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AIDS education for nurses in Poland
HIV/AIDS Education for Nurses in Poland
Jane Burgess, MS, RN; Irena Chalecka, RN; Jolanta Orlowska, RN; Emma Ortowska, RN; Wladyslawa Zielinska, MD, PhD; and Ann Williams, EdD, RN, FAAN
Funded by an agreement with the World AIDS Foundation, a team of American and Polish healthcare professionals was established to provide expert and timely training on HIV/AIDS in Poland. An experiential HIV/AIDS training
Jane Burgess, MS, RN, is AIDS consultant, Connecticut State Department of Education, Hartford, CT. Irena Chalecka, RN, is an AIDS home care nurse, New York City. Jolanta Orlowska, RN, is outpatient clinic nurse, Skorna- Wener Ologiczna, Gdansk, Poland. Emma Ortowska, RN, is head nurse, AIDS Ward, and Wladyslawa Zietinska, MD, PhD, is Director, Klinika Chorob Zakanych, Gdansk, Poland. Ann Williams, EdD, RN, FAAN, is Associate Professor, Yale University, New Haven, CT.
course for nurses was conducted in Gdansk, Poland. The course identified significant professional concerns of Polish nurses, including fear of infection, discomfort with male sexuality, and lack of information about drug users.
W o r l d w i d e , 19 million people are currently infected with the human immunodeficiency virus (HIV). Given current trends, by the end of 1995 the cumulative global total of HIV-infected individuals will exceed 28 million (Global AIDS Policy Coalition, 1993). As the epidemic continues to take its toll throughout the second decade of this tragedy, prevention efforts specific to different nations must be expanded.
Precourse and postcourse evaluations Background
demonstrated significant changes in level of comfort during discussions of sensitive topics and improvement in instructional self-confidence. K e y w o r d s : HIV/AIDS in Poland, international
cooperation, nursing educational needs
JANAC Vol.6, No. 4, July-August1995
In Eastern Europe and the former USSR, major social and political upheavals have set the stage for increased spread of HIV. In Poland, the first case of HIV was reported in 1988. By June 1993, 2,663 Poles who were HIV positive had been reported to the World Health Organization. Among these cases, 80% were known to have a history of injection drug use. With as many as 200,000-300,000 illegal drug injectors in Poland, the potential for epidemic growth is serious, and is heightened by shortages of both syringes and condoms. HIV tests have been available and performed in Poland since 1985. The test is mandatory for blood donors and prisoners. As in other countries, the AIDS epidemic in Poland should be viewed in the context of the society where it is occurring. The epidemic was identified in Poland at the end of the 1980s during a period of major political and social upheaval. [n June 1989, the Communist era ended. Along with joy and hope, feelings of apprehension and insecurity accompanied the transition from a repressive 37
HIV/AIDS
Education
for Nurses
in Poland
but predictable society to a less stable, rapidly changing social and political system (MONAR Youth Antidrug Movement, 1993). Significant social demands were met by a very weak welfare system with inadequate services, regulations, and funds. The primary route of HIV transmission in Poland is injection drug use, but the pattern of drug use differs from that of other countries. Since the 1970s, the injectable drug of choice has been a homemade opiate extract called compot. This drug is made from locally grown poppy straw. It can be made in the home by cooking the straw in a can on a household stove. Addicts then share the liquid, often drawing the liquid from a communal can into a needle, which is shared. Leftover compot is put back into the can. These practices facilitate the transmission of the virus among a social network of drug users. Homosexuals constitute another group of persons living with HIV infection and AIDS in Poland. However, only about 10% of men known to have HIV infection acknowledge sexual contact with other men. Many Polish men who have sex with other men are unwilling to be tested, reported as homosexuals, or registered as HIV infected. Acknowledging homosexuality is very difficult in Poland, where Catholic moral values are very strong. Additionally, it should be noted that homosexuality was illegal under the former Communist regime. Although a gay groups federation, "Lambda" was registered in January 1990, it operates only in big cities, and its social influence and l o b b y i n g p o w e r is w e a k (MONAR, 1993). Compared to other Eastern European countries, the profound influence of the Catholic Church is unique to Poland. Sexuality is rarely discussed, homosexuality almost never mentioned, and sex education is unknown. Estimates suggest that 75%-85% of Poles are Roman Catholic. The Church emerged under the new regime in an exceptionally strong position, which it would like to consolidate (Single, 1992). Initially, the Church obtained a decree that religious education must be incorporated into the school day. Next, the Church insisted religious education count as an 38
