79CHAPTER 8
Integration of Disability in Nursing Education With Standardized Patients
OVERVIEW AND BACKGROUND
It is estimated that almost 60 million people in the United States and more than 1 billion people worldwide live with a disability (World Health Organization [WHO], 2011). The number of people with disabilities in the United States makes this population the largest minority group in the country. Disability, a term that has many definitions, refers to limitations in one’s ability to perform usual daily activities and social roles because of physical, cognitive, sensory, or emotional impairment, which is often due in part to environmental barriers (Iezzoni, 2006). Although disability may have a negative connotation in society and in health care, the word is neither positive nor negative and merely reflects one’s ability to participate in activities and roles in a world made for those without disability. It does not imply dependence, reluctance, or unwillingness to participate.
Research indicates that individuals with disability often have difficulty obtaining health care and that the health care they receive is of lower quality than that provided to individuals without disability, despite the passage of the Americans with Disabilities Act in 1990 (Peacock, Iezzoni, & Harkin, 2015; WHO, 2011). Individuals with disability report poor communication, compromised care, negative attitudes on the part of health care professionals, lack of sensitivity, and fears related to quality of care—all issues of universal concern to the nursing and medical professions. In addition, people with disability report being stigmatized, stereotyped, ignored, and occasionally abused by health care professionals (Smeltzer, Avery, & Haynor, 2012; U.S. Department of Health and Human Services [USDHHS], 2002, 2005; WHO, 2011).
The lack of inclusion of disability-related content and the lack of exposure of health care professions students to individuals with disabilities during their education and training have been identified as major factors in disparities in health care that affect those with disabilities (Kirschner & Curry, 2009; USDHHS, 2005). Multiple calls have been issued in response to these health disparities to improve the knowledge, skills, and attitudes of health care professionals (Institute of Medicine, 2007; Smeltzer, Dolen, Robinson-Smith, & Zimmerman, 2005; USDHHS, 2005). Despite the multiple calls for action, progress in addressing these health care disparities has been slow.
One strategy consistently recommended to begin to address these health care disparities is to incorporate content and concepts related to disability in health professions’ education and training programs (Kirschner & Curry, 2009; USDHHS, 2005). Strategies to integrate such content and concepts include (a) revision of course and program objectives with attention to competencies (i.e., knowledge, attitudes, behaviors, and skills) required to ensure quality health care for those with disabilities; (b) use of innovative teaching strategies and learning experiences that address the health-related needs of individuals with disabilities; and (c) provision of interactive 80experiences for all health professions students in which they have the opportunity to communicate with individuals with disabilities and to learn firsthand about the health disparities these individuals experience and the barriers they often encounter in their efforts to obtain health care. The inclusion of individuals with disabilities in these efforts is essential to ensure that future health care providers learn about disability-related issues from those most knowledgeable about their experiences and the barriers they encounter in their efforts to obtain health care. Further, the practice of including individuals with disabilities is consistent with a patient-centered approach and the expression, “nothing about me without me” (Iezzoni & Long-Bellil, 2012). This expression clearly conveys the importance of individuals with a disability having a role or voice in determining what is relevant when their health needs are being discussed and care and treatment are being determined. The inclusion of persons with disabilities as standardized patients (SPs) for teaching and testing purposes is essential to ensure that the responses of the “patient” are authentic and credible (Long-Bellil et al., 2011).
Villanova University College of Nursing faculty have had a long-standing interest in addressing the health disparities of people with disabilities and the use of strategies to improve their health and health care, including nursing care, in the nursing education program. A small group of faculty members, hereafter referred to as the Project Team, addressed the topic through the integration of SPs with actual disabilities in the curriculum and to an already functioning SP program with actors and students serving the role of patient. Important to the faculty was the need to accomplish this without disrupting the existing curriculum and without increasing faculty workload. Previous research findings have suggested that these two issues could potentially scuttle the project because nursing faculty generally have considerable content to teach to students and report having heavy teaching loads (Smeltzer, Blunt, Marozsan, & Wetzel-Effinger, 2015; Smeltzer, Mariani, et al., 2005).
WHY ARE PEOPLE WITH DISABILITY IMPORTANT TO BE INCLUDED AS SPs?
