concern for personal safety. Conclusions The findings of this study suggest several important conclusions about nursing students' experiences caring for PWAs. Most significantly 134 perhaps, this study suggests that nursing students1 experience great concern for their own safety when caring for PWAs. Notable is the fact that this concern appears to be unique to caring for PWAs due to the combined effect of the contagious, incurable, and fatal properties of AIDS. Further, the findings indicate that nursing students implement a number of mental and observable behaviors in order to cope with their concern for personal safety. Level of concern appears to influence the kinds of activities students implement in order to cope with their experiences caring for PWAs. More specific conclusions derived from this study are listed below: 1. Nursing students experience feelings of concern for personal safety which begin when they first learn they are assigned to care for a PWA and conclude when their responsibilities for client care end. 2. Nursing students experience varying levels of concern for personal safety from a heightened awareness of the contagious nature of their clients' body fluids, to students being very scared that caring for their clients with AIDS could cause their own deaths. Nursing students experiencing higher levels of concern for personal safety tend to describe themselves as providing suboptimal care to their clients with AIDS. Concern for personal safety is driven by the contagious, incurable, and fatal properties of AIDS. For nursing students, the combined effect of these properties renders caring for PWAs different than caring for any other client population. Nursing students employ a collection of mental activities, termed analyzing by the researcher and comparable to Lazarus' (1966) conceptualization of cognitive appraisal processes, in order to gauge the degree of threat or potential for gain or growth attached to their experience of caring for a PWA and to evaluate their own abilities to manage the event. Nursing students judge their clients with AIDS. Judging, a distinct mental activity within analyzing, involves students rendering value-laden opinions of their clients with AIDS' affiliations with certain transmission groups, of clients' risk behaviors, and their degree of responsibility for contracting HIV. 7. Nursing students who render negative judgements have higher levels of concern for personal safety and tend to describe themselves as providing suboptimal care to their clients with AIDS. Students who do not render negative judgements may possess the quality of open-mindedness. 8. Some nursing students categorize PWAs according to their affiliations with certain transmission groups as a way of differencing themselves from their clients with AIDS. Originally referred to by one student in this study as 'psychic survival' and comparable to 'intrapsychic coping' as conceptualized by Lazarus and Launier (1978), this strategy is utilized by students to reduce their concern for personal safety. 9. Nursing students implement a number of deliberate and observable behaviors to manage their experiences caring for PWAs. Level of concern for personal safety seems to be a predictor of the managing behaviors students choose to implement in their care of PWAs. Nursing students with higher levels of concern for personal safety tend to implement the strategy of distancing as a means of managing the experience of caring for a PWA. Distancing, the physical and emotional withdrawal from PWAs by nursing students, results in suboptimal care being provided to this client population. Nursing students with lower levels of concern for personal safety tend to implement the strategies of advocating/supporting and increasing involvement as means for managing the experience caring for PWAs. Nursing students discuss their experiences caring for PWAs with peers and significant others. Nursing students do not discuss their experiences with their nursing instructors due to concerns that divulging their thoughts and feelings may affect their clinical evaluations. Implications for Nursing Practice The findings of this study of nursing students' experiences caring for PWAs have important implications for nursing practice. Although this study's relatively small size limits the generalizability of its findings, this study does provide some evidence that concern for personal safety is a predominant and enduring theme for nursing students who provide care to PWAs. The findings suggest that nursing students or nurses having their first experiences caring for PWAs must be aware that their own safety may, to some degree, be a concern for them as they care for PWAs, and that this concern may be a phenomenon unlike any they have experienced in previous clinical situations. Experienced staff nurses also need to be aware of the intense emotional responses caring for a client with AIDS for the first time can produce so that they can be more sensitive to the needs of students and their neophyte colleagues on their units. Nurses need to recognize the value of collegial support in this situation and must strive to promote a cohesive and supportive work environment. Furthermore, the findings that nursing students with higher levels of concern for personal safety and negative attitudes toward PWA may provide suboptimal care to their clients with AIDS and that nursing students, themselves, were sometimes dissatisfied with the quality of their care, suggest that nursing students and beginning nurses need to explore their own feelings of concern for personal safety and