|
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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