Inclusion of people with disability (PWD) as SPs is essential because these individuals have a unique perspective and expertise that other people who may act out a role do not have. They are most knowledgeable about living with the complexities of their disability and are most credible in discussing the consequences of their disability on their daily lives, health, and well-being. Inclusion of PWD as SPs also provides learners with the opportunity to learn from those who are the true “experts” and helps to dispel fears and preconceptions that learners may have about disability. An individual without disability who acts out the role of a patient with disability lacks the authenticity that is valued by students and may also harbor unrecognized personal misconceptions related to disability, which could be inadvertently conveyed to learners (Long-Bellil et al., 2011).
INTEGRATION OF SPs WITH DISABILITY ACROSS THE CURRICULUM
The goal of integrating a program of simulation that includes SPs with disability is to do so in a way that maximizes the value of this learning experience for students and for people with disabilities, with the least disruption to the academic program to allow for a smooth transition. Oftentimes, new curricular content is seen as difficult to implement, as most curricula are already so rich with content and concepts that faculty find it difficult to envision how they can fit “one more thing” into the program. The goal of this integration is to facilitate simulation experiences while assimilating these experiences into the curriculum in a meaningful way that fosters attainment of student learning objectives (Masters, 2014). A key factor to this integration is faculty support and investment in the significance of this curricular integration (Conrad, Guhde, Brown, Chronister, & Ross-Alaolmolki, 2011; Masters, 2014).
81First, it is important to assemble a team of champions who are committed to adopting this important curricular intervention. Building a team with a shared vision, and supporting this team are key steps to success (Conrad et al., 2011). The team can develop a strategic plan outlining the goals and objectives of the program, key stakeholders, recruiting and training of SPs, financial considerations, and sustainability of the program. Part of the strategy is to keep the faculty well informed, to elicit their feedback and thoughts, to provide a clear picture of the plan, and provide for ongoing evaluation. Meeting with faculty gives a voice to their concerns, and helps them feel invested in the plan. It is important for faculty to understand why this is important not only to student learning, but also to the delivery of safe, quality care to people with a disability.
In a study by Brown, Graham, Richeson, Wu, and McDermott (2010), medical students demonstrated lower performance on objective structured clinical examinations (OSCEs) with SPs with disability than with those without disability. Brown and colleagues (2010) concluded that greater emphasis needs to be placed on teaching disability-related concepts and content throughout the curriculum. It is important to critically examine the existing curriculum to determine where it can be modified or adapted to include simulation-based learning experiences (SBLEs) with SPs with disability. There are two main goals of this curricular integration. The first goal is to have students learn about caring for patients with preexisting disability within the context of their current health problem to learn to provide quality care for people with disability. The second goal is to ensure a smooth transition along with curricular integration. These concepts about the care of people with disability are crucial to integrate into nursing’s and other health care professions’ curricula to assist students in learning to care for people with a disability.
PLAN FOR IMPLEMENTATION
Communication between the project team and the faculty is critical to the successful integration of the SBLEs with SPs with disability. The project team should develop a plan for transition, and discuss the plan with the course faculty, so they can understand how to best integrate the SBLE with SPs with disability and what the outcome will be for students and ultimately for patients. Next, a plan for the changes to existing curriculum and the SBLEs has to be designed. This could be as simple as adapting an existing communication learning strategy to include an SP with disability. In the original communication unit, the student may learn communication techniques through communicating with an SP without disability or with a student peer. In the SBLE that incorporates learning about PWD, the SBLE would include an SP with an actual disability. As the program progresses into sophomore, junior, and senior years, more opportunities can be identified to integrate SPs with disability into simulation experiences that already include SPs or human patient simulators.
A critical piece of the program of incorporating SBLEs with SPs with disability includes students receiving information to prepare them for the experience with an SP with disability. This includes readings that help to inform students about caring for PWD. Based on the International Nursing Association for Clinical Simulation and Learning Design Standard of Practice (Lioce et al., 2015), SBLEs include prebriefing, the scenario, and debriefing. The prebriefing addresses the objectives of the SBLE, as well as provides an overview of the scenario and the environment. The students participate in the scenario, followed by debriefing. In addition to the debriefing that is customary with an SBLE, if possible, the SP with disability can provide postscenario feedback to the students about their interaction with the SP with disability. Table 8.1 illustrates the changes made in one nursing curriculum to integrate SPs with disability into SBLEs.
An important part of the curricular integration is to provide continuous evaluation of the SBLE, the SPs with disability, the logistics of the program, and student feedback and to continually review the strategic plan.
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