Development of a contextual computer-based nursing simulation.

This paper will present a brief review of the use of simulations in clinical reasoning research and education, followed by a case-study describing the development of a research tool which attempted to elicit the decision-making strategies of novice and competent hospital nurses. The central feature of this simulation was the degree of flexibility and control it gave to the nurse participants over their information seeking strategies. The ability of this interactive multimedia simulation to mimic a real ward environment has a great potential in the teaching of clinical reasoning skills to health professionals.

Three lay mental models of disease inheritance.

Genetics are coming to play an increasing role in biomedical understanding of common diseases. The implication of such findings is that at-risk individuals may be offered predictive genetic tests. How do individuals make decisions about predictive tests and what information do they need to make informed choices? Richards [Richards, M.P.M., 1993. The new genetics: some issues for social scientists. Sociology of Health and Illness 15, 567-586] has argued the first step in understanding and helping people to make these decisions is to investigate lay beliefs of genetics. This study examined mental models of inheritance in a sample of 72 lay people. Through analysis of open-ended questionnaires we found three mental models which loosely corresponded to three phases of historical development in the science of genetics. These we labelled the Constitutional, Mendelian and Molecular Models. Predictions for individuals holding each model are made for the comprehension of genetic information in a testing situation.

Lay representations of genetic disease, and predictive testing.

As research in human genetics advances, genes for familial forms of cancer and heart disease will continue to be identified. The implication of such findings is that at-risk individuals will be offered a predictive genetic test. How do individuals make such decisions and what information do they need to make informed choices? Richards (1993) has argued that the first step in understanding and helping people to make these decisions is to investigate lay beliefs of genetics. This study examined illness representations of genetic disease, and predictive testing in a sample of 20 educated lay people. Through content analysis of open-ended interviews, we discovered that individuals have limited knowledge of late-onset genetic disorders and predictive testing. Most of the sample identified genetic diseases that manifest in childhood, and were more familiar with prenatal testing. They did not mention any treatment options for genetic disorders, which may indicate that lay people are more deterministic about diseases with a genetic component. Finally, they consistently raised concerns about the ethics of genetic testing and research. The implications of our findings for the provision of information in a genetic testing situation are discussed.

Primary care physicians and AIDS. Attitudinal and structural barriers to care.

OBJECTIVE: To explore the extent to which primary care physicians are providing health care for people with human immunodeficiency virus (HIV) infection and to document barriers to HIV care giving. DESIGN: National random-sample mailed survey. PARTICIPANTS: Population-based random sample of 2004 US general internists, family physicians, and general practitioners in 1990. Response rate was 59%. MAIN OUTCOME MEASURES: HIV treatment experience, willingness to treat HIV-infected patients, negative attitudes toward homosexuals and intravenous drug users, fear of contagion of the acquired immunodeficiency syndrome (AIDS), perceived lack of information about AIDS, and time demands of HIV care. RESULTS: Most physicians (75%) had treated one or more patients with HIV infection. A majority (68%) believed that they had a responsibility to treat people with HIV infection, yet half (50%) indicated that they would not, if given a choice. Over 80% of respondents believed that they lacked information about AIDS and that caring for people with AIDS is time consuming. Further, 35% of respondents agreed that they "would feel nervous among a group of homosexuals" and 55% expressed discomfort about having intravenous drug users in their practice. Physicians who had treated 10 or more HIV-infected patients expressed less negativity toward members of these stigmatized groups who are likely to be HIV infected. CONCLUSIONS: These data suggest that many primary care physicians are responding professionally to the AIDS epidemic but that attitudinal barriers may be hindering some physicians from providing treatment to HIV-infected patients.

Possible health care professional-to-patient HIV transmission. Dentists' reactions to a Centers for Disease Control report.

On July 27, 1990, the Centers for Disease Control reported possible transmission of the human immunodeficiency virus (HIV) from a dentist to a patient as a result of patient care. We surveyed a random national probability sample of 300 dentists with a 26-item survey in August and September 1990 to assess reactions to the report (response rate, 59%). Respondents tended not to believe the report (mean was 3.2, median 3.0, where 1 indicated "do not believe" and 7 indicated "believe"). Our sample also tended to believe that transmission of HIV from dentists to patients was unlikely in the future (mean was 2.0, median 2.0, where 1 indicated "not at all likely" and 7 indicated "very likely"). Fifty-one percent of our sample recommended that dentists infected with HIV should discontinue practice, while 38% recommended continuing practice with changes in procedures. Seventy-four percent believed patients should be told if their dentist was infected with HIV. In summary, dentists doubted the possibility of dentist-to-patient transmission of HIV and did not believe the Centers for Disease Control case report, but they did believe infected dentists should refrain from clinical work or modify their practice.

Planning, implementation, and evaluation of AIDS education programs for dentists.

Because many dentists were trained before HIV disease was recognized and its implications for dentistry understood, there is a need for effective continuing education programs about the disease for health professionals. Unfortunately, much of the continuing professional education about AIDS in the last few years has been poorly evaluated and the value of continuing education itself has increasingly been called into question. In order to clarify how continuing educational efforts can be designed and evaluated, we report on our continuing educational projects and research which culminated in research on a nationwide educational intervention about AIDS for dentists. We outline and evaluate the steps taken in designing both the intervention and the research. The strengths and weaknesses of the design are discussed and suggestions made about how the design could be improved.

The impact of who you know and where you live on opinions about AIDS and health care.