their attitudes and values toward PWAs. For example, through exercises which address the valuing process, such as values clarification and values inquiry which include games, questionnaires, and role play (Brown et al., 1990; Reilly & Oermann, 1992), beginning practitioners could explore their attitudes and values toward stigmatized transmission groups in order to address those feelings which have the potential to negatively affect client care. Similarly, neophytes to the profession of nursing must be aware that, in caring for PWAs, their concern for personal safety may fluctuate given their involvement in those care activities in which the risk of disease transmission is greater and in which they lack confidence. It may be especially important for beginning practitioners to seek out both clinical situations to practice specific skills and in-services or other continuing education opportunities to gain further confidence with the knowledge and skills required to care for PWAs. Education The findings of this study have significant implications for nursing education. That some nursing students in this study had negative attitudes toward stigmatized transmission groups and that these attitudes may have negatively influenced their care directs nurse educators to design nursing curricula which reflect the importance of cultivating students' sensitivity to diversity among client populations. By providing learning experiences which foster students' valuing of and appreciation for differences among clients, nurse educators may increase the likelihood that PWAs receive quality nursing care (Kelly et al., 1988). That some nursing students in this study were hesitant to interact with PWAs and their families because of their uncertainty about the psychosocial aspects of the AIDS experience and because they lacked confidence in their communication skills suggests that nurse educators must provide opportunities for students to learn about the affective as well as the cognitive and behavioral components of AIDS care should be provided. Organizing learning activities where PWAs and their families, and nurses caring for PWAs talk to students about their experiences would foster student learning in the affective domain (Elaison, 1993), a necessary requirement for those providing care to client populations whose psychosocial needs are so marked. The absence of descriptions of direct involvement by faculty in the care of students' assigned clients with AIDS may be evidence that nurse educators are not utilizing role modelling as a strategy for teaching with this client population. Certainly role modelling has been described as an especially effective teaching strategy in the achievement of attitude objectives (Mager, 1968). Since attitudes of health care providers have been linked to the quality of care received by PWAs, it is imperative that nurse educators utilize this valuable strategy in their teaching. The finding that some nursing students had negative attitudes toward PWAs and the fact that nurse educators should role model professional nursing practice for their students suggests that nurse educators must also explore and address their own attitudes toward PWAs to ensure that they are role modelling quality nursing care of this client population. Similarly, that some nursing students had negative attitudes toward PWAs as well as powerful feelings of concern for their own safety renders it imperative that nurse educators assist students to address these emotions. As Klisch (1990) stated, "efforts should be made to assist students to deal with their often intense emotional reactions.... Students should also be alerted to the probability of experiencing strong fears and should be made aware of the emotional conflict that may result" (p. 19). Nurse educators should facilitate trusting relationships with their students in order that students feel comfortable sharing their experiences caring for PWAs with their instructors. Recognizing that, realistically, this may not be possible given the nature of the relationship between nursing student and clinical instructor, Klisch (1990) recommends that the confidante be someone other than the student's clinical instructor. The finding that nursing students evaluated their own abilities in relation to the skills they anticipated were necessary in caring for PWAs and that negative evaluations by students increased their levels of concern for safety suggests that nurse educators be sensitive to the time, within the clinical experience, at which they assign students to care for PWAs. That PWAs have multiple physical and psychosocial needs renders their care challenging for nursing students, especially those beginning students who are struggling to feel confident in their abilities to provide nursing care. A teaching strategy such as the clinical journal may assist students to explore their attitudes toward PWAs and to evaluate the care they provide. From students' entries in their journals, nursing instructors may gain valuable insights into students* thoughts and feelings and could, in turn, utilize these data to plan effective strategies to assist students in their care of PWAs. Moreover, to foster responsibility and accountability in students, nurse educators should also direct students to solicit feedback from their assigned clients with AIDS regarding the quality of care they provide. Feedback from their clients would assist students in their activities of self-reflection and self-evaluation. Administration As well as implications for nursing practice and education, the findings of this study have implications for