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The Impact of an Education Intervention to Change Nurses’ HIV-Related Knowledge and Attitudes in Lithuania

A Randomized Controlled Trial

Mockiene, Vida, RN1; Suominen, Tarja, PhD, RN2; Valimaki, Maritta, PhD, RN3; Razbadauskas, Arturas, PhD, MD4; Martinkenas, Arvydas, PhD, ID5; Caplinskas, Saulius, PhD, MD6

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Journal of the Association of Nurses in AIDS Care: March-April 2011 - Volume 22 - Issue 2 - p 140-149
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Abstract

Nurses are the largest segment of the health care workforce in the world. They are involved in virtually all levels of health care and are often the central points of contact for the clinical care of people living with HIV (PLWH). Adequate preparatory education is the precondition for effective nursing action. However, reports have shown that most nurses have not received adequate pre-service education or acquired the knowledge, skills, and attitudes needed to provide quality care for PLWH (Bharat & Mahendra, 2007; World Health Organization [WHO], 2002). The lack of HIV-specific preparation has also been noted in Lithuania.

Background

Lithuania, one of the Baltic States, gained its independence from the Soviet Union in 1990. It has a population of approximately 3.5 million and is surrounded by countries where HIV is highly prevalent; nevertheless, the global HIV pandemic arrived late in Lithuania and it has a low HIV prevalence rate. The number of HIV infections among intravenous drug users (IDUs) remains low, which is in marked contrast to neighboring Russia (Kaliningrad district), Belarus, Latvia, Estonia, and Poland, where the incidence rates of HIV infection among IDUs have increased sharply in recent years (Čaplinskas, 2004). In Lithuania, the first HIV-infected individual was not diagnosed until 1988. Between 1988 and 2009, a total of 1,506 HIV infections were identified. According to the data from August 2009, the main routes of transmission were intravenous drug use (1,096 cases), heterosexual sex (205 cases), homosexual sex (95 cases), and unknown origin (95 cases; Lithuanian AIDS Centre, 2009).

Knowledge, training, and experience needed to care for HIV-infected patients are important; even the most informed practitioner must keep up with the new knowledge that accumulates in the published data for HIV on almost a daily basis (Glazier, Rackal, Tynan, Iacona, & Handford, 2002). Although high levels of knowledge are needed to make decisions in the event of an occupational exposure to HIV and care issues for HIV-infected patients (Petroll, Hare, & Pinkerton, 2008), various studies (e.g., Dijkstra, Kangawaza, Martens, Boer, & Rasker, 2007; Juan et al., 2004; Wu et al., 2002) have showed that health professionals often lack basic knowledge about HIV.

Nurses’ attitudes toward HIV influence the way they feel, believe, view, think, and value the lives of PLWH; environmental perception acquires meaning through the individual’s attitudes and belief systems (Gurung & Sangchart, 2008). The process of attitude change requires that the individual objectively examine critical elements of the attitude and identify those components that are valid and those that are prejudgments (Gross, 1987). Different studies (e.g., Hentgen, Jaureguiberry, Ramiliarisoa, Andrianantoandro, & Belec, 2002; Juan et al., 2004) have showed that health workers continue to have negative attitudes toward HIV. Negative reactions to HIV-infected patients can be a result of fear of contagion, homophobia, avoidance, unwillingness to provide care, and increased stress and burnout that can cause nurses to withdraw from nursing (Gurung & Sangchart, 2008). Juan et al. (2004) reported that nurses with higher levels of education showed less fear of HIV.

A recent review article (Mockiene, Suominen, Välimäki, & Razbadauskas, 2010) concluded that nurses’ attitudes toward HIV changed in a more liberalized direction after their participation in HIV-related courses. This has also been recognized and emphasized by other researchers (e.g., Ezedinachi et al., 2002; Williams et al., 2006).

The preparation received by nurses at various levels of training and career affects their roles in prevention and care. To provide effective care, nurses need to be equipped with appropriate knowledge and skills (Nkowane & Saxena, 2004). The published data has recommended that the trainings should focus on personal experiences and group support. Group experiences are useful because they allow participants to help each other understand the materials being presented, and personal experiences help learners understand how knowledge can be applied in the workplace (Kowalski & Vaught, 2002).

