Implications for nursing education

By law, students have the responsibility to notify the institution regarding a disability and the need for accommodation (Helms et al., 2006). While disclosure of disabilities is voluntary and not legally required, students who have a disability and require accommodation are encouraged to share this information with the institution’s office for students with disabilities. However, many students will not share information regarding their disabilities for fear of rejection (Maheady, 2005).

Barriers to student success may be related more to faculty attitudes rather than to student ability (Nichols & Quaye, 2009; Scullion, 2010; Sowers & Smith, 2004a, 2004b). Sowers and Smith (2004a) explored the impact of in-service training on faculty members’ attitudes regarding nursing students with disabilities. One hundred and twelve faculty members participated in a 2-hour training program. The program was developed based on survey results from a study of nursing faculty attitudes and knowledge regarding disabilities (Sowers & Smith, 2004b). Faculty who participated in the in-service training had more favorable attitudes toward and more knowledge about students with disabilities compared to faculty who participated in the survey that formed the basis of the in-service program. Education for faculty related to providing accommodations and understanding the possibilities for achievement among students with disabilities is key for students’ academic success. Helping staff in clinical agencies to understand that nursing is more than hard physical labor is also key to accommodating students with disabilities (Neal-Boylan & Guillet, 2008).

When a student makes known the presence of a disability, upon student consent, course faculty are notified about the disability that requires accommodation. Even when student consent is given to share information with faculty, the nature of the disability is not disclosed to faculty unless the student decides to disclose it. Box 4-1 is an example of a statement of services provided for students with disabilities.

Faculty are not allowed to inquire about the nature of the disability. In fact, decisions regarding whether accommodation is possible must be made after the student has been admitted, unless essential abilities are published and all students are asked before admission whether they possess the abilities needed for academic success (Helms et al., 2006). However, most lists of essential abilities focus, in part, on physical abilities such as lifting. Recent initiatives call into question such requirements (American Nurses Association [ANA], n.d.).

When considering the admission of a student who has a disability, admission committees in schools of nursing must consider the following questions:

Although institutions are not expected to lower or alter academic or technical standards to accommodate a student with a disability, they are expected to determine what accommodations would be reasonable for a student who is disabled. Examples of reasonable accommodations include altering the length of test taking times or methods, providing proctors to read tests or write test answers, allowing additional time to complete the program of study, providing supplemental study aids such as audiotapes of texts, providing note takers, or altering the method of course delivery. The same considerations must be given to students who become disabled during their enrollment in a nursing program. Questions to be asked include the following:

When considering accommodations, “Accumulating precedents, however, suggest that accommodations to curricula and to some testing methods may not be required if there are good pedagogical reasons that substantiate prevailing practices” (Helms et al., 2006, p. 193). For example, testing methods, such as multiple-choice questions, could be required for pedagogical reasons (Helms et al., 2006).

Faculty should consider in their decision making that just because a student has a disability, he or she is not necessarily ill, and the type of support needed is not the type needed to cure an illness, but to support health (Sin, 2009). Furthermore, how those with a disability are viewed is a result of social constructs (Marks, 2000; Nichols & Quaye, 2009). Whether a person’s limitations are viewed as a disability is defined by society rather than by the actual abilities of the person involved. Thus making the decision regarding what is a reasonable accommodation for a person with a disability is a complex process influenced as much by faculty attitudes as by actual student abilities. Marks further suggested that referring to those with disabilities as those with “special needs” invites discrimination against persons with disabilities.

As the impact of the ADA on nursing education continues to unfold in the courts and in the workplace, nurse educators must keep current with legal developments that relate to the education of individuals with disabilities who are pursuing degrees in the health professions. Some suggestions for increasing faculty awareness of the needs of students with disabilities include periodic continuing education sessions related to the legal implications of educating such students and the use of consultants who are experts in working with students with disabilities. Most institutions of higher education have an office dedicated to assisting and supporting students with disabilities who are enrolled on campus. This office can provide resources and expert advice to faculty and students. Another source of information may be individuals with disabilities who have successfully developed a career in nursing. These successful nurses can help nursing faculty understand the issues involved in educating students with disabilities and they can serve as mentors to students with disabilities who are pursuing a nursing education (Maheady, 2003, 2006).

Nursing faculty should begin to separate the truly essential components of nursing education from the merely traditional nursing curricula and teaching strategies. Bohne (2004) and Carroll (2004) have suggested that nursing faculty need to consider such philosophical issues as whether nursing education might be extended to those individuals who will never practice bedside nursing in an acute care setting. Such nursing jobs might include staff development, infection control, case management, or a variety of jobs in the community settings where nursing care is delivered. A study of admission and retention practices of California nursing schools (Persaud & Leedom, 2002) shows that nursing faculty struggle with what are reasonable accommodations that balance student access with patient safety. In making admission and progression decisions, faculty need to balance student rights, safety, and abilities with issues of patient safety and university responsibility for providing appropriate accommodations according to the ADA (Watkins & Kurz, 1997). Having an ongoing evaluation plan that shows how making appropriate accommodations affects student outcomes in terms of graduation and subsequent employment is essential (Watkins & Kurz, 1997). One note of caution, however: Faculty may need to seek alternative placements for disabled students if clinical agencies, despite ADA regulations, are reticent to work with a particular student (Andre & Manson, 2004).