We hypothesized that public attitudes towards AIDS and the safety of health care in the era of HIV would be more positive for people who knew someone with AIDS. We believed, moreover, that living in areas with high AIDS prevalence would result in more favorable attitudes. To test these hypotheses, we conducted telephone interviews with a random sample of 2000 U.S. adults (response rate = 75%) in summer 1988. Overall 19.5% of respondents said that they knew someone with AIDS or the AIDS virus. Thirteen percent of people who lived in low prevalences areas reported knowing someone with AIDS, compared with 27% of those in areas of high prevalence. Of the total sample, 38% reported knowing someone they believed was at risk. People who knew someone with AIDS were less likely to say they would change physicians or dentists if their provider was HIV infected or was known to be treating people who were infected. Knowing someone with AIDS was also associated with greater tolerance for those with AIDS to continue to work if they were able and with lower perception of risk of transmission in health care settings. Multivariate regression analyses indicated that personal contact was related to more positive attitudes. Counter to our hypothesis, living in a high prevalence area had no independent effect on attitudes. This surprising finding suggests that, after controlling for personal contact with someone with AIDS, where one lives does not influence attitudes. Because bringing people with AIDS into contact with others may have positive outcomes, we suggest implementation of interventions using this strategy.

Public perception of risk of AIDS in health care settings.

Our nationwide telephone survey conducted in 1988 (n = 2,000) reveals that the public perceives a considerable risk of contracting AIDS during routine transactions in health care settings. In addition to previously noted public concerns about getting infected with the AIDS virus through blood transfusions and blood donations, respondents also think that AIDS can be transmitted through contact with HIV-infected health care workers during routine treatment in medical or dental offices and in hospital emergency rooms. Effective education programs must be developed to address these public concerns.

Are nurse practitioners prepared for the AIDS epidemic?

Treatment of HIV-infected individuals will become a regular part of mainstream medical practice because of the increasing numbers of infected persons, the geographical dispersion of the disease, and the routine nature of much of the care required by seropositive patients. Nurse practitioners, like other health care professionals, need to be willing and able to provide such primary care. One hundred sixty-five NPs constituted an opportunity sample that was surveyed using an instrument that had been adapted from one used successfully in studies of other health professionals. The instrument consisted of 80 forced-answer and six open-ended questions. The response rate was 63 percent. It was found that nurse practitioners believed there was moderate risk of occupational contraction of HIV. NPs were more likely to agree on activities they believed to be of low risk than about the danger of perceived higher-risk activities. The respondents judged themselves as fairly competent in their ability to provide counseling and information to patients about HIV and risk-reduction. Half believed that their lack of knowledge was the biggest barrier to providing care to HIV-infected persons. Eighty-five percent thought courses on the medical aspects of AIDS were necessary, and 78 percent wanted courses in the social, ethical and legal implications of the disease. This study shows that there is a widely perceived need for continuing education on both medical and social aspects of AIDS in order to enable nurse practitioners to play a greater role in primary care provision for persons with AIDS.

Are patients talking to their physicians about AIDS?

We conducted a nationwide telephone survey of a random sample of United States adults in summer 1988 (n = 2000, response rate = 75 percent) to find out if physicians were providing education and counseling to the public about AIDS and AIDS prevention. Within the previous five years, 94 percent had seen a physician but only 15 percent had discussed AIDS even though most said they would not object to discussing the topic. AIDS-related conversations are not commonplace in physician's offices and in most cases (72 percent) patients are the initiators of such conversations.

Dental care experience of HIV-positive patients.

Three studies were conducted to assess the experiences of persons with acquired immune deficiency syndrome (AIDS) or risk factors for the disease in seeking dental care in Los Angeles; San Francisco; Seattle; and Tacoma, WA. Given previous reports from surveys of dentists that they would be reluctant to provide care to people from these groups, widespread denial of care was expected. Our two surveys conducted in San Francisco, however, showed that only 1.3% and 10.8% had been denied care by a dentist. These data suggest that dentist reactions to people with AIDS are more favorable than has previously been suggested, although denial of care is still a problem to some extent.

Physicians and acquired immunodeficiency syndrome. What patients think about human immunodeficiency virus in medical practice.

Are patients concerned about going to a physician who is infected with human immunodeficiency virus (HIV) or one who is treating HIV-infected patients? To answer these questions, we surveyed a nationwide sample of 2000 interviews (response rate, 75%). Forty-five percent of all respondents believed that physicians who were HIV infected should not be allowed to continue to practice. More than half of those who had seen a physician in the past 5 years said they would change physicians if they knew their physician were HIV infected, while one fourth said they would seek care elsewhere if their physician were treating people with HIV disease. These data suggest that patients are concerned about HIV in their physicians' offices. The American Medical Association recommends that HIV-infected physicians continue to practice as long as there is no risk to their patients. Physicians and the public need to be educated about this policy and its appropriateness.

KIE: The authors surveyed a nationwide sample of 2,000 Americans to assess public concern about AIDS in physicians' offices. Forty-five percent of all respondents believed that HIV-positive doctors should not be allowed to practice, although only 33% believed that it was very or somewhat likely that they could get AIDS from an infected physician. Many respondents who had seen a doctor within the last five years said that they would switch physicians if their doctor was infected with HIV or was treating HIV-infected patients. Gerbert, et al. conclude that their data is troubling for HIV-infected doctors. They urge physicians to begin to educate the public about the safety of doctors' offices, and to reassure patients that the medical profession is policing itself concerning physicians with HIV infection.