Programs that are developed to educate nurses to take care of PLWH vary widely, as have been reported in a systematic review and analysis of the effectiveness of such education programs (Kinnersley et al., 2007). In that study, single-component interventions included written materials, coaching, and an audiotape of the previous consultation; multiple component interventions consisted of coaching and a computer program, or coaching, written materials, and a video. The effects of different types of interventions (i.e., written materials alone and coaching alone) were assessed and the study reported similar, small to moderate, and statistically significant increases in satisfaction of participants.

In the review by Mockiene et al. (2010), 16 intervention studies were analyzed. Different studies revealed the beneficial effects of various forms of education on nurses’ HIV-related knowledge and attitudes. For example, training-of-trainers’ workshops to disseminate information about HIV and to change attitudes and behaviors were relatively inexpensive and thus easier to provide. Evidence was also found that education seminars (e.g., 2-4-day workshops) increased nurses’ knowledge (Charuluxananan, Somboonviboon, Kunthollaxami, Migasena, & Chinachot, 2000; Pisal et al., 2007). On the basis of the current global epidemic and economic situation, we need to know more about the effect of different education programs.

The purpose of this study was to build a realistic education intervention for nurses that could be used on a regular basis as part of continuing education and enhance acquisition of a broad knowledge base. The aim of the study was to describe the effect of an intervention program on nurses’ knowledge and attitudes concerning HIV in Lithuania. We sought to answer the following question: What is the effect of the intervention on nurses’ knowledge about HIV and their attitudes toward PLWH in Lithuania? The hypothesis was that the education intervention could increase nurses’ knowledge and positively change their attitudes toward HIV-infected patients.

Methods

Randomization

A randomized controlled trial (RCT) design with three group participants: two experimental groups ([EG]; EG1 and EG2) and one control group (CG) was used. RCTs are the most rigorous way to evaluate the effectiveness of interventions, regardless of their complexity. The complex interventions pose methodological challenges and require adaptations to the standard design of such trials because of their multifaceted nature and dependence on social context (Gueron, 2002; Oakley, Strange, Bonell, Allen, & Stephenson, 2006).

The hospitals (n = 3) were randomly selected from among the nine largest hospitals in Lithuania. Participants were selected by a cluster random sampling method from surgical, medical, or gynecology wards and the primary health care centers attached to the hospitals. A cluster sample was taken by identifying the different departments in hospitals as clusters. A sample of these departments (clusters) was chosen at random, and all nurses in the selected departments were included in the sample.

Participants

Participants of this study were Lithuanian registered nurses who worked in three randomly selected hospitals that were among the nine largest hospitals in Lithuania, and in primary health care centers attached to those. The hospitals were randomly assigned to intervention 1, intervention 2, and CGs. Nurses in the first hospital were assigned to EG1, those in the second hospital to EG2, and those in the third to the CG. Participants worked in the surgical, medical, or gynecology wards of the hospital and in primary health care centers attached to the hospitals.

Sample Size

Nurses were randomized from pools of about 300 at each hospital into the study groups. Nurses in the EG1 (n1 = 80 participants) received an education intervention with a 2-day workshop and written materials; those in the EG2 (n2 = 80 participants) received an education intervention with written materials only; and those in the CG (n2 = 80 participants) did not receive any intervention.

The three-group sample size was chosen to detect the difference in the change (analysis of variance, 1-way fixed effects sample size calculation) between the education intervention groups and the CG, with α = .05 (β = .20 [80% power] and Δ/σ = .6 [Δ = .43, σ = .7] – from previous analyses; Nelson, 1985). The minimum number of participants required per group was 55. However, the increase in the number of participants to 80 per group (as the response rate was 68.8%) could allow a more robust exploration.

Recruitment

All recruiting was completed in November 2008; baseline data were collected in December 2008, with follow-up data collection in March 2009. Each nurse was mailed a recruitment letter that explained the research purpose and process. Participants who were willing to participate in the study were asked to sign a consent form that was attached to the letter. Those who agreed were invited to participate.

Participant Flow

The baseline sample was 206 participants; 15% of the invited nurses refused to participate in the study. The response rate was 86% (n = 69) in EG1, 87% (n = 70) in EG2, and 81% (n = 67) in CG in December 2008 after one reminder. The follow-up sample was 185 participants; 10% of nurses withdrew from the study. The response rate was 79% (n = 63) in EG1, 79% (n = 63) in EG2, and 74% (n = 59) in CG after one reminder.

