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Health care
workers and AIDS: a differential study of beliefs and affects
associated with accidental exposure to blood
Cadernos de Saúde Pública
Print ISSN 0102-311X
Cad. Saúde Pública vol.21 no.1 Rio de Janeiro Jan./Feb. 2005
doi: 10.1590/S0102-311X2005000100031
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0102-311X2005000100031
Profissionais de saúde e AIDS: um estudo diferencial sobre crenças e
afetos associados à experiência de exposição acidental a material
biológico potencialmente contaminado
Maria
Rosa Rodrigues RissiI; Alcyone Artioli MachadoII;
Marco Antonio de Castro FigueiredoI
IFaculdade
de Filosofia, Ciências e Letras de Ribeirão Preto, Universidade de
São Paulo, Ribeirão Preto, Brasil
IIFaculdade de Medicina de Ribeirão Preto, Universidade
de São Paulo, Ribeirão Preto, Brasil
Correspondence
ABSTRACT
This study
aimed to analyze affective and cognitive determinants of the
professional work of individuals caring for patients with HIV/AIDS,
in view of the risk and/or experience of accidental exposure to
blood. We drew on the theoretical-methodological references of
Fishbein & Ajzen and Maslow's theory. Fifty health care workers were
evaluated using an attitudes questionnaire and a needs and
motivations instrument. The research verified differences between
answers by health care workers who had never suffered accidents and
those who had already experienced accidental exposure to blood.
Health care workers did their work activities motivated by the need
for self-fulfillment and valued their own performance when they were
able to meet the patients' emotional needs. Among health
professionals who had never experienced accidental exposure to
blood, the predominant beliefs was that patients feel remorse over
having expose themselves to HIV. Accidental exposure to blood raises
difficulties in personal life. Technical aspects are also associated
with the possibility of accidental exposure to blood.
Health
Care; Occupational Accidents; Acquired Immunodeficiency Syndrome
RESUMO
O objetivo
deste estudo foi analisar determinantes afetivos e cognitivos que
influenciam o trabalho de profissionais que cuidam de pessoas
vivendo com o HIV/ AIDS, frente ao risco ou experiência de exposição
acidental a material biológico potencialmente contaminado (MBPC).
Utilizou-se o referencial teórico metodológico de Fishbein-Ajzen e a
teoria de Maslow, que propõe a hierarquia das necessidades humanas.
Cinqüenta profissionais de saúde foram avaliados por meio de escalas
de atitudes, e de um instrumento de avaliação de necessidades e
motivações. Verificou-se a diferença entre as respostas de
profissionais que nunca sofreram acidente e aqueles que já passaram
pela experiência de acidente ocupacional. Os resultados indicam que
os profissionais exercem suas atividades motivados pela necessidade
de auto-realização e valorizam sua performance quando podem atender
as necessidades emocionais dos pacientes. Para os profissionais que
não se acidentaram predominam crenças de que os pacientes se
arrependem da exposição ao HIV. O episódio de acidente acarreta
dificuldades à vida pessoal e profissional do trabalhador
acidentado.
Aspectos
técnicos também aparecem associados à possibilidade de ocorrência de
acidentes.
Assistência
à Saúde; Acidentes de Trabalho; Síndrome de Imunodeficiência
Adquirida
Introduction
During
their professional experience, health care workers who care for
individuals with HIV/AIDS need to be qualified to deal with the
specific requirements of the syndrome, which demands technical and
scientific knowledge and understanding of the ties established
between the clinical team and patients with HIV/ AIDS. An implicit
concern during daily practice by health care workers is the
possibility of infection with pathogens through accidental exposure
to blood.
Several
studies 1,2,3,4,5 have attempted to shed light on the
extent of the problem from a clinical and epidemiological point of
view, besides defining prophylactic post-exposure measures, but
questions related to the psychological implications of accidental
exposure to blood have rarely been discussed in the literature
6,7,8,9.
Some
published studies and relevant informal observations have indicated
that accidental exposure is experienced with great anxiety by the
health care workers, and work by professionals caring for patients
with HIV/AIDS thus goes beyond intrinsic technical aspects,
requiring another dimension of care which includes awareness of
patients' psychosocial needs, indicating concern for the more human
side of the issue 4,10,11,12.