Some schools of nursing, as well as other professional schools, have identified in writing the abilities students need to possess to be successful in their chosen educational program. The essential abilities that students need to possess for successful progression through the nursing program at one school of nursing are presented in Box 4-2. Faculty should note that the delivery of holistic nursing care relies more on the use of complex cognitive processes than on physical labor.

Characteristics of learning disabilities

Learning disabilities may manifest as a number of characteristics, each necessitating a different treatment and accommodation. Eighty percent of those with diagnosed learning disabilities have trouble with basic reading skills (LD Online, n.d.). Memory difficulties, such as trouble remembering details and sequencing, commonly lead to reading and spelling difficulties. Poor handwriting, distractibility with difficulty concentrating, a history of poor academic performance, difficulty meeting deadlines, anxiety, and low self-esteem are also signs of a learning disability (Bradshaw, 2006; McCleary-Jones, 2008). Students with learning disabilities may have difficulty following verbal instructions and difficulty organizing ideas in writing or may be unable to articulate ideas verbally but be able to articulate them in writing. Students may also have auditory processing deficits that have an impact on their ability to recite from memory (Selekman, 2002). Time management may also be a problem for these students (Kolanko, 2003).

Learning disabilities are highly individualized and each student manifests a different grouping of characteristics (Selekman, 2002). Students with learning disabilities have average or above average intelligence and should be expected to meet the same academic standards as other students (McCleary-Jones, 2008).

Evidence supports the fact that despite sometimes facing overwhelming odds, students with learning disabilities can achieve success in nursing programs. Kolanko (2003) used a case study method to study nursing students with learning disabilities. She discovered that these students had to work harder to achieve passing grades. Students expressed anxiety and frustration and lack of confidence, which interfered with their ability to process information. Once students understood what facilitated their learning, they were able to better deal with the rigors of the curriculum. For example, students needed to learn personalized test taking skills so they could be successful on tests. For some students, sitting in classes for long periods hampered their concentration. Those students had to take breaks and move around every hour.

Performing in the classroom presents one set of challenges for those with learning disabilities. Success in the clinical arena presents another set. Price and Gale (2006) interviewed 10 British female nursing students with dyslexia, a form of learning disability, and 10 students who did not have dyslexia. Whereas both groups had some similar experiences, such as difficulty with understanding medical terminology and coping with a changing care environment, the dyslexic students had special issues. The dyslexic students often had difficulty with doing things rapidly, such as charting, and with remembering names. Students coped by practicing spelling over and over in order to chart without errors. Although both groups of students experienced some difficulty with keeping up with change-of-shift reports, those with dyslexia had more troubles. Dyslexic students were also more concerned with safety, because they knew they had to check their work more thoroughly than did the other students. The key to the dyslexic students’ success was to develop strategies to keep them on track. Several research participants mentioned that they wrote everything down or used colored stickers to highlight important details of their work and keep themselves more organized.

Morris and Turnbull (2006) studied 18 British nursing students with dyslexia. Five themes were identified: disclosure, self-managing strategies, need for more time, emotional aspects of being a dyslexic nursing student, and choice of future work setting. Six of the 18 students did not disclose their dyslexia to clinical staff. Twelve believed that disclosure leads to the potential for discrimination against them, but six saw disclosure as a way to receive more help.

Like students in Price and Gale’s (2006) study, these students also developed coping strategies. Some used reminder pads and others used a voice recorder to keep track of activities. Practicing clinical skills repeatedly facilitated learning for them. Students were keenly aware of the potential for making errors so they had drug calculations checked by others. They also knew that they needed more time than others to maintain safe patient care practices. Because of this, these students knew that they more than likely would not choose to work in a fast-paced acute care environment. Those who lacked self-confidence had trouble with accepting criticism and letting others know what they needed. However, the majority of the participants did not view themselves as disabled.

ADHD is closely linked with learning disabilities (Bradshaw, 2006; Bradshaw & Salzer, 2003). Students who have ADHD also have difficulty with academic performance. Most are diagnosed as children and their symptoms may persist into adulthood (Bradshaw & Salzer, 2003). Student nurses who have this disorder exhibit some of the same symptoms as those with learning disabilities, such as dyslexia and difficulties with memory and organization of work. Bradshaw and Salzer (2003) suggest that faculty members develop a trusting relationship with students whom they believe have ADHD but have not disclosed such, encouraging these students to receive accommodations, if needed, in the learning environment to help them succeed. They note, however, that if the student fails despite accommodations having been made or fails because ADHD was not disclosed and thus no accommodations were made, then the student must accept responsibility for his or her own actions.

