After completing the assigned readings and viewing the following YouTube video,?pen the Door, Get ‘Em a Locker: Educating Nursing Students with Disabilities?iscuss your response to the video and relate any personal experiences that you have related to working with those having disabilities. If you did not have this experience, reflect on your reaction and response to the video.
Some former students found this video to be somewhat outdated … nevertheless, it still presents a powerful message to facilitate exploring an important topic relevant in nursing education today.
After completing the assigned readings and viewing the following YouTube video, Open the Door, Get ‘Em a Locker: Educating Nursing Students with Disabilities discuss your response to the video and rel
Teaching Students With Disabilities Betsy Frank, PhD, RN, ANEF C ongress passed the Rehabilitation Act in 1973. This act states that any program or activity that receives federal funding cannot deny access or participation to individuals with disabilities. Section 504 of this act specifically addresses higher education and prohibits public postsecondary institutions that receive federal funds from discriminating against individuals with disabilities. Furthermore, almost 30 years ago Congress enacted the Americans with Disabilities Act (ADA, 1990). This act was further updated in 2008 and is now sometimes referred to as the Americans with Disabilities Act Amendments Act of 2008 (ADAAA). A summary of key provisions has been published to facilitate use of the act?s provisions (Equal Employment Opportunity Commission [EEOC], 2009). Because of these two laws, colleges and universities have experienced an increased number of students with disabilities admitted to their programs, including nursing programs Nursing students with special needs present a challenge to nursing faculty in both the classroom and clinical settings. Students who have special needs include those who have a physical disability, such as a visual, hearing, or mobility impairment; a chronic illness; a learning disability; mental health issues; or a chemical dependency problem. Many nursing programs have had experience in meeting the needs of these students, and learning disabilities are among the most common type of disability reported. The majority of students do not disclose their disability before admission. Neal-Boylan and Miller (2017) found that some students with disabilities had to apply to multiple schools before being accepted. This chapter addresses the issues related to the education of students with disabilities. It specifically focuses on common problems experienced by college students and nursing students: learning disabilities, physical disabilities, mental health problems, and chemical impairment issues. The Rehabilitation Act of 1973, the ADA as amended in 2008 (EEOC, 2009), and the significance of these acts to nursing education are also addressed. Legal issues related to students with disabilities Faculty should be aware of the legal issues associated with teaching students with disabilities. The ADA protects the rights of individuals with disabilities in the arenas of education, employment, and environmental accessibility. Higher education institutions must guarantee individuals with disabilities equal access to educational opportunities. Discrimination against individuals with physical and mental disabilities is prohibited by the ADA. However, the ADA does not guarantee that an admitted student will achieve academic success?only that the student has the opportunity to achieve academic success. A university or college has the obligation to maintain academic and behavioral standards for all students, disabled or not (Meloy & Gambescia, 2014). The full effect of the ADA on professional education continues to be determined as more potential students with disabilities seek admission to nursing and other health professions programs. Focusing on stated program outcomes rather than on specific skills puts faculty in a better position to make decisions about what are reasonable accommodations for students who are disabled or have other special needs. The institution and faculty may be sued for failing to make reasonable accommodations. For example, a Missouri Appeals Court ruled that a nursing program had erred in dismissing a deaf nursing student because she needed accommodations in clinical practice (Wells v. Lester E. Cox Medical Centers, 2012). However, if the student does not request accommodation, the university is not required to provide such (Buescher et al. v. Baldwin Wallace University, 2015). Implications for Nursing Education Although many students with disabilities are enrolled in nursing programs, faculty often have reservations about their ability to deliver safe patient care. However, several authors have pointed out that no evidence exists that nurses with disabilities delivered unsafe care (Matt, Fleming, & Maheady, 2015; Neal-Boylan & Smith, 2016). Furthermore, all nursing students presumably are supervised by faculty or preceptors. Therefore their practice is continually monitored for safety issues. Matt et al. (2015) have stated that as the nursing workforce ages, many changes in the work environment can be made to make the environment accessible to practitioners and students alike. Admitting nursing and other health professions students with disabilities to educational programs promotes cultural diversity (Shpigelman, Zlotnick, & Brand, 2016; Zazove et al., 2016). In 2016 the National League for Nursing emphasized this