Disability is a worldwide issue. According to the World Health Organization (WHO), more than 1 billion people throughout the world live with a condition that is classified as a disability. This number is expected to increase as populations age and the incidence of debilitating conditions such as diabetes, obesity, and cancer continues to grow (WHO, 2012).

Given these worldwide statistics, it is not surprising that a significant number of Americans live with a wide range of disabilities that affect them in a number of ways. In a recent report released by the U.S. Census Bureau (2012), nearly 60 million Americans (1 in 5) were estimated to have a disability, with almost half of these persons reporting a disability that was considered to be severe. According to Cornell University (2012), in 2011 almost 1 in 12 Americans aged 18-64 reported a disability severe enough to limit their ability to work.

Despite the statistics that imply disabilities are restricted to a certain percentage of the population, disabilities actually affect most people at some point in their lives. The aging process as well as the chronic and acute health conditions that affect almost everyone can cause temporary or permanent impairment in the functioning of people who were born without a disabling condition. As a consequence, nurses in all settings are likely to encounter clients who are facing the challenge of a functional impairment in themselves or in the family members they care for.

If the incidence of disabilities seems high, it is important to remember that not all disabilities are readily apparent. For example, among people with disabilities aged 15 and older, only 1.5% use a wheelchair, 0.02% are unable to have their speech understood, another 0.08% are unable to see, and 0.01% are unable to hear. By comparison, more than 4% of people with disabilities have a learning disability, 2% have a mental health problem, and almost 5% have a minor hearing or vision deficit—all disabilities that often remain hidden (U.S. Census Bureau, 2010).

Individuals with disabilities are more likely than people without disabilities to suffer health disparities and are less likely to receive preventive health services (Reichard, Stolzle, & Fox, 2011). For example, a review of the disabilities research conducted between 1990 and 2005 revealed disparities existed for women with disabilities in five categories—incidence of chronic disease, cancer, mental health and substance abuse, preventive screenings, and health-promoting behavior (Wisdom et al., 2010). Disparities such as these arise for a number of reasons. Some disabilities are associated with additional chronic health problems. For example, Down syndrome—a common cause of intellectual disability—is associated with a
number of chronic physical conditions, including heart disease, epilepsy, and leukemia. In the case of Down syndrome, the associated intellectual disability complicates the chronic health conditions; that is, individuals with Down syndrome are less likely to access health services due to fear, lack of understanding on the part of caregivers, and environmental barriers (Vander Ploeg Booth, 2011). For some people with disabilities, the cost of care is a contributing factor to health disparities. For example, Lee, Hasnain-Wynia, and Lau (2012) found that older adults with disabilities encountered greater economic difficulties in seeing a doctor despite having health insurance and a usual source of care.

It has been said that people with disabilities represent the U.S.’s largest minority group, a group that comprises individuals of all ages, of all racial and ethnic backgrounds, and from all walks of life (Disability Funders Network, 2012). Health care for this group of people is often complex and costly. More than 25% of healthcare expenditures in the United States are associated with disability care, borne largely by Medicaid and the public sector (Anderson, Armour, Finkelstein, & Wiener, 2010). As educators, nurses can play a significant role in promoting health and wellness, ensuring proper self-care, and improving overall quality of life.

Kaplan and the Center for an Accessible Society (2010) describe four models or perceptions of disabilities that influence the way in which disabilities are addressed in society:

The moral model, which views disabilities as sin, is an old model that unfortunately persists in some cultures. When a disability is viewed as sinful, individuals and their families not only experience guilt and shame but may also be denied the care they require. The United Nations has established a set of Standard Rules on the Equalization of Opportunities for Persons with Disabilities specifying that individuals with disabilities have a fundamental right of access to care, rehabilitation, and support services (WHO, 2012). WHO assists countries to comply with this United Nations ruling.