academic subject. Finally, it demanded that church participation be required of all school council members. As a result of this influence, sexuality and contraceptive education are limited. Vocabulary describing sexual activity is either medical or vulgar, and the sex education material recommended for adolescents clearly describes condoms as troublesome (Nagorski, 1993). On the other hand, the Polish Church has a strong tradition of cafiJngfor the sick, ardently values love of neighbor, and has taken important leadership positions. The Roman Catholic Church condemned prejudice against persons with H1V and AIDS, declaring at the 1990 plenary conference of bishops in Poland that such prejudice is "contrary to the basic principles of Christian ethics" (Rich, 1990, p. 18). As a matter of fact, the Church sponsors a home in Warsaw for adults with HIV infection. Nursing in Poland
Nursing in Poland is somewhat different from nursing in the United States. Most nurses receive their actual training during the time their American counterparts customarily attend high school. Nursing education focuses on the technical or mechanical aspects of nursing care, such as dispensing medications, performing treatments, following physician orders, and performing housekeeping tasks that, in the United States, are delegated to ancillary personnel. Polish nurses do not counsel patients routinely or provide very extensive health education for patients or their families. Although nurses spend more time on the wards than other healthcare providers, they are not involved in discussions or decisions about treatment planning for patients. In contrast, in the United States, many of the nurses who provide HIV care have a broad-based college education, including graduate-level preparation. Many are nurse practitioners or clinical spedalists in infectious disease, oncology, or psychiatry. They have extensive background and experience in performing physical and psychological assessments, making nursing and medical diagnoses, developing treatment plans, collaborating in JANAC Vol.6, No. 4, July-August 1995
the management of client care, and providing primary care and counseling. As the number of people living with HIV increases in Poland, so will the need for highly skilled nurses to provide sophisticated counseling, education, and care. In the United States, the first studies of nurses' knowledge about AIDS and attitudes toward people with AIDS revealed inadequate or inaccurate information and negative attitudes (Barrack, 1988; Breault & Polifroni, 1992; Campbell, Maki, Willenbring, & Henry, 1991; Flaskerud, 1992; Flaskerud, Lewis, & Shin, 1989; Pederson, 1993). Consequently, early nursing HIV-education programs were designed to provide information about routes of transmission and infection control procedures. Now, as a result of these efforts, the majority of nurses in the United States are well-informed about the basics of HIV transmission and disease. Concurrent116 institutional mandates to follow universal precautions have become widespread in clinical as well as community settings. Although factual information may dispel myths and increase knowledge, knowledge alone is not sufficient to change behavior. Because fears, values, and emotions surround people's attitudes toward sexuality, homosexuality, drug use, and death, attitudinal change is equally critical. AIDS education, framed by affective and cognitive learning, can address the personal values that nurses carry into their work, which dramatically influence the quality of care given to patients (Eliason, 1993). Polish nurses who will care for H1V-infected patients and educate other nurses must be both informed about HIV and comfortable discussing socially and personally sensitive topics. Comfort with these subjects is essential to meaningful direct service provision. Worldwide, few nursing preparatory programs provide clinical experience or teach specific techniques in the type of counseling and interventions required to provide comprehensive care to people with HIV and AIDS. It is not surprising then that Polish nurses have little experience counseling patients about H W risk reduction and no formal or informal training in human sexuality. In addition, as in the United States, nurses' attitudes toward drug users frequently are judgmental and negative. JANAC
Vol. 6, No. 4, July-August 1995
Educational strategies that successfully influence attitudes often include a strong affective component in which feelings are expressed openly in a nonthreatening atmosphere. The assumption underlying these programs is that an educational experience specifically designed to allow participants to identify, verbalize, and discuss their fears about HIV infection will help dismantle barriers to informed, compassionate nursing care. The experience allows participants to acknowledge and examine negative feelings and to identify factors that anger or frighten them about homosexuality, drug use, and caring for people with AIDS (Flaskerud, 1992). Program Description
Although the new openness between East and West has increased the potential for widespread HIV transmission, it also has created the possibility of international collaboration. In that spirit, a team of healthcare professionals from the United States met with members of the Gdansk Medical Academy AIDS Clinic in March 1993, to begin planning a continuing educational exchange. The purpose of the program was to introduce Polish healthcare professionals to experiential teaching strategies used successfully by American AIDS educators. The objectives of the resulting three-day course f o c u s e d on p r e p a r i n g n u r s e s w h o w o u l d offer HIV/AIDS e d u c a t i o n to three target p o p u l a t i o n s : patients, patients' families, and other healthcare workers. The curriculum allowed ample time for discussion, demonstration, and practice--increasing the participants' comfort in such topics as injection drug abuse, sexuality, homosexuality, and death. This approach also was geared toward raising the nurses' confidence in their ability to educate others. The participants were hospital nurses, midwives, outpatient clinic nurses, and prison nurses who were in a position to extend their training to others. The majority had not had substantial contact with persons living with HIV/AIDS, but about one half of the group occasionally had worked with an HIV-infected individual. All participants were women. 39