point in its vision statement Achieving Diversity and Meaningful Inclusion in Nursing Education. Admitting students that represent various groups within the population promotes a workforce that better reflects the population as a whole. As more students with disabilities seek admission to nursing programs, and as those within the profession age, retaining nurses with disabilities in the workforce will be essential. If faculty and students don?t have an open attitude (Shpigelman et al., 2016) toward students with disabilities, much potential nursing talent may be lost when such students aren?t admitted into nursing programs. By law, students have the responsibility to notify the institution regarding a disability and the need for accommodation (Walker, 2017). Although 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. Barriers to student success may be related more to faculty, fellow students, and practice partners? attitudes than to student ability (Neal-Boylan & Smith, 2016; Shpigelman et al., 2016). Based upon faculty interviews, Ashcroft and Lutfiyya (2013) developed a grounded theory about nurse educators? perceptions of working with students with disabilities. Their theory was named ?producing competent graduates? (p. 1317). Subthemes within the theory included ?let?s work with it? (the disability); ?it becomes very difficult? (to accommodate); ?what would happen if someone died?? (because of unsafe practice); a wary challenge; educator attributes, which included past experience in working with students with disabilities; and perceived student attributes or kind of disability. Faculty negative attitudes can change. A study by Tee and Cowen (2012) demonstrated that a variety of strategies can enhance the ability of practice partners to work with students who have disabilities. Such strategies included having students tell their stories and developing a series of DVDs and interactive slide shows that practice partners, called mentors, could use to understand the issues faced by students with disabilities and how to appropriately accommodate those students. Education for faculty related to providing accommodations and understanding the possibilities for achievement among students with disabilities is key for students? academic success. When a student makes known the presence of a disability and gives permission to share this information with faculty, course faculty are notified about the disability that requires accommodation. Course faculty must keep this information confidential and are not to share this information with other faculty, as it is the student?s responsibility to decide when and where to disclose the presence of a disability. Students may choose not to disclose a disability in some courses. 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 (Meloy & Gambescia, 2014). Box 4.1 is an example of a statement of services provided for students with disabilities. To receive accommodation, the student must disclose the presence of a disability before engaging in the learning experience; it is not possible to retroactively claim the need for accommodations after the student has already unsuccessfully engaged in the experience. Box 4.1 Services for persons with disabilities Disability Support Services provides reasonable, appropriate, and effective academic accommodations to students with known disabilities. This may include academic adjustments and services such as special testing arrangements. Note-taker services are available to qualified individuals. Services for persons with disabilities are based on individual needs and the university?s intent to offer appropriate accommodations according to the student?s documentation of need for same. These services are coordinated by the Student Support Services Grant Program. It is recommended that persons with disabilities visit Indiana State University before making a decision to enroll. Courtesy Indiana State University Undergraduate Catalog, 2017?2018. Retrieved from https://catalog.indstate.edu/content.php?catoid=32&navoid=860&hl=success&returnto=search#Center_for_Student_Success 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 (Aaberg, 2012). 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, 2013). Although some schools publish essential abilities that students must achieve, faculty need to consider if they are truly essential to nursing practice. Levey (2014) conducted an integrative literature review on faculty attitudes regarding various aspects of working with nursing students who have disabilities and concluded that disclosure of disability status before admission can be a barrier for students, especially if essential abilities are published. Furthermore, Levey stated that essential functions are more related to employment, not student status. Neal-Boylan and Smith (2016) reaffirmed this position and also reinforced that published essential functions were barriers for students who wish to apply to nursing programs, even though they may otherwise be qualified. When considering the standards that students must meet, Marks and Ailey (n.d.) and McKee et al. (2016) advocate for separating functional and technical standards. Functional standards for nursing include acquiring knowledge, developing communication skills, interpreting data, making clinical judgments, and using appropriate professional behaviors and attitudes (Marks & Ailey, n.d.). Technical standards such as being able to stand for long periods and working 12-hour shifts are standards that are meant to be used in the employment setting, not the