Interventions

The intervention in this study was an education program based on the results of a larger research project (Suominen et al., 2010) and a review of intervention studies (Mockiene et al., 2010). The 2-day education intervention was performed in collaboration with the Lithuanian AIDS Centre.

The education intervention process was implemented in two hospitals using different interventions: a 2-day workshop and distribution of written material in one hospital, and distribution of only written materials in the other hospital; another hospital was chosen for control purposes. Baseline data were collected before the intervention in December 2008, and the follow-up was completed 3 months later. Baseline and follow-up data were collected from participants in all three groups. The first group of participants completed the questionnaire at the beginning of the first day of the training program.

The intervention provided to EG1 consisted of a 2-day workshop and written materials. The workshops lasted 13 hours, including 1 hour for introduction to the research and instructions on how to complete the questionnaire. All the nurses in EG1 were trained together. Teaching elements included lectures, group discussions, conversation with PLWH, a film about HIV, lecture handouts, and distribution of written materials. A physician from the Lithuanian AIDS Centre provided lectures, whereas group discussions were led by a nurse scholar. The content areas were HIV epidemiology and history, prevention, transmission, HIV treatment, counseling, and ethical considerations. The written materials consisted of academic journal articles on the content areas (20 pages).

The intervention provided to EG2 consisted of the same academic journal articles (20 pages) that were provided to the EG1 nurses. Additionally, lecture handouts (two pages about new statistics of the HIV situation in Lithuania and in the world) from EG1 were provided to EG2. In total, EG2 participants received 22 pages of written materials. CG nurses received no lectures or written materials. Participants from EG1 and EG2 were also provided with continual education credits as a participation incentive.

Ethical Considerations

Permission for the study was obtained from the authorities of all the three institutions. The study was approved by the ethics committees of the institutions and by one university-based ethics committee. All participants were sent a formal letter explaining the scope and purpose of the study. In each EG1, EG2, and CG, participants were asked to return the consent form in a sealed envelope through mail. Participants gave written consent to take part in the intervention program before starting the study. To ensure data confidentiality, each participant was assigned a unique Informatics Doctor. Participants were free to withdraw consent at any time during the data collection phase without explanation.

Outcomes

The primary outcome measured in this study was knowledge level of nurses and the secondary outcome was their attitudes toward PLWH. The data for the study were collected by means of a questionnaire. The questionnaire included a modified version of the State University of New York at Buffalo School of Nursing AIDS Study Questionnaire (Held, 1993), as well as questions related to knowledge about HIV (33 items: HIV immunopathology, modes of transmission, universal precautions, etc.) and attitudes toward HIV-infected patients, and the disease itself (35 items). The attitude scale had two subscales: a general attitudes scale (26 items: nurses’ attitudes toward groups such as IDUs, etc.) and a homophobia scale (nine items: nurses’ attitudes towards homosexuals). The knowledge test asked respondents to indicate their agreement with each statement by circling one of three options: true, false, or do not know. Attitude-related items were rated on a 5-point Likert scale (strongly agree = 1, agree = 2, undecided = 3, disagree = 4, strongly disagree = 5).

The instrument used was developed by Held in 1993. It was modified in 2005 in collaboration with the developer of the questionnaire and medical experts. The modified version has been used in Lithuania, Estonia, and Finland to explore nurses’ knowledge and attitudes, and was reported to be both reliable and valid. In a recent study, the Cronbach’s alpha values for the attitude scale ranged between .80 and .93 (Suominen et al., 2008). In our study, the Cronbach’s alpha values for all three groups for the general attitude scale were .88 before the intervention and .87 after the intervention, whereas the Cronbach’s alpha values for the homophobia scale were .92 at preintervention and .89 at postintervention.

The translation into Lithuanian was performed using the back-translation technique. Back-translation improves the reliability and validity of the study by requiring that the quality of a translation is verified by an independent translator (Burns & Grove, 2001). Participant demographic characteristics included, among others, gender, age, education, years in current department, marital status, having children or not, work experience, and earlier experience with HIV (i.e., having cared for persons with HIV, as well as having known someone living with HIV).

Data Analysis

Statistical analysis was performed by using the SPSS 12.0 software package (SPSS Inc., Chicago, IL). The association between the nurses’ dichotomous background variables and their average scale scores was tested using a Student’s t-test for normally distributed scores and a nonparametric Mann–Whitney U-test for non-normally distributed scores. The categorical background variables and scores were tested using one-way analysis of variance and the non-normally distributed scores using the Kruskal–Wallis test. The differences between the three groups were tested using the t-test and Kruskal–Wallis test.

