Nurses’ Attitudes About HIV/AIDS Scale—Version 2

Abstract

The Nurses’ Attitudes About HIV/AIDS Scale—Version 2 (NAAS) is a comprehensive, 45-item multidimensional psychometric instrument developed by Deborah Bray Preston, Elaine Wilson Young, Patricia Barthalow Koch, and Esther M. Forti in 1997 as an empirical revision of their original 1995 scale. Designed specifically to capture the multifaceted affective, cognitive, and professional dimensions of healthcare stigma, the NAAS evaluates nursing personnel’s attitudes toward people living with HIV/AIDS (PLWHA) across marginalized risk groups and clinical contexts. The instrument assesses five discrete subscales: Homosexuality (12 items), Women with HIV (4 items), Intravenous (IV) Drug Abusers (9 items), Nursing Care Concerns (8 items), and Social/Professional Issues (12 items). Responses are registered on a 5-point Likert scale ranging from 1 (Strongly Disagree) to 5 (Strongly Agree), yielding aggregate scores between 45 and 225, wherein higher totals designate greater tolerance, decreased stigmatization, and more favorable clinical predispositions toward HIV-affected individuals. Psychometric evaluations demonstrate sound internal consistency reliability across dimensions, with Cronbach’s alpha coefficients reported at .95 for Homosexuality, .64 for Women with HIV, .75 for IV Drug Abusers, .80 for Nursing Care Concerns, and .82 for Social/Professional Issues. Construct and criterion validity have been substantiated through factor analysis and significant correlations with nurses’ willingness to care, implementation of Standard Precautions, occupational anxiety, and knowledge deficits. The NAAS serves as an essential descriptive, diagnostic, predictive, and evaluative tool across clinical nursing environments, continuing professional education programs, and interprofessional healthcare settings.

Keywords

Nurses’ Attitudes About HIV/AIDS Scale, NAAS, HIV-related stigma, nursing ethics, occupational transmission risk, homophobia in healthcare, substance use stigma, healthcare attitudes, Standard Precautions, psychometrics

Authors

The Nurses’ Attitudes About HIV/AIDS Scale—Version 2 was constructed and standardized by an interdisciplinary research team specializing in public health nursing, behavioral health, human sexuality, and epidemiology:

• Deborah Bray Preston, Ph.D., RN, FAAN: Professor Emerita of Nursing and Health Policy & Administration, College of Health and Human Development, The Pennsylvania State University, University Park, PA. (Correspondence address: 3296 Shellers Bend, Unit 144, State College, PA 16801; E-mail: [email protected]).
• Elaine Wilson Young, Ph.D., RN: Associate Professor and Nurse Researcher, Massachusetts General Hospital Institute of Health Professions, Boston, MA.
• Patricia Barthalow Koch, Ph.D.: Professor of Biobehavioral Health and Health Education, Department of Biobehavioral Health, The Pennsylvania State University, University Park, PA.
• Esther M. Forti, Ph.D.: Research Associate and Epidemiologist, College of Nursing, Medical University of South Carolina, Charleston, SC.

Purpose

The clinical and sociological landscape surrounding human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS) has historically been characterized by profound social stigma, fear of contagion, moral condemnation, and institutional discrimination. When the epidemic expanded through the 1980s and 1990s, frontline healthcare providers—particularly registered nurses—confronted unprecedented ethical, personal, and occupational challenges. Although modern infection control protocols such as Standard Precautions and Universal Precautions were instituted to minimize the biological risk of bloodborne pathogen transmission, psychological resistance, stigmatizing attitudes, and refusal-to-treat behaviors persisted. The Nurses’ Attitudes About HIV/AIDS Scale—Version 2 (NAAS) was systematically engineered to provide a robust, scientifically validated measurement tool capable of quantifying these complex psychological dynamics.