educational setting (Davidson et al., 2016; Marks & Ailey, n.d.). Such technical standards as being able to hear can be met with assistive devices (Argenyi, 2016). Furthermore, just as physicians will not practice across all specialty clinical areas (Bagenstos, 2016), not all nurses practice in all health care settings (Neal-Boylan & Miller, 2017). Faculty have the ability to accommodate students when meeting program outcomes in a variety of ways and settings appropriate to meeting those outcomes, including simulation. Although not all those with disabilities can successfully complete a nursing program, technological advances open the door to wider opportunities for students and practicing nurses. Faculty must remember, however, that students are not required to disclose disabilities before admission. When considering the admission of a student who has a disability, admission committees in schools of nursing must consider the following questions: ?Disregarding the disability, is the individual otherwise qualified to be admitted to the program? ?What reasonable accommodations can the school make to enable the student to be successful in the pursuit of becoming a nurse who can deliver safe patient care? Although institutions are not expected to lower or alter academic or technical standards to accommodate a student with a disability (Meloy & Gambescia, 2014), they are expected to determine what accommodations would be reasonable for a student who is disabled. According to Neal-Boylan and Miller (2017) most accommodations are determined by the campus offices that deal with students with disabilities and the nursing programs themselves. 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, such as the use of simulation for some clinical practice (Azzopardi et al., 2014). Other accommodations include closed captioning (Neal-Boylan & Miller, 2017). The same considerations must be given to students who become disabled during their enrollment in a nursing program. Questions to be asked include: ?Disregarding the disability, is the student otherwise qualified to continue in the nursing program? ?What reasonable accommodations can be made to allow the student to continue? Using concepts of universal design accommodates a variety of learning styles for all students, not just students with disabilities (Meloy & Gambescia, 2014). Dell, Dell, and Blackwell (2015) have stated that universal design in online courses, in particular, allows students with disabilities to have access without accommodation and students without disabilities can also gain access to course materials in a variety of ways. Universal design promotes course design that uses multiple ways to present course materials and multiple ways for students to demonstrate knowledge acquisition. Most learning-management systems allow faculty to use universal design in presenting their course materials. Technological advances such as lecture capture are easily incorporated into learning management systems (Watt et al., 2014). In addition, the willingness to be flexible in teaching formats, having a tolerance for mistakes, and promoting a climate of acceptance of those with disabilities through such strategies as placing an accommodation statement in the syllabus is important for teaching online and in face-to-face classes (Levey, 2016). Whether one teaches online or in face-to-face environments, instructional design specialists should be part of the team that designs accessible distance courses and on-campus classes. See Box 4.2 for suggested universal design strategies. Box 4.2 Universal design strategies 1.?ave course materials available in audio and video format. 2.?esign uncluttered webpages that don?t rely on color alone. 3.?rovide accessible javascript. 4.?rovide access to webpages that convert text to audio and audio to text. Universal design is not just applicable to the classroom setting; it can also be applied in the clinical setting. Heelan, Halligan, and Quirke (2015) presented several case studies of universal design applied in clinical placements. For example, a nursing student with dyslexia used a Livescribe pen to take notes that were intelligible. General design principles included prioritizing learning outcomes into essential and optional, adjusting shift work to account for a student with fatigue caused by a chronic illness, and providing expected tasks to all students ahead of the clinical placement to allow students to practice ahead of time. Even though many different teaching and learning strategies are a part of universal design (sometimes called inclusive teaching strategies), faculty and student attitudes toward the strategies can foster or hamper their use. Dallas, Sprong, and Upton (2014) studied faculty attitudes toward universal design; 381 faculty across a variety of disciplines including arts and sciences, education and human services, law, and medicine responded to a cross-sectional survey, the Inclusive Teaching Strategies Inventory (ITSI). This inventory measured attitudes toward instructional accommodations. Of note, was the fact that faculty in the colleges of education and human services, applied arts and sciences, and mass communication and media arts were more accepting of making accommodations using universal design strategies than were faculty in other colleges. Years of teaching and training were related to a more positive attitude toward using universal design principles. Levey (2016) investigated a nationwide sample of nurse educators? attitudes toward adopting inclusive teaching strategies