HIV/AIDS
Education
for Nurses
in Poland
Course activities included the following: 1. Didactic lectures and material, including condom demonstrations 2. Identification of major concerns a n d / o r fears related to H1V/AIDS 3. Examination of personal values and behaviors 4. Opportunity to interact with a gay man and identify community resources 5. Development of case studies to be used in future educational activities and based upon issues and concerns raised during the three days At the beginning of the course, participants were asked to identify the single HIV-related issue that most worried them. Those issues were incorporated into case studies for use during the course. The class was divided into four groups. Each group was assigned a case study and asked to develop an approach to that case, including identification of short-term and long-term goals, barriers, and strategies for overcoming barriers. Another strategy used during the course was role playing, with participant's behaving as patient and provider. Time was spent processing the successful c o m p o n e n t s of a patienthealthcare worker interaction. Evaluation
Two methods of evaluation were used. The first was a qualitative needs assessment and continuing evaluation based on identification of the major issues and concerns that emerged from the role playing, group activities, and discussions. The major professional issues that emerged from individual and group activities included fear of deliberate exposure to HIV from an aggressive patient, discomfort with discussion of sexual matters,,lack of understanding of injection drug users, and limited information about homosexuality. The o p e n d i s c u s s i o n of s e x u a l i t y a n d a c o n d o m demonstration provoked giggling and whispering; many participants had never touched a condom. Similarly, the opportunity to meet and speak with the representative 40
f r o m the gay c o m m u n i t y w a s a n e w e x p e r i e n c e . Participants responded well to the speaker, were very a t t e n t i v e , a n d r e p o r t e d t h e y f o u n d the e x p e r i e n c e extremely helpful. The second evaluation method used precourse and postcourse a n o n y m o u s u n m a t c h e d questionnaires to assess participants' knowledge, comfort with sensitive topics, a n d instructional confidence at baseline and course conclusion. The evaluation instruments were questionnaires a d a p t e d from the Centers for Disease Control and Prevention (CDC) Handbook for Evaluating HIV Education, (1992). The questionnaires first measure basic HIV/AIDS knowledge and then ask participants to report how comfortable they felt discussing topics associated with sexual and drug-using behaviors, and how confident they are about their ability to provide patients and others with appropriate instructional materials and learning experiences. Results K n o w l e d g e . Little change was noted between precourse and postcourse scores on factual items because the precourse scores were high. Participants had an adequate initial HIV/AIDS knowledge base, although some confusion about infectivity throughout the course of the disease existed. Before the course 53% (9 of 17) of the class were sure that a person has to be sick with AIDS to transmit HIV. This proportion decreased to 40% (9 of 22) after course participation. None of the changes in knowledge were statistically significant (data not shown). Comfort with sensitive topics. Table 1 summarizes changes in the participants' self-reported level of comfort discussing sensitive topics before and after participation in the course. Overall, participants reported significant changes in a number of areas, including discussions about AIDS, HIV transmission, sexual intercourse, and abstinence. However, the areas that showed the most dramatic changes after the course were related to male sexuality, including condom use, male genitalia, and homosexuality. Instructional confidence. A major w o r k s h o p goal was the preparation of the nurses to assume roles as JANAC Vol.6, No. 4, July-August 1995
Table 1. Self-Reported Comfort With S e n s i t i v e Topics
How comfortable are you discussing the following topics with students?
Before course After course # responding # responding positively/# positively/# total total
9 AIDS Completely comfortable
2/15 (13%)
11/22 (50%)
Table 2. Self-Reported Instructional C o n f i d e n c e
p value
4/15 (26%)
14/22 (63%)
.02
3/15 (20%)
13/22 (59%)
.04
9 Sexual a b s t i n e n c e
Completely comfortable Very comfortable
0
9/22 (41%)
5/15 (33%)
5/22 (22%)
.07
0
8/22 (36%)
.01
2/15 (13%)
12/21 (57%)
4/15 (27%)
7/21 (33%) NR -- 1
0
6/22 (27%)
4/14 (28%) NR= 1
11/22 (50%)
0
7/22 (32%)
4/15 (26%)
9/22 (41%)
.002
10/22 (45%) 9/22 (41%)
.05
9 O b t a i n i n g up-to-date information about HIV?
Completely confident 2/17 (12%) Very confident 8/17 (47%)
15/22 (68%) 6/22 (27%)
.03
9/22 (41%) 11/22 (50%)
02
16/22 (73%) 5/22 (23%)
.007
.007 9 Explaining how a c o n d o m s h o u l d b e used?