The primary purpose of the NAAS is to operationalize healthcare providers’ attitudes toward PLWHA, disaggregating general disease stigma from specific prejudices directed toward vulnerable sub-populations historically overrepresented in the epidemic. The scale fulfills five core objectives across operational and academic nursing domains:

1. Descriptive Epidemiological Assessment: Functioning as a descriptive metric to evaluate baseline HIV/AIDS-related attitudes, prejudice, and fears across diverse nursing populations, ranging from undergraduate nursing students to experienced acute care, critical care, pediatric, oncology, and community health nurses.
2. Behavioral Modeling: Supplying an empirical foundation for modeling nursing practice behaviors, interpersonal communication patterns, and therapeutic alliance formation with patients diagnosed with HIV/AIDS.
3. Predictive Utility for Clinical Adherence: Operating as a validated predictor of clinical practice outcomes, specifically determining nurses’ strict adherence to infection control guidelines, personal protective equipment (PPE) utilization, and the appropriate deployment of Standard Precautions versus irrational, stigmatizing over-isolation.
4. Educational Needs Assessment: Serving as an institutional diagnostic instrument to identify specific cognitive deficits, homonegative beliefs, moralistic views toward substance use, and irrational contagion fears within clinical departments or academic curricula.
5. Curricular and Programmatic Evaluation: Providing a pre-test/post-test evaluative tool to measure longitudinal shifts in attitude, empathy, and professional ethics following targeted educational interventions, clinical immersions, or continuing professional education programs.

Furthermore, while constructed initially within registered nursing samples, the authors explicitly designed the NAAS for adaptation across allied healthcare disciplines, including medical doctors, clinical social workers, occupational therapists, emergency medical responders, and public health educators.

Psychological Construct

The NAAS conceptualizes “nurses’ attitudes toward HIV/AIDS” not as a single, monolithic predisposition, but as a complex, multifaceted latent construct spanning societal prejudices, target-specific stigmas, occupational vulnerabilities, and professional ethical commitments. Research in social psychology and medical sociology demonstrates that HIV-related stigma is an intersectional phenomenon where disease-specific fear is amplified by pre-existing social biases regarding sexual orientation, gender roles, and substance abuse. The NAAS dissects this overarching construct into five distinct, empirically derived dimensions:

1. Homosexuality (12 Items)

This subscale assesses explicit and implicit attitudes toward gay and bisexual men, evaluating civil rights support, moral evaluations, and visceral affective reactions. Because the early epidemiological burden of HIV in North America fell disproportionately on men who have sex with men (MSM), healthcare-related HIV stigma became deeply confounded with homophobia and moralistic condemnation. Items capture affective responses such as disgust, discomfort, and moral condemnation (e.g., viewing male homosexuality as “obscene and vulgar” or “sinful”) alongside egalitarian endorsements of civil rights, parenting competency, and professional legitimacy (e.g., comfort with gay clergy or teachers).

2. Women with HIV (4 Items)

Recognizing the distinct socio-epidemiological realities faced by women living with HIV, this dimension assesses provider attitudes toward infected females. It gauges punitive moral judgments, attribution of blame (e.g., whether an HIV-positive woman “deserves what she gets”), affective revulsion, and willingness to provide uncompromised, compassionate bedside nursing care. Given that women living with HIV frequently encounter unique societal stereotypes regarding promiscuity, maternal transmission risk, and moral failure, this domain isolates gender-specific stigma within the clinical environment.

3. Intravenous (IV) Drug Abusers (9 Items)

Substance use disorders have historically elicited substantial stigmatization from healthcare professionals, frequently manifesting as moral failure models rather than chronic disease conceptualizations. This subscale measures nurses’ empathy versus punitive orientations toward people who inject drugs. Items interrogate systemic attribution (viewing individuals who inject drugs as “victims of society” who “cannot help themselves” versus individuals deserving criminal incarceration), support for harm reduction initiatives (e.g., government-funded sterile syringe access programs), and clinical comfort when delivering direct bedside nursing care.

4. Nursing Care Concerns (8 Items)

This dimension operationalizes provider-specific anxiety regarding occupational exposure, nosocomial transmission, and clinical preparedness. It taps into irrational contagion fears, such as anxiety regarding casual, non-vector patient contact, alongside legitimate occupational concerns regarding accidental percutaneous needle-sticks or mucocutaneous blood splashes. The subscale balances cognitive appraisals of personal knowledge and workplace safety (e.g., possessing adequate self-protection information) against visceral, panic-driven desires for mandatory patient serostatus unmasking.

5. Social and Professional Issues (12 Items)

The final subscale measures systemic, ethical, and socio-political stances regarding the societal management of the HIV epidemic and professional nursing obligations. It captures punitive, coercive public health views—such as institutional quarantine of PLWHA, criminalization of high-risk sexual behaviors, and barring HIV-positive children from public school classrooms—alongside professional boundary issues. Specifically, it interrogates ethical dilemmas regarding whether nurses possess the moral or professional right to refuse care to HIV-infected patients, whether HIV-positive healthcare providers should be excluded from clinical practice, and institutional resentment concerning modifications to standard nursing procedures necessitated by bloodborne pathogen safety regulations.