using the Inclusive Teaching Strategies in Nursing Education (ITS-NE). This instrument was a modification of the ITSI used by Dallas et al. (2014). In contrast to Dallas et al., Levey?s results showed that more years of teaching experience negatively correlated with willingness to use inclusive teaching strategies. Social support was a positive indicator of willingness to use universal design principles in nursing courses. Students also have a variety of attitudes about universal design principles. Black, Weinberg, and Brodwin (2015) conducted interviews with 15 students, 12 with disabilities and three without. All students desired success, wanted to communicate well with professors, and have ready access to course materials. Students valued the universal design principles such as providing slides before class, and a visually impaired student benefitted from the use of a screen reader. Providing a fully accessible classroom was another universal design principle valued by those with physical disabilities. Gawronski, Kuk, and Lombardi (2016) compared 179 community college faculty and 449 students? perceptions of universal design strategies using the ITSI and the Inclusive Teaching Strategies-Student (ITSI-S). Faculty and students alike perceived that accommodations, accessible course materials, multiple means of presentation, and inclusive lecture strategies were important. Students thought that course modifications such as allowing those with disabilities extra credit and inclusive assessments, such as having alternative assessments to demonstrate knowledge, were important?but faculty did not. One should note that 13% of student respondents identified as disabled, but disability status was not identified for faculty. Faculty should consider 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 promote positive attitudes toward and the potential for growth of students with disabilities (Neal-Boylan & Smith, 2016). 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 and practice partner attitudes as by actual student abilities. As the effect of the ADA?and now ADAAA?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. Practicing nurses with disabilities can serve as advocates for students and help nursing programs advocate for students who graduate and then seek employment. Nursing faculty should begin to separate the truly essential components of nursing education from what has traditionally been included in nursing curricula. Nursing faculty should also use a variety of teaching strategies (Marks & Ailey, n.d.). In addition, 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 (Betz et al., 2012) showed that nursing faculty vary in approaches to dealing with disabilities. In making admission and progression decisions for all students, 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. Faculty can use a variety of clinical settings to achieve the prescribed learning outcomes. Working with preceptors with disabilities in practice not only assists students in their educational process (Tee & Cowen, 2012) but could also demonstrate that disabled students can be successful as graduates by providing evidence of safe practice given by the students. The nursing student with a learning disability Learning disabilities are the most common type of student disability found on college campuses (National Center for Education Statistics [NCES], 2011). Despite a growing number of college students with learning disabilities, only about 17% seek help to be successful in their educational endeavors (Krupnick, 2014). The traditional definition of a learning disability is an incurable neurological disorder interfering with learning in a variety of ways. Approximately 15% of those in the United States have some form of learning disabilities. However, Tamboer, Vorst, and Oort (2016) studied 446 college students, including 63 with diagnosed dyslexia, and came to the conclusion that dyslexia may just be an alternative way of thinking that has evolved over time, because those without dyslexia often have similar learning characteristics to those without. Furthermore, Tamboer et al. (2016) stated that dyslexia may involve multiple cognitive difficulties. Clearly much more research is needed to understand the nature of dyslexia. Students frequently begin college with learning disabilities undetected. In nursing education, learning disabilities are commonly uncovered when faculty notice striking differences between a student?s classroom performance and clinical performance. The student may display an adequate knowledge base and competent skills during clinical experiences but be unable to demonstrate the same degree of knowledge when taking tests in the classroom. Such disparities in performance can lead to much frustration and stress for the student even though their reading difficulties in many instances may not hamper their ability to complete their program of study (Olofsson, Taub, & Ahl, 2015). Because some students may need some assistance to complete their education, faculty should have an understanding of the characteristics of learning disabilities so they can refer students to the university or college office that works with students with various disabilities. Characteristics of Learning Disabilities Learning disabilities may manifest as a number of characteristics, each necessitating a different treatment and accommodation. Learning disabilities, including dyslexia, may involve reading and spelling difficulties; problems with mathematical abilities; difficulty with writing, auditory, and visual