For tabulating HIV knowledge data, all correct answers were assigned the value 1, and all wrong or “unsure” answers the value 2. The data from the 33 HIV knowledge items were analyzed by summing all scores, resulting in individual scores between 0 and 33.

General attitudes toward HIV and homophobia were examined using descriptive analysis (presented in numbers of valid cases, means, and ranges) and compared between the EG1, EG2, and CG by cross-tabulation and the chi-square test. The average score for the scales was calculated by adding each participant’s response to each of the items on a scale from 1 (strongly agree) to 5 (strongly disagree) and by dividing the sum by the number of items. The attitude items were negatively worded; therefore, the higher the participant’s total score, the more positive the attitude.

The chi-square test was used to evaluate the significance of the association between the categorical variables and categorical values. Pearson’s product-moment correlation coefficients were used to examine the correlations between numeric background variables (e.g., age, work experience) and the normally distributed average scale score. Cronbach’s alpha was used to evaluate the internal consistency of the scales. Probability values less than .05 were interpreted as statistically significant and reported in the text only.

Results

Demographics

The “nurses' ages” ranged from 23 to 67 years (Table 1), with a mean of 43.1 years (standard deviation [SD] = 8.8). All study participants were women (100%). In all, 74.7% of nurses were married, 11.2% were single, and 14.1% were widowed or divorced; 85.4% had children. The average work experience was 21.9 years (SD = 9.4), ranging from .5 to 46.0 years.

Table 1
Table 1:
Demographic Characteristics of Nurses in the Three Groups (Pre- and Post-Intervention)

Preintervention levels of HIV knowledge.

The knowledge scores of study participants (EG1, EG2, and CG) ranged from 7 to 28 correct answers, out of a total possible score of 33, indicating a huge difference in the nurses’ knowledge levels. The mean of correct answers for the 33-item knowledge test in EG1 was 19.4 points (range = 7-27, SD = 3.67), in EG2 was 20.7 points (range = 13-28, SD = 3.70), and in CG was 18.7 points (range = 9-27, SD = 3.43) before the intervention. There were statistically significant differences in knowledge levels between the groups before the intervention: Knowledge level of EG2 nurses was higher compared with the EG1 (p = .037) and CG (p = .002).

Preintervention attitudes toward HIV.

The attitude toward HIV was fairly positive before the education intervention; the mean level in EG1 was 2.80 (range = 1.00-4.23, SD = .70), in EG2 it was 3.00 (range = 1.66-4.54, SD = .76), and in CG it was 2.81 (range = 1.50-4.20, SD = .70). There were no statistically significant differences in attitude between the groups before the intervention.

Postintervention effect on HIV knowledge and attitudes.

There was a statistically significant improvement in HIV knowledge in the first intervention group (EG1; p < .001, paired t-test; Table 2). The mean preintervention knowledge score was 19.4 (R = 20, median = 20.0, 95% confidence interval [CI] 18.5-20.2), whereas the mean postintervention knowledge score was 25.3 (R = 19, median = 27, 95% CI: 24.3-26.4). After the training, knowledge test for EG1 nurses’ included 60% more correct answers. After the intervention, there was a statistically significant difference in nurses’ knowledge levels between the groups: the knowledge level of EG1 nurses was higher than that of EG2 nurses (p < .001) and CG nurses (p < .001) and likewise, the knowledge level of EG2 nurses was higher than that of CG nurses (p < .001).

Table 2
Table 2:
Pre- and Post-Intervention Levels of Knowledge by Groups EG1, EG2, CG

The mean preintervention attitude was 2.80 (R = 3.23, median = 2.83, 95% CI: 2.63-2.97), whereas the mean postintervention attitude was 2.95 (R = 2.89, median = 3.00, 95% CI: 2.80-3.11; Table 3). Nurses’ attitudes had changed positively.