Completely confident 5/17 (29%) Very confident 5/17 (29%) HIV/AIDS educators in the workplace and community. C o n f i d e n c e in instructional ability is crucial to assist clients with H1V risk reduction or to counsel and care for i n d i v i d u a l s w i t h H I V infection. Table 2 s u m m a r i z e s changes in participants' reported self-confidence in their role as AIDS educators. They reported i m p r o v e m e n t in their ability to o b t a i n u p - t o - d a t e i n f o r m a t i o n a b o u t
Vol. 6, No. 4, July-August 1995
.07
9 D i s c u s s i n g h i g h risk sexual behaviors w i t h patients?
NR = no response
JANAC
14/22 (63%)
.005
9 Homosexuality
Completely comfortable Very comfortable
.08
9 Increasing patients and families tolerance towards people with
Completely confident 7/16 (44%) Very confident 4/16 (25%) NR= 1
9 M a l e genitalia
Completely comfortable Very comfortable
10/22 (45%) 8/22 (36%)
9 H e l p i n g patients a n d families reach more accurate perceptions of their vulnerability to H I V ?
AIDS? Completely confident 2/17 (12%) Very confident 8/17 (47%)
9 C o n d o m use
Completely comfortable Very comfortable
Completely confident 2/16 (12%) Very confident 6/16 (37%) NR= 1
Completely confident 5/17 (29%)
9 Female genitalia
Completely comfortable
p value
.03
9 Sexual intercourse
Completely comfortable
After course N = 22(%)
9 Presenting accurate information about H I V to patients?
9 HIV transmission
Completely comfortable
How confident are you doing the following: Before course N = 17(%)
NR = no response
AIDS, present accurate information, increase patients' and families' tolerance toward people with AIDS, and help patients and families reach an accurate perception of their vulnerability to HIV infection. The most significant gains
41
H I V / A I D S Education for N u r s e s in Poland
in instructional confidence, however, were assodated with discussion of high-risk sexual behaviors and condom use.
Campbell, S., Maki, M., Willenbring, K., & Henry K. (1991). AIDS- related knowledge, attitudes, and behaviors among 629 registered nurses at a Minnesota hospital: A descriptive study. JANAC, 2(1), 15 - 23.
Conclusion
C e n t e r s For Disease Control & P r e v e n t i o n . (1992). Handbook for Evaluating HIV Education. Atlanta, GA: National Center for Chronic Disease Prevention & Health Promotion.
The lack of skill, experience, and comfort in discussions of sexually sensitive topics demonstrated by nurses early in the HIV epidemic in the United States also was evident among nurses from this Eastern European country. Polish nurses have relatively high levels of knowledge about HIV/AIDS, and thus the major impact of HIV/AIDS training is in the area of affective educational skills. The strategies employed in this train-the-trainer session in Poland emphasized experiential learning, small group learning activities, ample time for ventilating concerns and fears, and values clarification. The program successfully increased the participants' level of comfort in addressing sensitive topics and confidence in teaching ability. Interactive educational techniques are not commonly employed outside of the United States. However, this project demonstrates that the approach can be effective in a different cultural context. An important follow-up question is whether this type of training might be indicated in other Eastern European countries grappling with some of the same issues. At this time, the most alarming trends in the spread of H1V infection are in South and Southeast Asia, where the epidemic has been growing at a rate similar to that found in sub-Saharan Africa. A greater potential for the spread of HIV exists in Asia because it is a region with more than twice the adult population of Africa. The authors' experience may help others designing programs for healthcare professionals in at-risk geographic regions.
Eliason, M. (1993). AIDS related stigma and homophobia and implications for nursing education. Nurse Educator, 18(6), 2 7 - 30. Flaskerud J. (1992). Overview: H W disease and nursing. In J. Flaskerud & P. Ungvarski (Eds.), HIV/AIDS, A guide to nursing care (2d ed., pp. 1 - 29). Philadelphia: Saunders. Flaskerud J., Lewis, M., & Shin, D. (1989). Changing nurses' attitudes through continuing education. Journal of Continuing Education in Nursing, 20,148 - 154. Global AIDS Policy Coalition. (1993). The HIV/AIDS pandemic: Status report. Cambridge, MA: Author. MONAR Youth Antidrug Movement. (1993, January). HIV/AIDS activities in relation to current situation in Poland. Warsaw, Poland: Author. Nagorski, A. (1993, June, 21). Trying to say "sex" in Polish. Newszoeek,
121(25), 44. Pederson, C. (1993). Structured controversy versus lecture on nursing students' beliefs about and attitude toward providing care for persons with AIDS. Journalof Continuing Education in Nursing, 24(2), 74 - 81. Rich, V. (1990, April 14). Polish bishops denounce anti-AIDS protests. Nezo Scientist, 126, 18. Single, D. (1992, Dec. 7). Poland--the taste of ashes. The Nation, 225(19),696.
References Barrack, B. (1988). The willingness of nursing personnel to care for patients with acquired immunodeficiency syndrome: A survey and recommendations. Journal of ProfessionalNursing, 45, 366 - 372. Breault, A., & Polifroni, E. (1992). Caring for people with AIDS: Nurses' attitudes and feelings. Journal of Advanced Nursing, 17, 21 27.