processing; and nonverbal processing such as intuition and holistic processing (LD Basics, 2018). Among those with diagnosed learning disabilities, 80% have trouble with basic reading skills (What is a learning disability, 2018). Students with learning disabilities may have difficulty following verbal instructions and difficulty organizing ideas in writing or may be unable to articulate ideas orally but able to articulate them in writing. Students may also have auditory processing deficits that may have an effect on their ability to recite from memory, although the diagnosis of auditory processing is not clear cut (de Wit et al., 2016). Prioritization is often a problem for those with learning disabilities (Locke, Scallan, Mann, & Alexander, 2015). In turn, time management may become problematic for the student. Learning disabilities are highly individualized, and each student manifests a different grouping of characteristics. Some students without learning disabilities may experience the same difficulties as those with learning disabilities. In one study, Wray, Aspland, Taghzouit, Pace, and Harrison (2012) screened 242 British preregistration students using the Adult Dyslexia Checklist. Results showed that 28.5% of the sample achieved a score possibly indicative of a learning disability. For those students undergoing further evaluation, six students were shown not to have a learning disability. Tamboer et al.?s (2016) study confirms that those without dyslexia may also have some of the characteristics as those with dyslexia. Thus strategies to help students with learning disabilities may also help those without disabilities. Being accurately diagnosed with a learning disability means students can make adjustments in their study habits and receive support. Support, which is sometimes difficult to get, is critical to their successfully meeting the academic standards. Sanderson-Mann, Wharrad, and McCandless (2012) compared the clinical experiences of students with dyslexia to those without. Students with dyslexia rated reading and writing on patients? charts, using care plans, and following a set of instructions more difficult than those without dyslexia. However, such tasks as change-of-shift reports, drug calculations, and time management were difficult for all students (Sanderson-Mann et al., 2012). Evans (2014a) investigated how nursing students with dyslexia construct their identities. Twelve students enrolled in Irish nursing programs were interviewed. Students reported varying feelings regarding their dyslexia, including embracing their identity or having conflicting feelings. Some stated they had experienced being considered stupid by others. Students didn?t want their dyslexia to be used as an excuse for poor performance and recognized the need to uphold standards. In fact, many students don?t want to disclose their learning disability for fear of stigma (Evans, 2015; Nolan, Gleeson, Treanor, & Madigan, 2015). In another study, Evans (2014b) interviewed 19 nurse educators (lecturers) from two schools in Ireland using vignettes depicting students with various learning disabilities. Themes emerged related to faculty perceptions of students with learning disabilities. Lecturers stated that if students needed support in getting the work done, the students might be viewed as less capable. One lecturer acknowledged that ?babysitting? students was problematic and some appeared reluctant to provide accommodations. Evans interpreted these and other similar quotes as indicative of the need for faculty development to help them understand the need and legal obligation to support students. Accommodating Learning Disabilities When faculty believe that a student may have a previously undiagnosed learning disability, the initial action is to refer the student to the campus office that assists students with special needs. After the diagnosis has been 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. Once diagnosed, some students may need some accommodation, such as permission to take tests in an alternate setting or more time to complete assignments. The use of color overlays to read text, voice-activated software, spellcheckers, completing work without distraction, and written contracts for completing assignments may also be appropriate accommodations (Locke et al., 2015). McPheat (2014) outlined other strategies that could be useful in both the clinical and classroom settings. For example, printing paperwork on colored paper and using 12- to 14-point Arial font can make text easier to read. Audio recordings of lectures also facilitate understanding of complex materials, which can be done easily with lecture-capturing software integrated into learning management systems (Watt et al., 2014). Helping students understand their own learning styles helps them discover strategies that promote success. Box 4.2 lists universal design strategies that can guide faculty when teaching students with learning disabilities. The use of simulation is another strategy that can help students build self-confidence in their ability to develop clinical competence (Azzopardi et al., 2014). Students may also benefit from the assistance of an in-class note taker, which is a generally accepted accommodation according to ADA. 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. 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 accommodations. 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. Again, use of universal design principles can help s
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