The medical and rehabilitation models are similar in that both view disabilities as problems requiring intervention, with the goal being cure or reduction of the perceived deficiency (Kaplan & Center for an Accessible Society, 2010). The health or rehabilitation professional is central to both models. Many positive results have come out of efforts to develop medical and surgical treatment, prostheses and other equipment, and strategies to improve the quality of life of people with disabilities. However, the underlying belief associated with these two models—namely, that people with disabilities must be “fixed”—has been criticized by disability advocates. The medical model, in particular, is blamed for promoting expensive procedures in an attempt to treat conditions that often cannot be cured.

The disabilities model, sometimes referred to as the social model, is the framework that has had the most influence on current thinking. The disabilities model embraces disability as a normal part of life and views social discrimination, rather than the disability itself, as the problem (Kaplan & Center for an Accessible Society, 2010). Whereas the medical and rehabilitation models focus on the problem or condition of the individual, the disabilities or social model views disability as a social construct and focuses on barriers in society that limit opportunities (Matthews, 2009).

The term disability has been defined in a number of ways, with many of these definitions reflecting one or more of the models described by Kaplan and the Center for an Accessible Society (2010).
Most definitions are broad and serve to categorize a wide variety of impairments stemming from injury, genetics, congenital anomalies, or disease. WHO (2012) defines disability as “a complex phenomenon, reflecting an interaction between features of a person’s body and features of the society in which he or she lives.” The connection that this definition makes between an individual’s ability and the expectations of society reflects the spirit of the disabilities model. WHO uses the International Classification of Functioning, Disability and Health (ICF) as a framework for measuring health and disability at the individual and population levels. Adopted in 2001, the ICF provides a means of classifying the consequences of disease and trauma and recognizes three dimensions of disabilities: body function/impairment, activity/restrictions, and participation/restrictions (Centers for Disease Control and Prevention [CDC], 2012d). The ICF identifies disability as a universal human experience and places emphasis on the impact of a disability rather than on its cause.

In the United States, the Social Security Administration (SSA) defines disability in terms of an individual’s ability to work. This definition and its associated criteria are designed to be used to determine eligibility for Social Security payments for individuals with severe disabilities. The criteria used by the SSA require that the individual be classified as disabled only if he or she has a condition that interferes with basic work activities. Individuals are approved for disability benefits if they are diagnosed with a condition that is severe enough to prevent them from engaging in gainful employment for an extended period of time. The SSA (2012) does not pay benefits for partial or short-term disability.

On July 26, 1990, President George H. W. Bush signed into law the Americans with Disabilities Act (ADA). The definition of disability under the ADA is “a physical or mental impairment which substantially limits one or more of the major life activities of the individual” (U.S. Department of Justice, 2009, p. 1). A major life activity includes functions such as caring for oneself, standing, lifting, reaching, seeing, hearing, speaking, breathing, learning, and walking. This significant legislation has extended civil rights protection to millions of Americans with disabilities. The first part of the law, which became effective in January 1992, mandated accessibility to public accommodations. The second part of the law went into effect in July 1992 and required employers to make reasonable accommodations in hiring people with disabilities (Merrow & Corbett, 1994; Pelka, 2012).

Although the ADA’s definition of disability, with its emphasis on physical and mental impairments, may give the impression that it is steeped in the medical or rehabilitation model, the protections it provides are consistent with the disabilities model’s perspective. The ADA legislation makes it illegal to discriminate on the basis of a disability in the areas of employment, public service, public accommodations, transportation, and telecommunications. On a practical level, it means that an individual cannot be denied employment or promotion because of misconceptions or biases in regard to that individual’s disability (Pelka, 2012).

ADA legislation provides the foundation on which all facets of society will be free of discrimination, including the healthcare system. Therefore, health professionals can expect to encounter people with disabilities in every setting in which they practice, such as schools, clinics, hospitals, nursing homes, workplaces, and private homes. Persons with a disability will expect nurses and other healthcare professionals to provide appropriate instruction adapted to their special needs.

Since the 1960s, the disability rights movement has worked to improve the quality of life of people with disabilities through political action. Through
this effort, tremendous gains have been realized, including improved access to public areas, education, and employment. The disability rights movement also advocates for appropriate use of language in regard to people with disabilities—for example, use of “people-first language” (Haller, Dorries, & Rahn, 2006). As a result of this effort, the federal government uses people-first language in its legislation and many professional journals require authors to use it in their manuscripts.