42
JANAC
Vol. 6, No. 4, July-August 1995
Jane Burgess, MS, RN; Irena Chalecka, RN; Jolanta Orlowska, RN; Emma Ortowska, RN; Wladyslawa Zielinska, MD, PhD; and Ann Williams, EdD, RN, FAAN
Funded by an agreement with the World AIDS Foundation, a team of American and Polish healthcare professionals was established to provide expert and timely training on HIV/AIDS in Poland. An experiential HIV/AIDS training
Jane Burgess, MS, RN, is AIDS consultant, Connecticut State Department of Education, Hartford, CT. Irena Chalecka, RN, is an AIDS home care nurse, New York City. Jolanta Orlowska, RN, is outpatient clinic nurse, Skorna- Wener Ologiczna, Gdansk, Poland. Emma Ortowska, RN, is head nurse, AIDS Ward, and Wladyslawa Zietinska, MD, PhD, is Director, Klinika Chorob Zakanych, Gdansk, Poland. Ann Williams, EdD, RN, FAAN, is Associate Professor, Yale University, New Haven, CT.
course for nurses was conducted in Gdansk, Poland. The course identified significant professional concerns of Polish nurses, including fear of infection, discomfort with male sexuality, and lack of information about drug users.
W o r l d w i d e , 19 million people are currently infected with the human immunodeficiency virus (HIV). Given current trends, by the end of 1995 the cumulative global total of HIV-infected individuals will exceed 28 million (Global AIDS Policy Coalition, 1993). As the epidemic continues to take its toll throughout the second decade of this tragedy, prevention efforts specific to different nations must be expanded.
Precourse and postcourse evaluations Background
demonstrated significant changes in level of comfort during discussions of sensitive topics and improvement in instructional self-confidence. K e y w o r d s : HIV/AIDS in Poland, international
cooperation, nursing educational needs
JANAC Vol.6, No. 4, July-August1995
In Eastern Europe and the former USSR, major social and political upheavals have set the stage for increased spread of HIV. In Poland, the first case of HIV was reported in 1988. By June 1993, 2,663 Poles who were HIV positive had been reported to the World Health Organization. Among these cases, 80% were known to have a history of injection drug use. With as many as 200,000-300,000 illegal drug injectors in Poland, the potential for epidemic growth is serious, and is heightened by shortages of both syringes and condoms. HIV tests have been available and performed in Poland since 1985. The test is mandatory for blood donors and prisoners. As in other countries, the AIDS epidemic in Poland should be viewed in the context of the society where it is occurring. The epidemic was identified in Poland at the end of the 1980s during a period of major political and social upheaval. [n June 1989, the Communist era ended. Along with joy and hope, feelings of apprehension and insecurity accompanied the transition from a repressive 37
HIV/AIDS
Education
for Nurses
in Poland
but predictable society to a less stable, rapidly changing social and political system (MONAR Youth Antidrug Movement, 1993). Significant social demands were met by a very weak welfare system with inadequate services, regulations, and funds. The primary route of HIV transmission in Poland is injection drug use, but the pattern of drug use differs from that of other countries. Since the 1970s, the injectable drug of choice has been a homemade opiate extract called compot. This drug is made from locally grown poppy straw. It can be made in the home by cooking the straw in a can on a household stove. Addicts then share the liquid, often drawing the liquid from a communal can into a needle, which is shared. Leftover compot is put back into the can. These practices facilitate the transmission of the virus among a social network of drug users. Homosexuals constitute another group of persons living with HIV infection and AIDS in Poland. However, only about 10% of men known to have HIV infection acknowledge sexual contact with other men. Many Polish men who have sex with other men are unwilling to be tested, reported as homosexuals, or registered as HIV infected. Acknowledging homosexuality is very difficult in Poland, where Catholic moral values are very strong. Additionally, it should be noted that homosexuality was illegal under the former Communist regime. Although a gay groups federation, "Lambda" was registered in January 1990, it operates only in big cities, and its social influence and l o b b y i n g p o w e r is w e a k (MONAR, 1993). Compared to other Eastern European countries, the profound influence of the Catholic Church is unique to Poland. Sexuality is rarely discussed, homosexuality almost never mentioned, and sex education is unknown. Estimates suggest that 75%-85% of Poles are Roman Catholic. The Church emerged under the new regime in an exceptionally strong position, which it would like to consolidate (Single, 1992). Initially, the Church obtained a decree that religious education must be incorporated into the school day. Next, the Church insisted religious education count as an 38
academic subject. Finally, it demanded that church participation be required of all school council members. As a result of this influence, sexuality and contraceptive education are limited. Vocabulary describing sexual activity is either medical or vulgar, and the sex education material recommended for adolescents clearly describes condoms as troublesome (Nagorski, 1993). On the other hand, the Polish Church has a strong tradition of cafiJngfor the sick, ardently values love of neighbor, and has taken important leadership positions. The Roman Catholic Church condemned prejudice against persons with H1V and AIDS, declaring at the 1990 plenary conference of bishops in Poland that such prejudice is "contrary to the basic principles of Christian ethics" (Rich, 1990, p. 18). As a matter of fact, the Church sponsors a home in Warsaw for adults with HIV infection. Nursing in Poland