Table 3
Table 3:
Pre- and Post-Intervention Attitudes by Groups EG1, EG2, CG

There were no statistically significant improvements in the knowledge level and attitudes in the second intervention group (EG2) because of the intervention (Tables 2, 3). Among the EG2 nurses, whose education program included only written self-study materials, the mean preintervention knowledge score was 20.6 (R = 15, median = 20.0, 95% CI: 19.8-21.5), whereas the mean postintervention knowledge score was 21.9 (R = 20, median = 23.0, 95% CI: 20.9-22.8). This change in HIV knowledge was not statistically significant (p = .056, paired t-test). After the training, the EG2 nursing knowledge test provided 9% more correct answers. The mean preintervention attitude was 3.00 (R = 2.89, median = 2.89, 95% CI: 2.82-3.18), whereas the mean postintervention attitude test score was 2.88 (R = 2.97, median = 2.89, 95% CI: 2.71-3.05). This change in the attitude test was not statistically significant (p = .325, paired t-test; Table 3). The positive attitude changes were minor.

Likewise, no statistically significant changes were reported in the CG nurses’ knowledge levels or in their attitudes (Tables 2, 3). The mean preintervention knowledge score of the CG nurses was 18.7 (R = 18, median = 19.0, 95% CI: 17.9-19.6), whereas the mean postintervention score was 17.9 (R = 16, median = 18.0, 95% CI: 16.9-18.9). There were only 3% more correct answers at postintervention compared with the baseline. The mean attitude before the intervention was 2.81 (R = 2.70, median = 2.66, 95% CI: 2.66-2.98) and after the intervention 2.74 (R = 2.37, median = 2.69, 95% CI: 2.59-2.89). Nurses’ attitude changes were minor.

Discussion

The purpose of this study was to describe the effect of an intervention program on nurses’ HIV-related knowledge levels and attitudes toward PLWH in Lithuania. Our study showed that nurses’ knowledge levels had improved, but the changes in attitudes were minor. Theoretical change models suggest that attitude change occurs slowly over time (Williams et al., 2006). Participation in HIV nursing workshops is thus likely to represent only the first step for the Lithuanian nurses.

Participation in the first education program (intervention 1), which included a workshop and written materials, was shown to significantly improve scores on knowledge and attitude variables. Changes in nurses’ attitudes were not statistically significant. The education intervention thus proved to be successful in increasing the knowledge levels of nurses, which has also been shown in previous studies (e.g., Mockiene et al., 2010).

In this study, distribution of written materials alone (intervention 2) did not have a positive effect on nurses’ knowledge levels and their attitudes toward PLWH. The result of this study corroborates the results of previous studies (e.g., Mohsen, 1998; Uwakwe, 2000). Thus, we need to combine several education methods to achieve a positive effect on nurses’ knowledge and attitudes. The use of written materials alone in continuing education will certainly be less expensive, but ineffective in terms of raising the knowledge level of nurses in this context.

Previous studies have reported an association between a high level of knowledge and positive attitudes among nurses (McCann & Sharkey, 1998; Uwakwe, 2000). Nurses need to be updated on HIV knowledge that could boost morale in HIV care because attitude seems to be positively correlated with knowledge (Wu et al., 2002; Williams et al., 2006). The care of patients with HIV may often be far less than optimal because of inadequate knowledge, negative attitudes, and consequent fear.

The major limitation of the study was a change in the sample size between the baseline and follow-up data. In total, 240 nurses were chosen to participate in the study. In the baseline, 15% of those invited to participate in the study refused, and in the follow-up the proportion of those who refused to participate was 10%. This could influence the conclusions of the study.

Conclusions

HIV is a chronic disease, and nurses should be able to adequately address patients’ problems and needs. HIV is a socially stigmatized disease, and it is the responsibility of health care workers in general and nurses in particular to address this issue for the well-being of patients and family members affected by HIV.

Lithuania is considered to be a country with low HIV prevalence. Despite the benefits of nurses’ education (in college, university, and workplace; e.g., Mockiene et al., 2010; Williams et. al., 2006) and a number of recommendations aiming to ensure that nurses receive information (e.g., International Center for HIV/AIDS Research and Clinical Training in Nursing, 2010; Lithuanian nursing staff training and specialization centre, 2010), differences in the effect of nurse education on clinical practice have been reported. In our opinion, this fact has a negative effect on awareness in Lithuania. This study is the first nursing intervention study and the first attempt to use RCTs in Lithuania. Our education intervention opened a door to discussion about sensitive topics such as sexual behavior, stigma, and homosexuality in Lithuanian society.

The results of this study offer a realistic model for further education of Lithuanian nurses in this topic area. Consequently, a more organized education structure and more outcome research must play a leading role in education strategies to help nurses and future researchers understand and change their attitudes toward those living with HIV.