The term people-first language refers to the practice of putting “the person first before the disability” in writing and speech and “describing what a person has, not what a person is.” People-first language is based on the premise that language is powerful and that referring to an individual in terms of his or her diagnosis devalues the individual (Snow, 2012, p. 3). Consider the following statements:

In each of these statements, the emphasis is on the disability, rather than the person. Using people-first language, these statements would be reworded as follows:

Using people-first language is more than an exercise. It reflects a deliberate action on the part of the nurse or other healthcare provider to focus on the person with his or her unique qualities rather than to place the individual into an impersonal category based on limitations. The words and labels nurses use to describe people have the ability to influence the way individuals think about themselves and the way individuals are perceived by society. Therefore, it is important that nurses and all health professionals be sensitive to the way in which they write about, talk about, and talk to people with disabilities. Snow (2012) offers the following suggestions for using disability-sensitive language:

The role of the nurse in teaching persons who have a disability continues to evolve as, more than ever before, clients expect and are expected to assume greater responsibility as self-care agents. Here, the focus is on wellness and strengths—not
limitations—of the individual. The role of the nurse educator in working with clients who have a disability is varied and situation dependent.

The nurse may encounter clients who are newly disabled due to injury or illness or who have an illness that affects an existing disability. The nurse may also work with clients whose health or illness needs are related to their disability only insofar as the disability influences the way in which they learn or respond to treatment. For example, the nurse may teach self-care skills to a client with a new spinal cord injury, teach modification of self-care skills following orthopedic surgery to a client with an old spinal cord injury, or adapt a teaching plan for a client who is blind and newly diagnosed with diabetes. It is the role of the nurse to teach these individuals the necessary skills required to maintain or restore health and maintain independence (habilitation) and to relearn or restore skills lost through illness or injury (rehabilitation). When clients with disabilities are encountered in health and illness settings, nurses are responsible for adapting their teaching strategies to help them learn about health, illness, treatment, and care.

When teaching clients who have a disability, the nurse must assess the degree to which families can and should be involved. Families of individuals who have a new disability are becoming increasingly involved in the individual’s care and rehabilitation efforts. However, when working with a client who has an existing disability, the appropriateness of involving family must be assessed carefully. The nurse must never assume that because a client has a disability, he or she is incapable of self-care.

Because of the complex needs of this population group, healthcare teaching often requires an interdisciplinary team effort. In developing a teaching plan, the nurse must assess the need to involve other health professionals such as physicians, social workers, physical therapists, psychologists, and occupational and speech therapists. As with other clients, the nurse educator has the responsibility to work in concert with clients with disabilities and their family members to assess learning needs, design appropriate educational interventions, and promote an environment that will enhance learning. The teaching plan must reflect an understanding of the client’s disability and incorporate interventions and technologies that will assist the client in overcoming barriers to learning.

Application of the teaching-learning process is intended to promote adaptive behaviors in clients that support their full participation in activities designed to promote health and, in the case of illness, optimal recovery. Emphasis on the various components of the learning process may differ depending on the disability, but it often requires changes in all three domains—cognitive, affective, and psychomotor.

Prior to teaching, assessment is always the first step in determining the needs of clients with respect to the nature of their problems or needs, the short- and long-term consequences or effects of their disability, the effectiveness of the coping mechanisms they employ, and the type and extent of sensorimotor, cognitive, perceptual, and communication deficits they experience. When dealing with persons experiencing a new disability, the nurse must determine the extent of the clients’ knowledge with respect to their disability, the amount and types of new information needed to effect changes in behavior, and the clients’ readiness to learn. Assessment should be based on feedback from the client as well as observation, testing when appropriate, and input from the healthcare team. In some cases, it may be wise to interview family members and significant others to obtain additional information.

When working with a client who has a new disability, it is critical to assess readiness to learn. Diehl (1989) outlines the following questions to
be asked when determining if the timing of the teaching-learning process is appropriate:

1. Do the individual and family members demonstrate an interest in learning by requesting information or posing questions in an effort at problem solving or determining their needs?