Nursing in Poland is somewhat different from nursing in the United States. Most nurses receive their actual training during the time their American counterparts customarily attend high school. Nursing education focuses on the technical or mechanical aspects of nursing care, such as dispensing medications, performing treatments, following physician orders, and performing housekeeping tasks that, in the United States, are delegated to ancillary personnel. Polish nurses do not counsel patients routinely or provide very extensive health education for patients or their families. Although nurses spend more time on the wards than other healthcare providers, they are not involved in discussions or decisions about treatment planning for patients. In contrast, in the United States, many of the nurses who provide HIV care have a broad-based college education, including graduate-level preparation. Many are nurse practitioners or clinical spedalists in infectious disease, oncology, or psychiatry. They have extensive background and experience in performing physical and psychological assessments, making nursing and medical diagnoses, developing treatment plans, collaborating in JANAC Vol.6, No. 4, July-August 1995
the management of client care, and providing primary care and counseling. As the number of people living with HIV increases in Poland, so will the need for highly skilled nurses to provide sophisticated counseling, education, and care. In the United States, the first studies of nurses' knowledge about AIDS and attitudes toward people with AIDS revealed inadequate or inaccurate information and negative attitudes (Barrack, 1988; Breault & Polifroni, 1992; Campbell, Maki, Willenbring, & Henry, 1991; Flaskerud, 1992; Flaskerud, Lewis, & Shin, 1989; Pederson, 1993). Consequently, early nursing HIV-education programs were designed to provide information about routes of transmission and infection control procedures. Now, as a result of these efforts, the majority of nurses in the United States are well-informed about the basics of HIV transmission and disease. Concurrent116 institutional mandates to follow universal precautions have become widespread in clinical as well as community settings. Although factual information may dispel myths and increase knowledge, knowledge alone is not sufficient to change behavior. Because fears, values, and emotions surround people's attitudes toward sexuality, homosexuality, drug use, and death, attitudinal change is equally critical. AIDS education, framed by affective and cognitive learning, can address the personal values that nurses carry into their work, which dramatically influence the quality of care given to patients (Eliason, 1993). Polish nurses who will care for H1V-infected patients and educate other nurses must be both informed about HIV and comfortable discussing socially and personally sensitive topics. Comfort with these subjects is essential to meaningful direct service provision. Worldwide, few nursing preparatory programs provide clinical experience or teach specific techniques in the type of counseling and interventions required to provide comprehensive care to people with HIV and AIDS. It is not surprising then that Polish nurses have little experience counseling patients about H W risk reduction and no formal or informal training in human sexuality. In addition, as in the United States, nurses' attitudes toward drug users frequently are judgmental and negative. JANAC
Vol. 6, No. 4, July-August 1995
Educational strategies that successfully influence attitudes often include a strong affective component in which feelings are expressed openly in a nonthreatening atmosphere. The assumption underlying these programs is that an educational experience specifically designed to allow participants to identify, verbalize, and discuss their fears about HIV infection will help dismantle barriers to informed, compassionate nursing care. The experience allows participants to acknowledge and examine negative feelings and to identify factors that anger or frighten them about homosexuality, drug use, and caring for people with AIDS (Flaskerud, 1992). Program Description
Although the new openness between East and West has increased the potential for widespread HIV transmission, it also has created the possibility of international collaboration. In that spirit, a team of healthcare professionals from the United States met with members of the Gdansk Medical Academy AIDS Clinic in March 1993, to begin planning a continuing educational exchange. The purpose of the program was to introduce Polish healthcare professionals to experiential teaching strategies used successfully by American AIDS educators. The objectives of the resulting three-day course f o c u s e d on p r e p a r i n g n u r s e s w h o w o u l d offer HIV/AIDS e d u c a t i o n to three target p o p u l a t i o n s : patients, patients' families, and other healthcare workers. The curriculum allowed ample time for discussion, demonstration, and practice--increasing the participants' comfort in such topics as injection drug abuse, sexuality, homosexuality, and death. This approach also was geared toward raising the nurses' confidence in their ability to educate others. The participants were hospital nurses, midwives, outpatient clinic nurses, and prison nurses who were in a position to extend their training to others. The majority had not had substantial contact with persons living with HIV/AIDS, but about one half of the group occasionally had worked with an HIV-infected individual. All participants were women. 39