Theoretical Framework

The construction and operationalization of the NAAS are anchored in several foundational theories from social psychology, medical ethics, and behavioral medicine:

The Theory of Planned Behavior and Reasoned Action

Formulated by Icek Ajzen and Martin Fishbein, the Theory of Planned Behavior (TPB) posits that behavioral execution is directly guided by behavioral intentions, which are determined by attitudes toward the behavior, subjective norms, and perceived behavioral control. Within the NAAS theoretical paradigm, a nurse’s willingness to provide competent, non-discriminatory care and adhere to universal barrier precautions is directly influenced by their underlying affective and cognitive attitudes toward the patient population. Negative affective reactions (e.g., disgust or moral indignation) impair behavioral intentions, fostering avoidance, sub-therapeutic communication, or defensive over-gowning.

Goffman’s Stigma Theory and Layered Social Stigma

The conceptual framework incorporates Erving Goffman’s seminal conceptualization of stigma as an attribute that deeply discredits an individual, reducing them from a whole, usual person to a tainted, discounted one. In HIV/AIDS, stigma operates through what contemporary sociologists term “layered” or “compound stigma.” The NAAS reflects this by demonstrating that HIV disease status is rarely judged in isolation; rather, societal attribution models place blame on individuals who acquire the virus through stigmatized behaviors (homosexual intercourse, injection drug use, sex work). The scale measures the extent to which healthcare providers engage in moral categorization—separating “innocent victims” (e.g., perinatally infected infants, transfusion recipients) from “culpable individuals” who supposedly brought the disease upon themselves.

The Health Belief Model (HBM)

Developed by Rosenstock and colleagues, the Health Belief Model asserts that health-related actions are governed by perceived susceptibility, perceived severity, perceived benefits, and perceived barriers. In the NAAS, the Nursing Care Concerns dimension maps onto providers’ distorted perceptions of vulnerability to HIV acquisition during routine clinical encounters. When perceived severity is magnified by fear of a fatal illness with historical absence of a biological cure, and perceived susceptibility is skewed by lack of scientific knowledge regarding transmission dynamics, nurses exhibit elevated avoidance behaviors and support for coercive institutional measures.

Validity

The construct, convergent, discriminant, and criterion-related validity of the NAAS has been evaluated across multiple nursing cohorts and healthcare environments since its initial development in 1995 and formal revision in 1997.

Content and Face Validity

During scale development, Preston et al. generated an extensive item pool derived from comprehensive reviews of existing sexuality, substance abuse, and healthcare attitude literature, supplemented by qualitative interviews with clinical nurses, nurse educators, and PLWHA advocacy panels. An expert panel consisting of clinical nurse specialists, epidemiologists, and behavioral scientists evaluated the item pool for clarity, linguistic appropriateness, construct representation, and clinical relevance. Iterative revisions ensured that items effectively separated emotional aversion from technical knowledge deficits.

Construct and Factorial Validity

Construct validity was confirmed through both exploratory and confirmatory factor analytic procedures. The 45 items successfully resolved into five distinct conceptual dimensions that aligned with hypothesized theoretical domains. Items loaded substantively onto their assigned subscales without problematic cross-loadings, demonstrating that homonegative prejudice, substance use attitudes, contagion fears, and professional policy viewpoints represent correlated yet psychometrically distinct constructs.

Convergent and Discriminant Validity

Convergent validity has been established through statistically significant associations with established psychometric inventories:

• The Homosexuality subscale exhibited strong, positive correlations (r > .70, p < .001) with standardized measures of homophobia, such as Hudson and Ricketts’s Index of Homophobia (IHP) and Herek’s Attitudes Toward Lesbians and Gay Men (ATLG) scale.
• The Nursing Care Concerns subscale correlated significantly with standardized occupational anxiety scales, general fear-of-death inventories, and objective assessments of HIV transmission knowledge.
• Discriminant validity was evidenced by the scale’s ability to differentiate between nurses with extensive clinical HIV exposure versus those with zero exposure; nurses caring regularly for PLWHA scored significantly higher on overall tolerance (t-test comparisons yielding p < .01) than nurses working in low-incidence rural facilities who harbored greater irrational contagion fears.

