Running Head: THE RELATIONSHIP BETWEEN NURSES PERCEPTIONS 1

The Relationship Between Nurses Perceptions and

Healthcare Outcomes for Patients with HIV and AIDS

Toni Francis, Morgan Palange, Kimberly Reinhart, Madison Scrocco, Brock Wooten

Youngstown State University

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Abstract

In a healthcare setting, a diagnosis of HIV and AIDS often affects the quality of nursing care that

patients receive. This paper will explore whether the hesitation of nurses to perform competent

care is associated with a lack of knowledge about the disease processes, a desire to protect

themselves and other patients against infection, or if it lies solely in a preconceived idea about

the patient themselves. The effects of anticipated and experienced perceptions on the

competency of nursing care is relatively unknown; however, this can affect both the delivery of

care and the patient outcomes in a healthcare setting. This reluctance to perform adequate care

can affect the patient outcomes in a plethora of ways, including hospital acquired infections,

pneumonia, and increased patient anxiety or depression. In an attempt to eliminate these

inadequacies, this paper will delve into existing interventions and their effectiveness on

improving patient outcomes.

Keywords: c​ ompetent care, hospital acquired infections, healthcare outcomes

Competent care: the ability of nurses to properly assess patients, perform skills, and provide

holistic care.

Hospital acquired infections: infections that patients contract while receiving treatment or care

for medical conditions in a hospital setting.

Healthcare outcomes: changes in health that result from specific health care interventions or

treatments.
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The Relationship Between Nurses Perceptions and

Healthcare Outcomes for Patients with HIV and AIDS

Visualize the moments when a nurse opens up the Electronic Health Record (EHR) of a

patient, only to scroll through the chart and find a diagnosis of HIV or AIDS. A confident,

well-rounded nurse may think nothing of it; however, a nurse who does not frequently care for

patients with such diagnoses might feel unprepared or inept. These uneasy reactions can stem

from a multitude of sources, including but not limited to: the risk of self contamination, a

knowledge deficit related to insufficient education on the disease process, or a bias regarding the

patient themselves. Nurses are held to some of the highest ethical standards of almost any other

profession, and are looked up to for their empathy, flexibility, and respect for others. As one of

the first lines of support for patients hospitalized with HIV and AIDS related complications, it is

a nursing duty to provide the most competent care possible. For this reason alone, it is

“​imperative that nurses have the knowledge, skills, and ‘right attitude’ to be able to respond to

issues in an appropriate, ethically warranted and just manner” (Tilley & Crock, 2016).

Nevertheless, just like any other human, nurses do in fact make mistakes, which have the

potential to elicit poor healthcare outcomes for patients.

In order to understand the disinclination of nurses to care for patients struggling with HIV

and AIDS, it is crucial that we first explore the disease itself. The Human Immunodeficiency

Virus (HIV) attacks the infection fighting cells of the immune system, making it difficult for the

body to defend itself against infection and certain cancers. As HIV progresses, it gradually

destroys our immune functions and advances into the latest stage, that of Acquired

Immunodeficiency Syndrome (AIDS). This virus is spread through contact with bodily fluids,
THE RELATIONSHIP BETWEEN NURSES PERCEPTIONS 4

such as rectal, vaginal, and penile fluids, as well as blood and breast milk. On a day to day basis,

nurses may come into contact with these fluids a countless amount of times. Providing care to

patients with these diagnoses “​may put health professionals at risk for acquiring an infection,

with the risk following a contaminated needle stick or sharps injury” as just one example

(Ishimaru et al., 2017). Whether this hesitation of nurses is a result of basic fear of

contamination or preconceived notions about the patient, professionals who withdrew from

caring for those “infected with HIV were perceived by some as abandoning patients; others

perceived these caregivers as wisely cautious” (Locher & Didion, 2003). Due to the nature of

these diseases, patients are already at a significantly higher risk of contracting hospital-acquired

infections, making it essential for nurses to prevent cross contamination between patients.