HIV/AIDS
Education
for Nurses
in Poland
Course activities included the following: 1. Didactic lectures and material, including condom demonstrations 2. Identification of major concerns a n d / o r fears related to H1V/AIDS 3. Examination of personal values and behaviors 4. Opportunity to interact with a gay man and identify community resources 5. Development of case studies to be used in future educational activities and based upon issues and concerns raised during the three days At the beginning of the course, participants were asked to identify the single HIV-related issue that most worried them. Those issues were incorporated into case studies for use during the course. The class was divided into four groups. Each group was assigned a case study and asked to develop an approach to that case, including identification of short-term and long-term goals, barriers, and strategies for overcoming barriers. Another strategy used during the course was role playing, with participant's behaving as patient and provider. Time was spent processing the successful c o m p o n e n t s of a patienthealthcare worker interaction. Evaluation
Two methods of evaluation were used. The first was a qualitative needs assessment and continuing evaluation based on identification of the major issues and concerns that emerged from the role playing, group activities, and discussions. The major professional issues that emerged from individual and group activities included fear of deliberate exposure to HIV from an aggressive patient, discomfort with discussion of sexual matters,,lack of understanding of injection drug users, and limited information about homosexuality. The o p e n d i s c u s s i o n of s e x u a l i t y a n d a c o n d o m demonstration provoked giggling and whispering; many participants had never touched a condom. Similarly, the opportunity to meet and speak with the representative 40
f r o m the gay c o m m u n i t y w a s a n e w e x p e r i e n c e . Participants responded well to the speaker, were very a t t e n t i v e , a n d r e p o r t e d t h e y f o u n d the e x p e r i e n c e extremely helpful. The second evaluation method used precourse and postcourse a n o n y m o u s u n m a t c h e d questionnaires to assess participants' knowledge, comfort with sensitive topics, a n d instructional confidence at baseline and course conclusion. The evaluation instruments were questionnaires a d a p t e d from the Centers for Disease Control and Prevention (CDC) Handbook for Evaluating HIV Education, (1992). The questionnaires first measure basic HIV/AIDS knowledge and then ask participants to report how comfortable they felt discussing topics associated with sexual and drug-using behaviors, and how confident they are about their ability to provide patients and others with appropriate instructional materials and learning experiences. Results K n o w l e d g e . Little change was noted between precourse and postcourse scores on factual items because the precourse scores were high. Participants had an adequate initial HIV/AIDS knowledge base, although some confusion about infectivity throughout the course of the disease existed. Before the course 53% (9 of 17) of the class were sure that a person has to be sick with AIDS to transmit HIV. This proportion decreased to 40% (9 of 22) after course participation. None of the changes in knowledge were statistically significant (data not shown). Comfort with sensitive topics. Table 1 summarizes changes in the participants' self-reported level of comfort discussing sensitive topics before and after participation in the course. Overall, participants reported significant changes in a number of areas, including discussions about AIDS, HIV transmission, sexual intercourse, and abstinence. However, the areas that showed the most dramatic changes after the course were related to male sexuality, including condom use, male genitalia, and homosexuality. Instructional confidence. A major w o r k s h o p goal was the preparation of the nurses to assume roles as JANAC Vol.6, No. 4, July-August 1995
Table 1. Self-Reported Comfort With S e n s i t i v e Topics
How comfortable are you discussing the following topics with students?
Before course After course # responding # responding positively/# positively/# total total
9 AIDS Completely comfortable
2/15 (13%)
11/22 (50%)
Table 2. Self-Reported Instructional C o n f i d e n c e
p value
4/15 (26%)
14/22 (63%)
.02
3/15 (20%)
13/22 (59%)
.04
9 Sexual a b s t i n e n c e
Completely comfortable Very comfortable
0
9/22 (41%)
5/15 (33%)
5/22 (22%)
.07
0
8/22 (36%)
.01
2/15 (13%)
12/21 (57%)
4/15 (27%)
7/21 (33%) NR -- 1
0
6/22 (27%)
4/14 (28%) NR= 1
11/22 (50%)
0
7/22 (32%)
4/15 (26%)
9/22 (41%)
.002
10/22 (45%) 9/22 (41%)
.05
9 O b t a i n i n g up-to-date information about HIV?
Completely confident 2/17 (12%) Very confident 8/17 (47%)
15/22 (68%) 6/22 (27%)
.03
9/22 (41%) 11/22 (50%)
02
16/22 (73%) 5/22 (23%)
.007
.007 9 Explaining how a c o n d o m s h o u l d b e used?