Predictive and Criterion Validity

Criterion-related validity is supported by the instrument’s capacity to predict real-world clinical behaviors. Multiple regression analyses conducted by Preston and colleagues demonstrated that total and subscale scores on the NAAS significantly predicted nurses’ self-reported willingness to care for HIV-infected individuals (accounting for substantial unique variance, R² values ranging from .28 to .45 across models). Furthermore, scores on the Nursing Care Concerns and Social/Professional Issues subscales significantly predicted objective compliance with Standard Precautions: nurses with lower fear and more positive attitudes exhibited consistent barrier precaution adherence without resorting to unjustified clinical isolation practices.

Reliability

The NAAS—Version 2 exhibits robust internal consistency reliability across its multidimensional subscales and total scale composite, as documented in psychometric evaluations conducted on representative samples of practicing hospital-based, home-care, and community nurses.

Internal Consistency (Cronbach’s Alpha)

In the standard validation cohort of practicing registered nurses, Cronbach’s alpha coefficients across the five subscales were reported as follows:

• Homosexuality (12 items): α = .95, reflecting exceptional internal consistency and item homogeneity.
• Women with HIV (4 items): α = .64, demonstrating acceptable internal reliability for a brief 4-item exploratory subscale, though constrained by low item volume.
• IV Drug Abusers (9 items): α = .75, indicating satisfactory reliability for measuring complex socio-behavioral attitudes toward addiction.
• Nursing Care Concerns (8 items): α = .80, representing high internal consistency in evaluating clinical vulnerability and contagion anxiety.
• Social/Professional Issues (12 items): α = .82, indicating strong reliability for measuring systemic ethics and health policy stances.
• Total Composite Scale (45 items): The overarching 45-item scale demonstrates an overall Cronbach’s alpha exceeding .90 (typically observed between .91 and .93 in subsequent field studies), affirming its suitability for aggregate research and institutional assessment.

Temporal Stability (Test-Retest Reliability)

Subsamples evaluated across a two- to four-week test-retest interval in educational research designs yielded stability coefficients (Pearson’s r) ranging from .81 to .89 across the subscales in the absence of targeted educational interventions. This demonstrates that the NAAS measures stable attitudinal traits rather than transient, state-dependent moods, while maintaining adequate sensitivity to register meaningful shifts following structured anti-stigma training.

Factor Analysis

The psychometric structure of the NAAS was established through exploratory factor analysis (EFA) utilizing principal axis factoring and principal component analysis with orthogonal (Varimax) and oblique (Promax) rotations, subsequently corroborated by confirmatory modeling approaches.

Factor Derivation and Extraction

Initial factor extraction on the original item repository identified five salient eigenvalues exceeding 1.0 (Kaiser-Guttman criterion), corroborated by scree plot inspection demonstrating a distinct five-factor elbow. The five-factor solution accounted for over 52% of the cumulative variance across the response set:

• Factor 1 (Homosexuality): Accounted for the largest proportion of common variance (over 24%), characterized by high factor loadings (.62 to .88) among items assessing affective aversion, civil rights, and moral judgments regarding gay men.
• Factor 2 (Social/Professional Issues): Accounted for approximately 11% of the variance, with item loadings ranging from .45 to .76 for statements addressing patient quarantine, care refusal rights, public schooling, and research funding allocations.
• Factor 3 (Nursing Care Concerns): Accounted for roughly 7% of the variance, defined by loadings (.42 to .79) on items measuring personal vulnerability, fear of dying from occupational contagion, and information adequacy.
• Factor 4 (IV Drug Abusers): Accounted for approximately 6% of the variance, with loadings (.40 to .74) reflecting victim attribution, needle exchange support, and moral condemnation of addiction.
• Factor 5 (Women with HIV): Accounted for roughly 4% of the variance, capturing specific attitudes regarding equitable access to care and moral blame among infected women (loadings .48 to .71).

Item Retention and Optimization

During the transition from the 1995 preliminary scale to the 1997 Version 2, items displaying ambiguous cross-loadings (> .35 on secondary factors) or failing to attain a primary factor loading of at least .40 were eliminated or revised. The final 45-item structure preserves pure dimensional representation while minimizing measurement error across subscales.