2. Are there barriers to learning such as low literacy skills, vision impairments, or hearing deficits?

3. If sensory or motor differentiation exists, is the client willing and able to use supportive devices?

4. Which learning style best suits the client in processing information and applying it to self-care activities?

5. Is there congruence between the goals of the client and the goals of the family?

6. Is the environment conducive to learning?

7. Does the client value learning new information and skills as a means to achieve functional improvement?

Prerequisite to the role of the nurse as teacher and provider of care is the nursing responsibility to serve as a mentor to clients and family in coordinating and facilitating the multidisciplinary services required to assist persons with a disability in attaining optimal functioning. This role is especially important when working with a client who has a new disability. When family members or significant others are involved in care and serve as the individual’s support system in the community, they must be invited right from the very beginning to take an active part in learning information as it applies to assisting with self-care activities and treatments for their loved ones (see Appendix B).

Disabilities can be classified into two major categories: mental and physical. Physical disabilities typically are those that involve orthopedic, neuromuscular, cardiovascular, or pulmonary problems but may also include sensory conditions such as blindness. A disability is not an illness or disease but rather the consequence of an illness, injury, congenital anomaly, or genetics. Therefore, a physical problem such as a brain injury may result in a physical disability such as impaired ability to ambulate. Physical problems also may result in a mental disability. For example, the mental disability of dementia that is associated with Alzheimer’s disease is a result of physical changes in the brain. Mental disabilities include psychological, behavioral, emotional, or cognitive impairments.

Multiple subcategories of physical and mental disabilities exist. Seven subcategories of physical and mental disabilities have been chosen for discussion in this chapter because they represent common conditions that the nurse is likely to encounter in practice: (1) sensory disabilities, (2) learning disabilities, (3) developmental disabilities, (4) mental illness, (5) physical disabilities, (6) communication disorders, and (7) chronic illness. The specific disabilities that fall under each of these subcategories are described here, along with the teaching strategies that should be used to meet the needs of the learner.

Sensory disabilities include the spectrum of disorders that affect a person’s ability to use one or more of the five senses—auditory, visual, tactile, olfactory, and gustatory. The most common sensory disabilities are those that involve the ability to hear or see. Sensory disabilities can be complex, with multidimensional consequences that the nurse must address when in the role of educator. Nurses must be prepared to attend to the physical and emotional issues that may be related or subsequent to the sensory loss. For example, vision impairment in older adults is associated with depression (Qian, Glaser, Esterberg, & Acharya, 2012). Children with impaired hearing have been
found to have an injury rate twice that of children without hearing impairments (Mann, Zhou, McKee, & McDermott, 2007).

Over the past 30 years, learning disabilities have emerged as a major issue in the United States (CDC, 2008). Although often associated with school-aged children, these neurologically based disorders begin in childhood and persist through adulthood (National Institute for Literacy, 2008). Learning disorders are complex conditions that are frequently hidden and vary from individual to individual. As a result, they are often misunderstood and underestimated (Bridges to Practice, 2004).

A definitive definition of the term learning disability (LD) has been the subject of a great deal of controversy over the years as educators and psychologists alike have debated the issues (Crandell, Crandell, & VanderZaden, 2012; Santrock, 2011; Snowman, McCown, & Biehler, 2012; Ysseldyke & Algozzine, 1983). Because of the multidisciplinary nature of the field, experts continue to engage in the discussion and agree that the underlying mechanisms are complex and that many unanswered questions remain. However, despite the debate, professionals agree on some common characteristics of learning disabilities (Child Development Institute, 2012; LDOnline, 2012; National Joint Committee on Learning Disabilities, 2011):

A number of definitions of learning disabilities can be found in the literature. The Individuals with Disabilities Education Improvement Act (1997) defines learning disability as a “disorder in one or more of the basic psychological processes involved in understanding or in using language, spoken or written, that may manifest itself in an imperfect ability to listen, think, speak, read, write, spell or do mathematical calculations” (Learning Disabilities Roundtable, 2005). This definition stands as the accepted working definition for purposes of assessment, diagnosis, and categorization of an array of learning disabilities.