nursing administration. The findings that nursing students in this study had concern for their own safety while caring for PWAs, that some students had negative attitudes toward PWAs, and that some students lacked confidence in the skills required to provide quality care to PWAs suggest that nurse administrators should provide appropriate in-services and other continuing education activities for their staff who are caring for PWAs for the first time or who have very little experience in providing nursing care to this this client population. Adequate support for these inexperienced staff members is important in the form of educational activities which address the cognitive, behavioral, and affective learning needs of nurses caring for PWAs. The development of a mentor program where practitioners seasoned in the care of PWAs guide less experienced nurses in their development of knowledge and skills in AIDS care might prove useful. Moreover, the finding that nursing students did not seek out nursing instructors—hence persons with influence on their evaluations—with whom to discuss their experiences caring for PWAs has implications for nursing administration. This finding suggest that it may be important for nurse administrators to provide further staff support in the form of counsellors, or other persons who do not have input into job appraisals, with whom nurses inexperienced in AIDS client care may share their feelings about caring for PWAs. That some nursing students in this study had negative attitudes toward PWAs which may have affected their nursing care has specific implications for the hiring practices of nurse administrators. In the process of selecting new staff, nurse administrators must ensure that they are candid with prospective staff about the client populations served by their units, especially if their client mix typically has a large compliment of PWAs or other stigmatized client populations. In their interviews with prospective staff, administrators need to ascertain candidates' attitudes and feelings about caring for PWAs and should exercise caution in the hiring of staff whose attitudes may not be conducive to providing unbiased, empathic care to these clients. Finally, to ensure that PWAs are receiving quality nursing care, nurse administrators should solicit feedback from those PWAs cared for by their staff. Whether feedback is in the form of a questionnaire or a personal dialogue with the client, this feedback would be invaluable in ensuring quality care is being provided to this client population. Research Finally, the findings of this study also have implications for nursing research. Though caution must be exercised in generalizing the findings from a study of this nature, description of nursing students' experiences caring for PWAs derived from this qualitative study demonstrates the necessity for further use of inductive methods in the study of the experiences of nursing students and nurses as they care for PWAs. Certainly replication of this study with other samples of nursing students is recommended to permit further understanding of the phenomenon. The findings that higher levels of concern for personal safety and the negative attitudes of nursing students toward stigmatized transmission groups affected the quality of care afforded PWAs indicates the necessity for further research. Accurate description of how fear of contagion and attitudes are manifested in care is warranted. The findings that nurses students employed various mental activities and deliberate, observable behaviors in their care of PWAs warrants further study. The efficacy of these strategies in enabling students to manage their experiences caring for PWAs is necessary knowledge for nurse educators in their quest for ways to assist students in their care of this client population. Another interesting area of research would be the efficacy of teaching strategies in assisting students to overcome the obstacles to giving quality care to PWAs. Valuable information would be gained by studying both instructors' and students' perceptions of the effectiveness of specific teaching strategies to facilitate the delivery of quality care to this client population. That nursing students did not discuss their experiences caring for PWAs with their nursing instructors has implications for further research. The findings from a comparison of the experiences of nursing students caring for PWAs and the perceptions of their experiences by their nursing instructors may have utility given that nurse educators must plan teaching strategies and techniques based on the accurate evaluation of student learning needs. That some nursing students held negative attitudes toward their clients with AIDS which, in turn, affected the care received by these people and the fact that nurse educators facilitate students' learning through their role modelling of professional nursing practice has implications for further research. Few studies have described the attitudes of nursing faculty toward PWAs (Mueller et al., 1992; Oermann & Gignac, 1990). Knowledge of nurse educators' attitudes toward PWAs has utility if educators are to affect positive attitude change in their students. From the finding that nursing students with higher levels of concern for personal safety distanced themselves, both physically and emotionally, from their clients with AIDS also warrants further investigation. Although other studies have examined the intent of health care providers to refuse provision of care to PWAs (Barrick, 1988; Jemmott et al., 1992; Kemppainen et al.; 1992), this present finding demonstrates