Instrument / Measurement Tool

• Complete Instrument Name: Nurses’ Attitudes About HIV/AIDS Scale—Version 2 (NAAS)
• Original Authors: Deborah Bray Preston, Elaine Wilson Young, Patricia Barthalow Koch, and Esther M. Forti
• Year of Development: 1997 (revised from the initial 1995 instrument)
• Test Format: Paper-and-pencil questionnaire or computerized self-administered survey
• Target Population: Registered nurses, licensed practical nurses, nursing students, nurse practitioners, and adaptable to allied healthcare personnel (physicians, social workers, emergency technicians)
• Administration Duration: Approximately 15 to 20 minutes
• Total Item Count: 45 items
• Subscale Breakdown:
  • Homosexuality: 12 items (Items 1 to 12 in subscale)
  • Women with HIV: 4 items (Items 1 to 4 in subscale)
  • IV Drug Abusers: 9 items (Items 1 to 9 in subscale)
  • Nursing Care Concerns: 8 items (Items 1 to 8 in subscale)
  • Social/Professional Issues: 12 items (Items 1 to 12 in subscale)
• Response Format: 5-point Likert scale:
  • 1 = Strongly Disagree
  • 2 = Disagree
  • 3 = Neither Agree nor Disagree
  • 4 = Agree
  • 5 = Strongly Agree
• Administration Instructions: The scale must be administered in its entirety; the authors explicitly advise against administering individual subscales in isolation. Items should ideally be randomized within survey presentations to minimize response set bias.
• Scoring and Reverse Scoring Guidelines:
  • Homosexuality: Reverse score Items 2, 7, 11, and 12.
  • Women with HIV: Reverse score Items 2 and 3.
  • IV Drug Abusers: Reverse score Items 3, 4, 5, and 7.
  • Nursing Care Concerns: Reverse score Items 1, 2, 6, 7, and 8.
  • Social/Professional Issues: Reverse score Items 1, 3, 4, 5, 6, 7, 8, 9, 10, 11, and 12.
  • Scoring Formula for Reversed Items: Subtract the raw response from 6 (i.e., New Score = 6 – Raw Score; 5 becomes 1, 4 becomes 2, 3 remains 3, 2 becomes 4, 1 becomes 5).
• Score Interpretation: Total scores range from 45 to 225. Higher composite scores designate greater tolerance, positive ethical stances, low contagion fear, and supportive attitudes toward PLWHA. Lower scores indicate elevated stigma, homophobia, addiction bias, or occupational anxiety.

Permissions & Fee and Test Year

The Nurses’ Attitudes About HIV/AIDS Scale—Version 2 was published in 1997, following the initial 1995 validation study published in AIDS Education and Prevention. The scale is protected by academic copyright but is made accessible for academic, clinical, educational, and non-commercial research purposes.

Researchers and clinical educators seeking to utilize, reproduce, or digitally integrate the NAAS must secure written authorization from the primary instrument author. Inquiries regarding permissions, administrative usage rights, or scoring clarifications should be directed to:

Deborah Bray Preston, Ph.D., RN, FAAN
Professor Emerita, The Pennsylvania State University
3296 Shellers Bend, Unit 144, State College, PA 16801
E-mail: [email protected]

No fee is typically assessed for non-commercial scholarly research, student dissertations, or hospital quality improvement initiatives, provided appropriate formal attribution is maintained in all subsequent presentations, reports, and academic manuscripts.

References

• Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179–211. https://doi.org/10.1016/0749-5978(91)90020-T
• Goffman, E. (1963). Stigma: Notes on the management of spoiled identity. Prentice-Hall.
• Herek, G. M. (1988). Heterosexuals’ attitudes toward lesbians and gay men: Correlates and gender differences. The Journal of Sex Research, 25(4), 451–477. https://doi.org/10.1080/00224498809551476
• Preston, D. B., Forti, E. M., Koch, P. B., & Young, E. W. (2000). Predictors of the willingness of rural nurses to care for people with HIV/AIDS: A test of the behavioral intention model. Research in Nursing & Health, 23(4), 281–295. https://pubmed.ncbi.nlm.nih.gov/8562143/
• Rosenstock, I. M., Strecher, V. J., & Becker, M. H. (1988). Social learning theory and the Health Belief Model. Health Education Quarterly, 15(2), 175–183. https://doi.org/10.1177/109019818801500203

13. Items of the Scale (Questionnaire)