Clinical Considerations

  • A 2-day teaching program can have a positive impact on nurses’ knowledge levels.
  • The use of written materials only is insufficient to increase knowledge levels and promote positive attitudes concerning sensitive topics in nursing care.
  • Nurses need more information and have to keep up with the new knowledge about HIV infection; they should be given a chance to explore their attitudes about the disease.

Disclosures

The authors report no real or perceived vested interests that relate to this article that could be construed as a conflict of interest.

Acknowledgment

This study was funded by the Finish Nursing Education Foundation, which is gratefully acknowledged. We would also like to thank the nurses in Lithuania and others for their contributions to this study.

References

Bharat, S., & Mahendra, V. S. (2007). Meeting the sexual and reproductive health needs of people living with HIV: Challenges for health care providers. Reproductive Health Matters, 15, 93-112. doi:10.1016/S0968-8080(07)29030-5
Burns, N., & Grove, S. K. (2001). The practice of nursing research: Conduct, critique and utilization (4th ed.). Philadelphia, PA: Saunders.
Caplinskas, S. (2004). Epidemiology of HIV/AIDS in Lithuania in 1988-2001: Review of present situation and prognosis of HIV transmission trends. Medicina, 20, 161-168.
Charuluxananan, S., Somboonviboon, W., Kunthollaxami, A., Migasena, R., & Chinachot, T. (2000). Effect of national seminar on AIDS and anesthesia upon knowledge, attitude and practice concerning HIVamong Thai anesthesia personnel. Journal of the Medical Association of Thailand, 83, 174-181.
Dijkstra, A., Kangawaza, E., Martens, C., Boer, H., & Rasker, J. J. (2007). Knowledge about HIV/AIDS and policy knowledge in a South African state hospital. Journal of Social Aspects of HIV/AIDS Research Alliance, 4, 636-639.
Ezedinachi, E. N., Ross, M. W., Meremiku, M., Essien, E. J., Edem, C. B., … Ita, O. (2002). The impact of an intervention to change health workers{L-End} ' HIV/AIDS attitudes and knowledge in Nigeria: A controlled trial. Public Health, 116, 106-112. doi: 10.1038/sj.ph.1900834
Glazier, R. H., Rackal, J. M., Tynan, A. M., Iacona, S., & Handford, F. (2002). Provider training and experience for people living with HIV/AIDS. (Protocol). Cochrane Database of Systematic Reviews. (Issue 3) doi: 10.1002/1465 1858.CD00393
Gross, R. D. (1987). Psychology. London, England: Edward Arnold.
Gueron, J. M. (2002). The politics of random assignment: Implementing studies and affecting policy. In F. Mosteller, & R. Boruch (Eds.), Evidence matters: Randomized trials in education research (pp. 15-49). Washington, DC: Brookings institution press.
Gurung, A. B., & Sangchart, B. (2008). Nurses knowledge, attitude and willingness to take care for HIV/AIDS patients in Bhutan. Khon Kaen University Research Journal, 8, 53-64.
Held, S. L. (1993). The effects of an AIDS education program on the knowledge and attitudes of a physical therapy class. Physical Therapy, 73, 156-164.
Hentgen, V., Jaureguiberry, S., Ramiliarisoa, A., Andrianantoandro, V., & Belec, M. (2002). Knowledge, attitude and practices of health personnel with regard to HIV/AIDS in Tamatave (Madagascar). [Abstract]. Bulletin de la Société de pathologie exotique, 95, 103-108.
International Center for HIV/AIDS Research and Clinical Training in Nursing. (2010). Overview, research, clinical training. Retrieved from http://nurseweb.ucsf.edu/www/ctrhiv.htm
Juan, C.-W., Siebers, R., Wu, F. F.-S., Wu, C.-J., Chang, Y.-J., & Chao, C. (2004). The attitudes, concerns, gloving practices and knowledge of nurses in a Taiwanese hospital regarding AIDS and HIV. International Journal of Nursing Practice, 10, 32-38. doi: 10.1111/j.1440-172X.2003.00455.x
Kinnersley, P., Edwards, A. G. K., Hood, K., Cadbury, N., Ryan, R., Prout, H., & Butler, C. (2007). Interventions before consultations for helping patients address their information needs. Cochrane Database of Systematic Reviews. (Issue 3) doi: 10.1002/14651858.CD004565.pub2