the necessity for additional study of AIDS client care intentions among nursing students. A multitude of research studies have documented health care professionals' negative attitudes and their provision of suboptimal care to PWAs. Continued research efforts by nurses to understand the phenomenon of nursing students' experiences caring for PWAs demonstrates nursing's commitment to the preparation of future nurses who are competent to provide quality care to clients with AIDS. In this chapter, the researcher provided summary remarks regarding this qualitative study of nursing students' experiences caring for PWAs. As well, important conclusions from this research were presented. Finally, this study's implications for nursing practice, education, administration, and research were proposed. References Alexander, R., & Fitzatrick, J. (1991). Variables influencing nurses' attitudes toward AIDS and AIDS patients. AIDS Patient Care, 5(6), 315-20. All, A. (1989). Health care workers' anxieties and fears concerning AIDS: A literature review. The Journal of Continuing Education in Nursing, .20(4) , 162-5. Armstrong-Esther, C., & Hewitt, W. E. (1989). Knowledge and perceptions of AIDS among Canadian nurses. 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Field, P. A., & Morse, J. M. (1985). Nursing research: The application of qualitative approaches. Rockville, MD: Aspen. Flaskerud, J. H. (1991). A psychoeducational model for changing nurses' AIDS knowledge, attitudes, and practices. The Journal of Continuing Education in Nursing, 22.(6), 237-44. Flaskerud, J. H. (1992a). Overview: HIV Disease and Nursing. In J. H. Flaskerud & P. J. Ungvarski (Eds.), HIV/AIDS: A guide to nursing care (2nd ed.) (pp. 1-29). Toronto: W. B. Saunders. Flaskerud, J. H. (1992b). Cofactors of HIV and public health education. In J. H. Flaskerud & P. J. Ungvarski (Eds.), HIV/AIDS: A guide to nursing care (2nd ed.) (pp. 314-349). Toronto: W. B. Saunders. Flaskerud, J. H. (1992c). Psychosocial aspects. In J. H. Flaskerud & P. J. Ungvarski (Eds.), HIV/AIDS; A guide to nursing care (2nd ed.) (pp. 239-74). Toronto: W. B. Saunders. Forrester, D. A., & Murphy, P. A. (1992). Nurses' attitudes toward patients with AIDS and AIDS-related risk factors. Journal of Advanced Nursing, 17(10) . 1260-66. Gerberding, J. L. (1989). Risks to health care workers from occupational exposure to hepatitis B virus, human immunodeficiency virus, and cytomegalovirus. Infectious Disease Clinics of North America, 2, 735-45. Grady, C. (1989). Ethical issues in providing nursing care to human immunodeficiency virus-infected populations. Nursing Clinics of North America, 24(2), 523-34. Guba, E. G., & Lincoln, Y. S. (1981). Effective evaluation. San Franscisco, CA: Jossey-Bass. Jemmott, L. S., Jemmott III, J. B., & Cruz-Collins, M. (1992). Predicting AIDS patient care intentions among nursing students. Nursing Research, 41(3), 172-77. Jemmott III, J. B., Freleicher, J., & Jemmott, L. S. (1992). Perceived risk of infection and attitudes toward risk groups: Determinants of nurses' behavioral intentions regarding AIDS patients. Research in Nursing & Health, 15, 295-301. Katz, I., Hass, R. G., Parisi, N., Astone, J., & McEvaddy, D. (1987). Lay people's and health care personnel's perceptions of cancer, AIDS, cardiac, and diabetic patients. Psychological Reports. 60, 615-29. Kelly, J. A., St. Lawrence, J. S., Hood, G. V., Smith, S., Jr., & Cook, D. J. (1988). Nurses' attitudes toward AIDS. The Journal of Continuing Education in Nursing, 19(2), 78-83. Kemppainen, J., St. Lawrence, J. S., Irizarry, A., Weidema, D. R., Benne, C., Fredericks, C. D., & Wilson, M. (1992). Nurses' willingness to perform AIDS patient care. The Journal of Continuing Education in Nursing, 11(3), 110-17. Kerr, C. I., & Horrocks, M. J. (1990). Knowledge, values, attitudes and behavioral intent of Nova Scotia nurses toward AIDS and patients with AIDS. Canadian Journal of Public Health, 81, 125-128. Klisch, M. L. (1990). Caring for persons with AIDS: Student reactions. Nurse Educator. .15(4), 16-20. Lawrence, S. A., & Lawrence, R. M. (1989). Knowledge and attitudes about acquired immunodeficiency syndrome in nursing and nonnursing groups. 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Munhall, P. L. (1988). Ethical considerations in qualitative research. Western Journal of Nursing Research. 10, 150-162. Oermann, M. H., & Gignac, D. (1991). Knowledge and attitudes about AIDS among Canadian nursing students: Educational implications. Journal of Nursing Education. 30, 217-221. Pickthall, L. E. (1990). A phenomenological study of nurses' experiences caring for patients with acquired immunodeficiency syndrome (AIDS). Unpublished master's thesis, The University of British Columbia, Vancouver. Polit, D. F., & Hungler, B. P. (1991). Nursing research: Principles and methods (4th ed.). Philadelphia: Lippincott. Reed, P., Wise, T. N., & Mann, L. S. (1984). Nurses' attitudes regarding acquired immunodeficiency syndrome (AIDS). Nursing Forum, 21(4), 153-6. Reilly, D. E., & Oermann, M. H. (1992). Clinical teaching in nursing education (2nd ed.). New York: National League for Nursing. Reimen, D. J. (1986). The essential structure of a caring interaction: Doing phenomenology. In P. L. Munhall & C. J. Oiler (Eds.), Nursing research: A qualitative perspective (pp. 85-108). Norwalk, CT: Appleton-Century-Crofts. Reutter, L. I., & Northcott, H. C. (1993). Making risk meaningful: Developing caring relationships with AIDS patients. Journal of Advanced Nursing, 18. 1377-1385. Royse, D., & Birge, B. (1987). Homophobia and attitudes towards AIDS patients among medical, nursing, and paramedical students. Psychological Reports. 