It thus
seems evident that in addition to training for AIDS care as a whole,
it is crucial to understand the different psychosocial aspects
inherent to health professionals' practical work 13,14,
indicating the increasing need for support programs and
psychological help in order to establish a less threatening and more
genuine relationship with the patient.
In the
present study, the Fishbein-Ajzen affective-cognitive model was
used, which conceives attitude as the result of the conjunction of
beliefs, values, and emotions 15 associated with any
phenomenon 16, a model representing an advance in the
study of social attitudes.
To
investigate the direction of motivations and needs inherent to
professional activity, Maslow's theory was also used 17,18.
This model proposes a hierarchy of human needs, supporting the
theory that individuals act in such a way as to satisfy or reduce
their needs according to factors inherent to their personality.
The
theory's general principle is that individuals have primary or
physiological needs which, when satisfied, make way for secondary
needs, which in turn acquire the power of motivation. In this
respect, these models are believed to fulfill the objective of
identifying affective and cognitive determinants that lead health
care workers to work with AIDS.
The
objectives of the present study were: (1) to analyze affective and
cognitive determinants of professional work by individuals caring
for patients with HIV/AIDS, using assessment instruments, and (2) to
determine which representations and motivations are part of the
experience of these professionals in view of accidental exposure to
blood risk and/or experience.
Population and methods
Study
site
The study
was carried out at the Special Unit for Treatment of Infectious
Diseases (SUTID), a regional reference center for this type of care.
The unit is a department of the University Hospital, School of
Medicine, Ribeirão Preto, University of São Paulo (HCFMRP-USP), a
600-bed facility with various medical specialties. The city of
Ribeirão Preto has a population of approximately 500,000 and is
located in northeastern São Paulo State, Brazil.
The
research project was approved by the Institutional Review
Board/Research Ethics Committee of HCFMRP-USP (HCRP case no.
1170/99). All health care workers participating in this study
received detailed written information on the study procedures and
objectives, and only those who provided their consent to participate
were included, after signing the document.
Study
phases
• Survey
of prevalent modal beliefs
(a)
Subjects: Fifteen subjects participated in the first phase of the
study after written informed consent was obtained, including five
nurses and ten nurse technicians who care for patients treated at
the SUTID.
(b)
Procedures:
1.
Interviews: Subjects answered individual semi-structured interviews,
following a procedure of evocation-enunciation-verification, in
order to obtain data regarding three categories of representation:
work itself, patients with HIV/AIDS, and accidental exposure to
blood.
2. Content
analysis and verification of the selected beliefs: During this
phase, a list of statements was presented to three reviewers who
grouped those that showed the closest content-related proximity. The
statements that were found to be at the judgment intersection for
each category were then verified graphically using the Venn diagram
19.
3.
Construction of affective-cognitive scales: Content analysis of the
selected beliefs permitted their association with "b" scales, which
evaluate affective contents, and "e" scales, which evaluate
cognitive contents, using a 7-point Likert type scale ranging from
+3 to -3 with a median interval of zero 20.
•
Application of a questionnaire for evaluation of needs and
motivation:
(a)
Subjects: Fifty health care workers participated in this phase of
the study, including 13 physicians, 9 nurses, 22 nurse technicians,
5 general service technicians, and 1 dentist, who provide services
in the SUTID. Inclusion criteria were the type of activity carried
out, their link with the service, and their availability and
willingness to participate in the study.
(b)
Procedures: The questionnaire for evaluation of needs and motivation
was administered at the subjects' workplace. The responses were then
submitted to descriptive analysis according to the variable "health
care workers with a history of accidental exposure to blood" and
"health care workers without a history of accidental exposure to
blood". On the basis of this analysis, cutoff points were
established and subgroups defined for differential analysis.
After
statistical analysis, distribution of responses within the levels of
need satisfaction was determined using Maslow's theory 21.
Data were analyzed for differences between satisfaction levels and
for each differential group.
•
Determination of health professionals' attitudes towards certain
categories of AIDS-related contents
(a)
Subjects: The same 50 subjects evaluated during the previous step
were assessed during this phase.
(b)
Procedures: This phase consisted of three steps as proposed by
Figueiredo 20:
1.
Application of the attitude instrument: Fifty observations were made
by applying two probability scales using a 7-point Likert evaluation
in order to determine affective "e" and cognitive "b" attitude
components. The responses were processed on the basis of the
Fishbein-Ajzen equation, calculating the relative attitudes for each
item and each category studied.