Kowalski, K. M., & Vaught, C. (2002). Principles of adult learning: Application for mine trainers. NIOSH Information Circular, 9463, 3-8.
Lithuanian AIDS Centre. (2009). Statistical data. Retrieved from: http://www.aids.lt/stats.lt.php?id=1
Lithuanian nursing staff training and specialization centre. (2010). List of programmes. Retrieved from http://www.sdtsc.lt/index.php?id=203
McCann, T. V., & Sharkey, R. J. (1998). Educational intervention with international nurses and changes in knowledge, attitudes and willingness to provide care to patients with HIV/AIDS. Journal of Advanced Nursing, 27, 267-273. doi: 10.1046/j. 1365-2648.1998.00513.x
Mockiene, V., Suominen, T., Välimäki, M., & Razbadauskas, A. (2010). Impact of intervention programmes on nurses{L-End} ' knowledge, attitudes, and willingness to take care of patients with human immunodeficiency virus/acquired immunodeficiency syndrome: A descriptive review. Medicina, 46, 159-168.
Mohsen, A. M. (1998). Assessment and upgrading of knowledge and attitudes among nurses and university graduates towards AIDS. Journal of Egypt Public Health Association, 73, 433-448.
Nelson, L. S. (1985). Sample size tables for analysis of variance. Journal of Quality Technology, 17, 168-169.
Nkowane, A. M., & Saxena, S. (2004). Opportunities for an improved role for nurses in psychoactive substance use: Review of the literature. International Journal of Nursing Practice, 10, 102-110. doi: 10.1111/j.1440-172X.2004. 00471.x
Oakley, A., Strange, V., Bonell, C., Allen, E., & Stephenson, J. (2006). Process evaluation in randomised controlled trials of complex interventions. British Medical Journal, 332, 413-416. doi: 10.1136/bmj.332.7538.413
Petroll, A. E., Hare, C. B., & Pinkerton, S. D. (2008). The essentials of HIV: A review for nurses. Journal of Infusion Nursing, 31, 228-235. doi: 10.1097/01.NAN.0000326831. 82526.c4
Pisal, H., Sutar, S., Sastry, J., Kapadia-Kundu, N., Joshi, A., Joshi, M., & Shankar, A. V. (2007). Nurses health education program in India increases HIV knowledge and reduces fear. Journal of the Association of Nurses in AIDS Care, 18, 32-43. doi: 10.1016/j.jana.2007.06.002
Suominen, T., Koponen, N., Staniuliene, V., Istomina, N., Aro, I., Kisper-Hint, I.-R., … Välimäki, M. (2008). Nurses{L-End} ' and nursing students{L-End} ' perceptions of sexual risk behavior: A study in Finland, Estonia, and Lithuania. AIDS Patient Care and STDs, 22, 803-810. doi: 10.1089/apc.2008.0023
Suominen, T., Koponen, N., Mockiene, V., Raid, U., Istomina, N., Vänskä, M.-L., … Välimäki, M. (2010). Nurses{L-End} ' knowledge and attitudes of HIV/AIDS: An international comparison between Finland, Estonia and Lithuania. International Journal of Nursing Practice, 16, 138-147. doi:10.1111/ j.1440-172X.2010.01822.x
Uwakwe, C. B. U. (2000). Systematized HIV/AIDS education for student nurses at the University of Ibadan, Nigeria: Impact on knowledge, attitudes and compliance with universal precautions. Journal of Advanced Nursing, 32, 416-424. doi: 10.1046/j.1365-2648.2000.01492.x
Williams, A. B., Wang, H., Burgess, J., Wu, C., Gong, Y., & Li, Y. (2006). Effectiveness of an HIV/AIDS educational programme for Chinese nurses. Journal of Advanced Nursing, 53, 710-720. doi: 10.1111/j.1365-2648.2006.03777.x
World Health Organization. (2002). Nursing role in HIV/AIDS care and prevention in South-East Asia Region: A review. New Delhi, India: World Health Organization Regional Office for South-East Asia.
Wu, Z., Detels, R., Ji, G., Xu, C., Rou, K., & Li, V. (2002). Diffusion of HIV/AIDS knowledge, positive attitudes, and behaviors through training of health professionals in China. AIDS Education and Prevention, 14, 379-390. doi: 10.1521/ aeap.14.6.379.24074
Keywords:

attitude; education; HIV; knowledge; Lithuania; nurse

© 2011Elsevier, Inc.