Stigma is society’s negative evaluation of certain features or aspects of behavior. It is

relatively common with various medical conditions and is essentially unavoidable. Most of the

general public is taught from a young age to have a preconceived notion regarding numerous

ideals and what should be accepted and what should not. Unfortunately, when investigating

stigmas and preconceived notions and the effects they may have on nursing care, studies have

shown a strong relationship between the two. Patients diagnosed with HIV are often victims of

stigma as well as discrimination. The nursing care associated with HIV and AIDS patients is

crucial since treatment and compassionate care is essential for a good prognosis. Over the past

35 years, progress has certainly been made in regards to overcoming challenges related to

insufficient care given to patients with controversial diagnoses. However, because ethical issues

play a major role in the care of patients with conditions such as HIV and AIDS, it is imperative
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that nurses have the proper skills, knowledge, and open perspectives on patients with these

diagnoses (Tilley & Crock, 2016).

Clinical skills related to HIV and AIDS patient care can be taught in undergraduate

courses, but reducing stigmatizing behavior may be achieved by familiarizing healthcare workers

with HIV. Several studies have shown a frequent barrier against quality nursing care is

stigmatizing behaviors directed at patients with a diagnosis of HIV and AIDS. Nurses and other

healthcare personnel often view such patients with a negative perspective due to the lack of

knowledge of how exposure occurs, the thought that illegal drug use and needle injections is a

causative factor in the spread of these diseases, or the homosexuality aspect behind contraction

of these diseases (Frain, 2016). Therefore, educators and hospital management must make

nurses aware of the background of the disease before making assumptions and accusations about

a patient, as well as teaching faculty how personal protective equipment can be used when

interacting with these patients. Another study has shown there is a decrease in medication

adherence, decreased retention in care, and an increase in the number of new HIV infections

when stigmatizing behaviors from nurses are exhibited during care for these patients. Not only

do these factors contribute to a decreased quality of life, but it also results in increased morbidity

and mortality for this vulnerable patient population (Frain, 2016).

Approximately 80% of new HIV transmissions are from persons who do not know they

have HIV and/or are not receiving regular care (Zihao et al., 2019). To control the spread of this

virus, at-risk patients must seek out regular testing. Since individuals are often unaware that they

carry the virus, regular testing should be prioritized and incorporated just as yearly check-ups

and physicals have. Seeing as a diagnosis of HIV is made through a blood antibody test, nurses
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are often the healthcare professionals in charge of screening such patients. The spread of HIV is

based on the viral load, or amount of infectious particles in the body. Viral suppression is

possible within 6 months of diagnosis thanks to the recent debut of antiretroviral therapies, but it

is this short timeline that makes early diagnosis crucial (Zihao et al., 2019). Nurses are often the

biggest advocates for their patients, making it a nursing responsibility to recognize not only

at-risk patients, but those who exhibit signs and symptoms of HIV to encourage testing. If

nursing interventions are introduced early in the disease process, regardless of the stigma

surrounding the diagnosis, existing infections will remain present in the host but will not spread

to other patients or healthcare professionals as easily.

Nursing interventions occur at numerous points of care in an individual’s life, and range

anywhere from preventative to therapeutic. According to a long-term study done in Georgia

over the past five years, individuals who had more healthcare resources were more likely to take

advantage of what was being offered (​Wingood et al., 2019). ​ At this specific research site, the

group provided free and discrete HIV testing administered by nursing professionals that yielded

rapid results. If the patients tested positive for HIV, they would then receive a referral for pre

and post-counseling. Along with referrals, the nurses involved provided direction for patients to

access additional information if they were interested in learning more about the disease. In this

study alone, three different levels of interventions were utilized, increasing the likelihood of

knowledge retention and the number of patients who will benefit from healthcare. However,

none of these positive outcomes could have been achieved had the nurses let their outside

perceptions of patients impede their ability to deliver competent care.