2.
Differential studies: Differential studies were carried out using
the t-test and Mann-Whitney test for the determination of
differences within each subgroup ("health care workers with a
history of accidental exposure to blood" and "health care workers
without a history of accidental exposure to blood"), with the level
of significance set at p < 0.5 for rejection of the equality
hypothesis. Descriptive statistics were also applied to the data for
each sub-sample when differences were observed, or for the whole
sample (n = 50) when differential analysis did not reveal any
difference, considering all categories evaluated.
3. Quadrant
analysis: To determine the conjugation of cognitions and emotions
leading to the attitudes evaluated, quadrant analysis consisting of
the trisection between the "b" scores on the abscissas and the "e"
scores on the ordinates of the beliefs-versus-values relationship
was carried out. Conjugations were determined based on the
distribution of subjects among quadrants using the scores obtained
by the two scales. The modal quadrant was compared to the sum of the
remaining quadrants, with the level of significance set at p < 0.5
for rejection of the equality hypothesis. The results were
interpreted and discussed on the basis of the meaning of the modal
quadrant.
Results
Survey of prevalent modal beliefs
Table 1
shows the final list of statements selected on the basis of content
analysis, which form the attitude instrument. A predominance of
contents related to the characteristics of the relationship
established between healthy care workers and patient can be noted,
as well as contents related to work contingencies and psychosocial
aspects of the patients that render work with AIDS specific as
compared to other diseases.
Determination of satisfaction rates using a needs instrument
Table 2
shows the distribution of different needs satisfaction rates for
health care workers with and without a history of accidental
exposure to blood. For those accidentally exposed to blood, the
results indicate satisfaction in terms of the need for security
(54%) and a tendency towards satisfaction with the need for
self-fulfillment (40%), but lack of satisfaction of more basic needs
such as survival, a need which most professionals found to be unmet
(72%).
According
to the distribution of needs satisfaction rates for health care
workers who had never been accidentally exposed to blood, the needs
of security and self-fulfillment were satisfied, with both needs
showing a 64% satisfaction rate. A tendency towards satisfaction was
also observed in the need for socialization (36%). In contrast, a
high rate of lack of satisfaction was observed in relation to
survival (54%) and self-esteem (41%).
Summary of
results obtainedby quadrant analysis
Table 3
shows an analysis of the conjugation of "b" and "e" values assigned
to the statements presented to the subjects as shown in Table 1.
Quadrant analysis based on the conjugation of beliefs and values for
the work category demonstrated that contents related to emotional
needs (need for understanding and care) are part of the repertoire
of beliefs concerning the HIV/ AIDS patient and are positively
valued, regardless of history of accidental exposure to blood.
The results
for the patient category indicate the importance of the patient's
role in the health care workers' work and the perception of
difficulties at the biological, psychological, and social levels
experienced by the HIV/AIDS patient. In this category, two items
showed statistically significant differences between the
accidentally exposed and non-exposed health care workers subgroups:
the item related to the importance of patients' perceiving their
improvement and the item related to patients' remorse over having
been exposed to HIV. In the first case, although significant
differences were detected, conjugation of the responses pointed in
the same direction, i.e., patients perceive their improvement and
this is viewed positively (item 2.7, Table 3). As for HIV/AIDS
patients' remorse over having been exposed to the virus, the results
indicate that only professionals who were never accidentally exposed
to HIV believe in and positively value such an attitude. For
professionals who have been accidentally exposed, the results do not
indicate a prevalent quadrant.
Analysis of
the accident category did not show any significant difference
between the two sub-samples for the items evaluated.
Analysis of
the "b"/"e" conjugation for the whole sample showed the presence of
strong beliefs for two items, which were negatively valued by the
subjects: the fact that accidental exposure to blood results in
complications in the lives of health care workers and the
possibility that occupational exposure to HIV may have been caused
by haste.
Discussion
The results
indicate that health care workers' professional practice
extrapolates intrinsic technical aspects, requiring consideration of
the psychosocial needs of HIV/AIDS patients during daily work. A
tendency of professional activity based on the search for
self-fulfillment can be observed. Since the clinical and
psychosocial aspects of AIDS are quite complex, health care workers
involvement with the work and patients becomes a privileged and
essential instrument for a favorable treatment prognosis.