Completely confident 5/17 (29%) Very confident 5/17 (29%) HIV/AIDS educators in the workplace and community. C o n f i d e n c e in instructional ability is crucial to assist clients with H1V risk reduction or to counsel and care for i n d i v i d u a l s w i t h H I V infection. Table 2 s u m m a r i z e s changes in participants' reported self-confidence in their role as AIDS educators. They reported i m p r o v e m e n t in their ability to o b t a i n u p - t o - d a t e i n f o r m a t i o n a b o u t
Vol. 6, No. 4, July-August 1995
.07
9 D i s c u s s i n g h i g h risk sexual behaviors w i t h patients?
NR = no response
JANAC
14/22 (63%)
.005
9 Homosexuality
Completely comfortable Very comfortable
.08
9 Increasing patients and families tolerance towards people with
Completely confident 7/16 (44%) Very confident 4/16 (25%) NR= 1
9 M a l e genitalia
Completely comfortable Very comfortable
10/22 (45%) 8/22 (36%)
9 H e l p i n g patients a n d families reach more accurate perceptions of their vulnerability to H I V ?
AIDS? Completely confident 2/17 (12%) Very confident 8/17 (47%)
9 C o n d o m use
Completely comfortable Very comfortable
Completely confident 2/16 (12%) Very confident 6/16 (37%) NR= 1
Completely confident 5/17 (29%)
9 Female genitalia
Completely comfortable
p value
.03
9 Sexual intercourse
Completely comfortable
After course N = 22(%)
9 Presenting accurate information about H I V to patients?
9 HIV transmission
Completely comfortable
How confident are you doing the following: Before course N = 17(%)
NR = no response
AIDS, present accurate information, increase patients' and families' tolerance toward people with AIDS, and help patients and families reach an accurate perception of their vulnerability to HIV infection. The most significant gains
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H I V / A I D S Education for N u r s e s in Poland
in instructional confidence, however, were assodated with discussion of high-risk sexual behaviors and condom use.
Campbell, S., Maki, M., Willenbring, K., & Henry K. (1991). AIDS- related knowledge, attitudes, and behaviors among 629 registered nurses at a Minnesota hospital: A descriptive study. JANAC, 2(1), 15 - 23.
Conclusion
C e n t e r s For Disease Control & P r e v e n t i o n . (1992). Handbook for Evaluating HIV Education. Atlanta, GA: National Center for Chronic Disease Prevention & Health Promotion.
The lack of skill, experience, and comfort in discussions of sexually sensitive topics demonstrated by nurses early in the HIV epidemic in the United States also was evident among nurses from this Eastern European country. Polish nurses have relatively high levels of knowledge about HIV/AIDS, and thus the major impact of HIV/AIDS training is in the area of affective educational skills. The strategies employed in this train-the-trainer session in Poland emphasized experiential learning, small group learning activities, ample time for ventilating concerns and fears, and values clarification. The program successfully increased the participants' level of comfort in addressing sensitive topics and confidence in teaching ability. Interactive educational techniques are not commonly employed outside of the United States. However, this project demonstrates that the approach can be effective in a different cultural context. An important follow-up question is whether this type of training might be indicated in other Eastern European countries grappling with some of the same issues. At this time, the most alarming trends in the spread of H1V infection are in South and Southeast Asia, where the epidemic has been growing at a rate similar to that found in sub-Saharan Africa. A greater potential for the spread of HIV exists in Asia because it is a region with more than twice the adult population of Africa. The authors' experience may help others designing programs for healthcare professionals in at-risk geographic regions.
Eliason, M. (1993). AIDS related stigma and homophobia and implications for nursing education. Nurse Educator, 18(6), 2 7 - 30. Flaskerud J. (1992). Overview: H W disease and nursing. In J. Flaskerud & P. Ungvarski (Eds.), HIV/AIDS, A guide to nursing care (2d ed., pp. 1 - 29). Philadelphia: Saunders. Flaskerud J., Lewis, M., & Shin, D. (1989). Changing nurses' attitudes through continuing education. Journal of Continuing Education in Nursing, 20,148 - 154. Global AIDS Policy Coalition. (1993). The HIV/AIDS pandemic: Status report. Cambridge, MA: Author. MONAR Youth Antidrug Movement. (1993, January). HIV/AIDS activities in relation to current situation in Poland. Warsaw, Poland: Author. Nagorski, A. (1993, June, 21). Trying to say "sex" in Polish. Newszoeek,
121(25), 44. Pederson, C. (1993). Structured controversy versus lecture on nursing students' beliefs about and attitude toward providing care for persons with AIDS. Journalof Continuing Education in Nursing, 24(2), 74 - 81. Rich, V. (1990, April 14). Polish bishops denounce anti-AIDS protests. Nezo Scientist, 126, 18. Single, D. (1992, Dec. 7). Poland--the taste of ashes. The Nation, 225(19),696.
References Barrack, B. (1988). The willingness of nursing personnel to care for patients with acquired immunodeficiency syndrome: A survey and recommendations. Journal of ProfessionalNursing, 45, 366 - 372. Breault, A., & Polifroni, E. (1992). Caring for people with AIDS: Nurses' attitudes and feelings. Journal of Advanced Nursing, 17, 21 27.
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JANAC
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