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There were numerous goals to be achieved at other levels that would affect the control

and detection of HIV. Since this community intervention was located at a church, the nursing

group decided to establish a goal of “mobiliz[ing] church leadership to support HIV… screening

events and, conduct social justice activities (e.g., discussing HIV testing during sermons)”

(Wingood et al., 2019). Although the perceptions surrounding HIV and AIDS patients are

misconstrued and misinterpreted every day, visiting the topic in a church sermon brings certain

stigmatizations into the light. Having trustworthy individuals of the community, such as clergy

members and nurses, discuss the importance of supporting HIV and AIDS patients could

influence individuals to choose their path for treatment more freely. It is nursing leadership and

interventions that can immensely affect the healthcare outcomes of patients living with such

communicable diseases. Nurses in particular possess the ability to give patients the courage to

take that first step, passing on knowledge and resources that HIV and AIDS patients so

desperately require.

Any patient admitted into the hospital poses a risk of acquiring an opportunistic infection,

especially those who have a weakened immune system. Living with HIV and AIDS means that

there is a deficit in the number of CD4 cells circulating in the body, making it difficult for

patients to fight off infection because “CD4 cells are white blood cells that play an important role

in the immune system” (Hughson, 2017). When an HIV or AIDS patient is hospitalized, their

risk of developing an infection increases even more:

Hospitals house large numbers of people who are sick and whose immune systems are

often in a weakened state; medical staff move from patient to patient provoking a way

for pathogens spreading; many medical procedures bypass the body’s natural
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protective barriers and the routine use of antimicrobial agents in hospital creates

selection pressure for the emergence of resistant strains (Panis, 2009).

Due to the infectious nature of hospital settings, it is of utmost importance that nurses are

aware of which patients are suffering from HIV and AIDS to help prevent the spread of

transmissible diseases. Many families are “concerned about transfer of the… agent to the home

setting”, leading nurses to be extra cautious around patients with these diagnoses (Locher &

Didion, 2003). Whether this discretion is taken through careful practice of standard precautions,

limited time spent in a patients room, or a limited number of interactions with the patient

themselves, the attention to detail in the care of people suffering from HIV and AIDS tend to be

overlooked.

One of the most common causes of death in HIV and AIDS patients are respiratory tract

infections, often acquired in the hospital setting. According to Lartey et al. (2015), “​tuberculosis

[is] the commonest cause of death accounting for… 57.7% of all deaths”, followed closely by

lobar or bronchopneumonia. It is a widely known nursing fact that in order to aid in the

prevention of respiratory tract infections, patients must be turned or rotated frequently in order to

help reposition lung secretions. However, when nurses voice their concerns about caring for

HIV and AIDS patients or simply limit patient interactions, these individuals may not change

positions for many hours. At the very least, HIV and AIDS patients who are already

immunocompromised require an increase in the frequency of nursing care in order to prevent the

contraction of potentially deadly respiratory infections. As previously stated, the perceptions

that nurses carry about HIV and AIDS patients are multifaceted, making it a challenge to

“uphold the ethical values of their professions in the face of profound stigmatization of those
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affected” (Tilley & Crock, 2016). If nurses allow this negative stigma surrounding such patients

to cloud their judgement, infection and subsequent death rates will skyrocket.

As with most chronic illnesses, patients diagnosed with HIV or AIDS are at an increased

risk for anxiety and depression. However, these patients in particular experience stigma that is

unique to their diagnoses. There are several types of stigma mechanisms that significantly

impact patient outcomes related to depression and anxiety. The behaviors and actions of those

working in healthcares setting have the ability to directly affect perceptions surrounding these

diagnoses.