With
respect to the work itself, beliefs and values identified among
health care workers demonstrate awareness of patients' emotional
needs. Meanwhile, patient care represents a component of the
professional role which in turn shifts the recognition of technical
and scientific competence to another level of meaning that is
necessary but not sufficient to treat AIDS.
Strawn
22 reports that people react individually to life-threatening
diseases, especially AIDS. Therefore, reactions are related to the
meaning each person ascribes to both the disease and its extent and
physical and mental consequences. Stigmatized diseases entail the
fear not only of death, but also of discrimination and possible
interference with social and affective relationships.
The
affective elements in the relationship between health care workers
and HIV/AIDS patients require reflection on the possibility of
maintaining a safe distance between technical knowledge and
emotional involvement. Health care workers appear to distance
themselves from the reality of daily difficulties and to act by
idealizing their work, viewing patients as deserving of care and
understanding, even though they need to distance themselves from
judgments regarding HIV infection routes and lifestyles.
Such
idealization also influences health care workers' perceived capacity
to exercise their functions, even though they may not feel
completely secure or exempt from infection by accidental exposure to
blood. A distancing process from the concrete risk of accidental
exposure to blood and HIV infection is observed here, which enables
Health care workers to continue their search for self-fulfillment.
This
idealization suggests a feeling of omnipotence which Figueiredo &
Turato 6 see as a determinant in the choice of the
profession itself, making health care workers feel consciously or
unconsciously more empowered within the context of human
vulnerability to disease and death.
We observed
a predominance of beliefs concerning the affiliation process
situating patients in first place in the lives of health care
workers. Since patients represent the main motivation for the
performance of health care workers' professional functions,
treatment evolution and response also depend on the success of those
providing patient care, thus ultimately leading to a "dilution" of
the control over their performance itself. Professional self-esteem
also depends on the patient's condition, mainly because health care
workers assume the obligation to maintain patients under treatment
and to provide them with care in order to guarantee their quality of
life based on information and support.
A
significant difference in health care workers' self-esteem was
observed using accidental exposure to blood as a parameter. Health
care workers without a history of accidental exposure to blood were
unsatisfied with their desire to be properly recognized for their
work. We can assume that health care workers who have been
accidentally exposed to blood draw somewhat closer to the universe
of the patient's representation of health care workers' professional
role. The importance of this role for maintaining the connection
with life thus becomes clearer, especially during contact between
the health care workers and the patient.
Due to
changes in AIDS treatment, health care workers have begun to act
within a different reality. The introduction of highly active
antiretroviral therapy (HAART) has turned AIDS into a chronic
disease, leading to better quality of life and thus longer survival
for patients. This process poses an ongoing challenge for health
care workers, who must constantly strive to review their motivations
and difficulties in order to continue caring for patients 23.
Another
level of representation refers to the impact of AIDS on patients and
their resulting feeling of revolt, besides the diagnosis/prognosis
of infection. Health care workers working with AIDS may not
significantly express a certain direction, indicating the real or
internally felt difficulties in judging the reactions of the
patients who show a heavily negative emotional content such as a
feeling of revolt.
Health care
workers see patients with HIV/ AIDS as "difficult", based on their
direct daily contact and the difficulties arising in this coping
process, leading to obstacles that impact these daily relationships.
Health care workers recognize that the "psychological component"
represents a special dimension of care, and the term "difficult"
thus appears to be associated with aggressiveness, demands, needs,
revolt, anxiety, and depression 24.
Another
belief among health care workers relates to the fact that some
patients feel remorse over their HIV exposure; however, the present
study showed a difference between health care workers with and
without a history of accidental exposure to blood. Health care
workers without a history of accidental exposure to blood positively
value such feelings of remorse in patients, based on the belief that
patients can redeem themselves, allowing a process of acceptance and
affiliation. Meanwhile, responses from those with a history of
accidental exposure to blood suggest a difficulty in rationally
evaluating the possibility of patients' recognition of the options
and choices they have made earlier in life.
This
difference indicates that the responsibility for possible HIV
infection through accidental exposure to blood appears to be related
to the so-called passive forms of infection (by blood transfusion or
mother-to-child transmission). According to Figueiredo & Turato
6, in such cases health care workers show sorrow and identify
with patients, while almost never questioning the individual's
shared responsibility. Therefore, health care workers succeed in
distancing themselves from their own responsibility for avoiding
accidental exposure to blood through the proper use of universal
precautions and personal protective equipment.