Accommodating learning disabilities

When faculty believe that a student, previously undiagnosed, may have a learning disability, the initial action is to refer the student to an expert in learning disabilities for assessment. After the diagnosis is made, a plan for accommodation of the disability can be developed. Counseling may also help a student with learning disabilities gain self-confidence in the learning environment. As stated earlier, if the student chooses, the faculty can be made aware of the disability and what accommodations are required. Faculty members who are made aware of a student’s disability are not allowed to discuss that information with other faculty members unless the student gives permission.

Depending on the type of learning disability, a variety of accommodations may be appropriate for the student. Students who have memory difficulties may have difficulty with remembering details and taking notes but will be able to grasp concepts. These students find learning to be a tiring experience and will usually experience greater success with learning activities that incorporate “hands-on” and observation experiences in the teaching strategies (Eliason, 1992). Simulation experiences help students to rehearse clinical skills in a safe environment (Ashcroft et al., 2008). Skills such as time management, prioritization, and dealing with multiple stimuli can be practiced over and over until students feel comfortable with the skills before entering the “real world.” These students may need specific step-by-step instructions for tasks and help with time management (Selekman, 2002).

Students may also benefit from the assistance of an in-class note taker. This allows students to concentrate on classroom discussion without the distraction of trying to take notes. Some students have difficulty processing multiple stimuli at once. Students who have difficulty reading, and as a result read slowly, often find this disability to be the greatest barrier to their academic success. Faculty can help students overcome this difficulty by providing an audio recording of textbooks and other readings and providing them with the required reading assignments early in the semester, or helping them identify the key sections of reading assignments. Findings from a research study by Tee et al. (2010) suggested that reading aloud to students and using simple words to describe medical terms may help students to learn better. For example, beginning by stating that high blood pressure is equivalent to hypertension may be useful. Tee et al. (2010) also suggested helping students build confidence early on.

Students with learning disabilities may also need accommodations for testing because slow reading skills can affect the student’s ability to complete a test within the time allowed. Questions that are grammatically complex or contain double negatives, although difficult for all students, can be particularly challenging for students with learning disabilities and should be avoided. Providing the student with an extended testing time and a quiet room free of distractions may also be necessary (Bradshaw & Salzer, 2003). A test proctor who either reads the test to the student or writes and records the student’s dictated answers to the test questions may also be helpful.

An additional strategy that faculty can use to assist students with learning disabilities is to incorporate a multimedia approach, such as computer-assisted instruction (McCleary-Jones, 2008; Selekman, 2002). Other strategies can benefit both students with learning disabilities and students without them. These include providing copies of PowerPoint slides or other notes before class, placing visual cues within class notes, and checking nursing notes before placing them on the patient charts (Ijiri & Kudzma, 2000; Selekman, 2002). Use of a pocket speller in the clinical area may also be beneficial (Ijiri & Kudzma, 2000). The use of smart phones with appropriate applications may also be helpful for all students, but particularly those with learning disabilities. Another strategy that benefits all students, including those with learning disabilities, is to meet with students on a regular basis to ensure that learning goals are being set appropriately and are then being achieved.

Part-time study is another option (Selekman, 2002). Accommodation does not mean that academic standards are lowered but that multiple ways to achieve those standards are provided for all students, including those with learning disabilities. Any one classroom contains students with multiple learning styles. By structuring classes to take into account different learning styles and by providing a variety of learning aids, nurse educators will also help accommodate those with diagnosed learning disabilities (Ijiri & Kudzma, 2000). Successful students with learning disabilities, and perhaps all other disabilities, are those who are cognizant of their learning needs and always focus on patient safety and meeting academic standards (Ashcroft et al., 2008).

Campus support services

As previously mentioned, most institutions of higher education have established an office responsible for providing support services to students who identify themselves as learning disabled. Use of these services is voluntary, and they are usually available at little or no cost to the student. Services vary among institutions but typically include assessment and diagnosis of learning disabilities, identification of appropriate accommodations for the student, guidance counseling, and development of study and test taking skills. Faculty education about students with learning disabilities is another service commonly provided by these offices.

Another resource for faculty might be a center for teaching and learning or some similar campus office. Those in such a center can assist faculty in using principles of universal design in the preparation of online course materials. When used, these principles facilitate the learning of those with a variety of disabilities, including those with learning disabilities (Crow, 2008). For example, when designing materials for students with learning disabilities, faculty should keep pages uncluttered, avoid a lot of flashing graphics, and use a larger font (Crow, 2008).

Accommodations for the national council licensure examination

Nurse educators need to be familiar with the accommodations provided for students with disabilities in their states when taking the National Council Licensure Examination (NCLEX). Accommodations are offered to individuals with learning disabilities in accordance with the ADA (National Council of State Boards of Nursing, n.d.). Each state individually determines the degree of accommodation offered to students on a case-by-case basis. Educators should investigate and verify the accommodations offered to students in their respective state and encourage students with disabilities to seek appropriate accommodations. One of the most common accommodations has to do with time allotted for the examination. Regulations do change, and the student and faculty are encouraged to check with the National Council of State Boards of Nursing website (www.ncsbn.org) or the individual state board of nursing for further information. The student must provide documentation as to what accommodations have been made during his or her course of study before arriving at the testing center.