The first type of stigma mechanism is internalized stigma. “This refers to endorsing

negative feelings and beliefs associated with HIV and applying them to the self” (Earnshaw,

2013). Internalized stigma begins with misunderstanding and lack of knowledge, and people

often first learn about and potentially create negative feelings and beliefs about the diagnosis

from the perspective of a person living without it. After acquiring the disease, the process of

confronting these previously held feelings and beliefs may result in internalized stigma. These

feelings of inadequacy, doubt, and shame about their diagnosis can cause many HIV and AIDS

patients to feel helpless and depressed. This in turn prevents patients from talking about their

experiences and stops them from seeking medical help. These patients require the unrelenting

support of nurses who do not bear any of the same perceptions about HIV and AIDS.

The second type of stigma mechanism is enacted stigma. In contrast to internalized

stigma, enacted stigma involves experiences with others. As stated by Earnshaw (2013), enacted

stigma involves experiences of discrimination, stereotyping, and/or prejudice from others in the
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past or present due to one’s diagnosis. A patient can experience enacted stigma from anyone in

the healthcare setting. A nurse who holds certain perceptions towards patients with HIV and

AIDS may be guilty of enacted stigma. Because nurses have direct one on one care with patients

usually over a period of days to weeks, they have the ability to positively alter their thinking.

However, this can also work the opposite way. Nurses who hold misconceptions regarding these

diagnoses can potentially cause increased internalized stigma in HIV and AIDS patients, leading

to feelings of depression and anxiety. The opinion of a healthcare professional is highly valued

to those who have do not have an understanding of their diagnosis. When the nurses personal

perceptions about the diagnoses are apparent, the patient may begin to feel even more hopeless

than they initially did. A nurse who is knowledgeable, unbiased, well-rounded, and comforting

can be a wonderful source of information for his or her patients. Without enacted stigma, there

would be a significant reduction in internalized stigma, patient depression, and anxiety. To

improve patient outcomes, it is crucial that nurses identify personal perceptions and bias before

caring for a patient with HIV and AIDS.

The majority of nurses do not work in positions focused on HIV and AIDS care,

however many nurses will find themselves called upon to care for patients living with such

patients regardless of their employment setting. According to Frain (2016), “as the HIV/AIDS

epidemic has faded from the headlines, HIV/AIDS education has decreased in most nursing

schools, and undergraduate students receive minimal education about HIV/AIDS”. A study was

conducted by Frain (2016) in order to gauge the impact of a six week education program which

utilized speakers living with HIV and AIDS as well as healthcare professionals; this was done in

preparation for undergraduate nursing students to master the care for patients living with these
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diagnoses. A sample of twenty-eight undergraduate nursing students took part in this education

experience, with ages ranging from twenty-five to over forty. Before the education experience,

many studies were conducted to assess the knowledge and perceptions these nursing students had

related to HIV and AIDS. After the six week education training, a similar test was conducted to

compare to the data in the previous test. Prior to the education intervention, 29% of students felt

unprepared to care for patients with HIV and only 7% of participants felt totally prepared to care

for this patient population. After the training, 54% of participants felt totally prepared to care for

patients living with HIV and there were no students who felt unprepared to provide care (Frain,

2016). The results of this study suggests that current nursing students and registered nurses

would benefit from receiving additional HIV and AIDS education from experts in the field and

from people living with the diagnosis. A lack of preparation results in a lack of knowledge,

which can perpetuate fear and negative attitudes towards people living with HIV or AIDS. A

disease specific training session prior to hire or added into the curriculum of nursing students

would significantly improve not only the confidence of nurses, but would also positively affect

patient outcomes.

Proper nursing care is one of the most vital interventions in preventing the spread of

disease from patient to patient, and family to family. By serving as a refuge for patients

struggling with many different conditions, nurses are recognized for their empathy and respect

for patients and their relatives. Through the implementation of focused HIV and AIDS nursing

education and involved nursing care, nurses not only have the ability to decrease hospital

acquired injuries/illnesses, but also to eliminate the stigma surrounding patients diagnosed with
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HIV or AIDS. Just imagine, a healthcare system in tune with providing inequivocabile care,

regardless of infection status or patient lifestyle choices.

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