However,
typical reactions at the time of accidental exposure to blood,
ranging from fear and emotional problems to despair, as reported in
different studies, appear to trigger the need to examine health care
workers' beliefs and myths about patients. Health care workers'
capacity to distance themselves from real suffering is jeopardized,
and they therefore identify with patients and consequently with the
whole range of prejudices and taboos surrounding patients' lives.
Health care workers become the target of AIDS-related stigmata, thus
forcing them to face their fears in caring for these patients
8,25,26.
Souza
27 has observed not only a concern on the part of health care
workers about accidental exposure to blood but also a return to
their own concepts about patients and their lifestyles, with a
predominant emergence of prejudices regarding risk behaviors. The
mode of infection, views concerning risk behaviors, and personal
judgment frequently permeate the relationships between health care
workers and HIV/AIDS patients in their daily contact 28.
health care workers are also subject to the same discrimination,
even within their own social group.
Tribonnière
et al. 26 observed feelings of anxiety, rage, anger,
insomnia, and depression among health care workers following
accidental exposure to blood. The ability to accept negative
feelings towards work and patients appears to be facilitated by the
accidental exposure to blood, accompanied by the subjective presence
of prejudices and judgment during Health care workers' contact with
HIV/AIDS patients 24,27,28.
AIDS-related fear is also akin to other fears such as abandonment by
family and friends, rejection by society, and contact with life and
death. Post-exposure prophylactic measures are also uncomfortable
and expose health care workers to circumstances similar to those
experienced by AIDS patients, e.g., the large pill burden, sometimes
highly inconvenient side effects, the need to use condoms in all
sexual relations, and the necessary care to avoid pregnancy during
the observation period. Accidental exposure to blood renders health
care workers as vulnerable as their patients.
According
to all evidence, the possibility of HIV infection through accidental
exposure to blood makes health care workers aware of more immediate
issues which had previously been located at another level of
representation. This is when health care workers realize that basic
needs associated with reality such as safety at work and one's own
health invariably lie on shaky ground. Fear of discrimination and
social rejection also begins to influence the lives and work of
these health care workers.
Therefore,
the two poles of representation and conduct by health care workers
caring for HIV/AIDS patients are defined between the loss of contact
with real immediate risks and over-valuing of the possibility of
reducing patients' suffering, on which is based a major portion of
the expectations for personal and professional fulfillment.
A third
level of revelation regarding technical aspects that impact work is
the belief that haste may be a cause of accidental exposure to
blood. However, this contingency appears to be associated with other
difficulties in the work setting, such as insufficient staff,
increasing neglect of personal protective equipment over time,
inadequate procedures for disposing of sharps and other materials,
haste during procedures, and teamwork difficulties.
Some
studies 8,26 have emphasized that many health care
workers with a history of accidental exposure to blood were able to
modify habits, especially those associated with the use of universal
precautions and personal protective equipment.
Professionals who succeed in consistently working out the situation
following accidental exposure to blood and reconsidering their lives
by viewing the past events in a normal light show important
cognitive responses, leading to transformation of their work in
terms of occupational safety. Souza 27 observed that
responses are not always determined exclusively by the stressful
situation, but also depend on prior experience and personal beliefs.
In
conclusion, the complexity of HIV/AIDS patient care results in
significant emotional stress, indicating the importance of actions
that offer favorable working conditions including help and
psychological support for health care workers in order to establish
a less threatening and more genuine relationship with HIV/AIDS
patients.
Contributors
M. R. R.
Rissi participated in the development of the research and drafting
of the article. A. A. Machado and M. A. C. Figueiredo contributed
with the choice and utilization of the research methodology and
collaborated in the analysis of the results and drafting of the
discussion.
Acknowledgments
We thank
the health care staff from the Special Unit for Treatment of
Infectious Diseases and all the individuals who participated
directly or indirectly in the present study.
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 Correspondece
to
M. R. R. Rissi
Departamento de Psicologia e Educação, Faculdade de Filosofia,
Ciências e Letras de Ribeirão Preto, Universidade de São Paulo
Rua Terezina 380, apto. 24
Ribeirão Preto, SP 14055-380, Brasil
mariarosarr@yahoo.com
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