61, 867-70. Sandelowski, M. (1986). The problem of rigor in qualitative research. Advances in Nursing Science, 8(3), 27-37. Spiegelberg, H. (1960). The phenomenological movement: A historical introduction (Vol. 2). The Hague: Martinus Nijhoff. Strauss, A., & Corbin, J. (1990). Basics of qualitative research: Grounded theory procedures and techniques. Newbury Park, CA: Sage. Stricof, R. L., & Morse, D. L. (1986). HTLV-III/LAV seroconversion following a deep intramuscular needlestick injury. New England Journal of Medicine. 314, 1115. 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APPENDIX A RESPONDENT INFORMATION LETTER (UBC School of Nursing Letterhead) Dear Nursing Students: My name is Kelly Negrin. I am a Registered Nurse and a student in the Graduate Nursing Program at the University of British Columbia. For my Master's thesis, I am interested in studying nursing students' experiences caring for persons with AIDS (PWAs). I initially became interested in this topic when, as a staff nurse, I had to confront my own feelings about caring for PWAs. I became interested in the experiences of nursing students caring for PWAs when I discussed with several of my colleagues their assigning of the care of PWAs to their students. I was curious to know what the students' experiences were like. Nursing students who share their experiences caring for PWAs will assist those nurses and nursing students who have not yet cared for PWAs. I wish to interview nursing students, without Registered Nurse status, who have cared for at least one person with AIDS (regardless of the quality of the experience) within their course of study and who are interested in participating in this study by discussing their experiences. Your involvement in this study will include being interviewed in a private, quiet setting which is convenient for you. Interviews will be one hour in duration and there is a possibility that you may be asked to participate in one to three separate interviews. With your permission, interviews will be audiotaped and transcribed. Only myself and two UBC professors will have access to the information you provide in the interview(s). Your identity will be known only to me so as to maintain confidentiality. Audiotapes and transcipts will be destroyed upon completion of my study. You are not obligated to participate in this study and refusal to do so will not jeopardize your academic standing or future career as a nurse. You may withdraw from the study at any time. Similarly, you may refuse to answer any questions during the interview(s). There is no financial benefit from participating in this study. If you are interested in becoming involved in this study, or would like more information prior to making your decision, please feel free to contact me at XXX-XXXX or my faculty advisor, Clarissa Green, at XXX-XXXX Sincerely, Kelly Negrin 158 APPENDIX B SAMPLE INTERVIEW QUESTIONS AND PROBES Tell me about one of your experiences caring for a person with AIDS. What was it like to care for him/her? How did you feel about caring for him/her? So you're saying that... So it was a concern... You sound like you were worried that... It sounds like... So what happened next? Can you tell me a little bit more about that? APPENDIX C RESPONDENT CONSENT FORM (UBC School of Nursing Letterhead) The Experiences of Nursing Students Caring for Persons with AIDS: A Qualitative Study In signing this document, I am giving my consent to be interviewed by Kelly Negrin, a graduate nursing student at UBC. I understand that she is interested in studying my experiences caring for persons with AIDS. This study will provide guidance to nurses and nursing students who have not yet cared for persons with AIDS. The results of this study will also provide direction for designing appropriate AIDS-related content for inclusion in nursing programs. I understand that being a respondent in this study will involve being interviewed and audiotaped in a setting which is convenient for me and that my involvement may require one to three separate interviews of one hour in duration. Interviews will be transcribed into written form. I understand my name and any other identifying information will not be revealed when reporting the results of this study. My identity will be known only to Kelly Negrin because she will apply a special code to the information I provide when she transcribes the audiotapes. I have been informed that I am under no obligation to participate in this study and that I am free to terminate involvement in this study at any time. Similarly, I have been informed that I may refuse to answer any questions during the interview(s). I understand that refusal to participate in this study will not jeopardize my academic standing or my future career as a nurse. I have been informed that I will not receive any financial benefit from my involvement in this study. I understand that the results of this study will be made available to me if I request them and that Kelly Negrin is the person to contact if I have any questions or concerns regarding my involvement in th study. I can contact Kelly Negrin at XXX-XXXX. I can also contact her faculty advisor, Clarissa Green, at XXX-XXXX for further information. I, the undersigned, understand the purpose of Kelly Negrin's study and I give my consent to participate as a respondent in her study. I acknowledge receipt of a copy of this consent form. Date: Respondent's name: Respondent's phone number: Respondent's signature: 

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