Being reasonable: Supporting disabled nursing students in practice

Nurse Education in Practice 10 (2010) 216–221 Contents lists available at ScienceDirect Nurse Education in Practice journal homepage: www.elsevier.com/nepr Being reasonable: Supporting disabled nursing students in practice Steve R. Tee a,*, Kathy Owens a, Sharon Plowright a, Paro Ramnath a, Sue Rourke a, Claire James b, Jane Bayliss a a b School of Health Sciences, University of Southampton, Highfield, Southampton SO17 1BJ, United Kingdom Trafalgar Ward, Queen Alexandra Hospital, Southwick Hill Road, Cosham PO6 3LY, United Kingdom a r t i c l e i n f o Article history: Accepted 6 November 2009 Keywords: Practice learning Disability Fitness Adjustment Reasonable adjustment mentor s u m m a r y Aim: To analyse recurring adjustments made in practice settings and the support strategies put in place to enable disabled students to achieve the levels of proficiency required on pre-registration nursing programmes. Background: Legislative and regulatory changes in the UK require higher education institutions to make reasonable adjustments for disabled students whose needs must be considered and adjustments made before their programmes of study begin. The student practice learning advisor’s (SPLA) primary role is to support disabled students and to operationalise recommended adjustments in practice. Method: An evaluative case study design was employed to analyse the work of the SPLA over 12 months using progression data, individual interviews and reflective accounts. Findings: The evaluation illustrates the need for support throughout the student’s programme which appears to reach a peak in the final year. Disabled students required 20% more contact time than their non-disabled peers. Operationalising adjustments requires attention to inter-disciplinary, practical and communication considerations. Conclusion: Implementing adjustments in practice requires a multi-disciplinary approach in order to support disabled students, and their mentors and to enable the development and application of coping strategies to overcome potential restrictions. The SPLA provides an essential role in ensuring opportunities for the disabled student to succeed are maximised. Ó 2009 Elsevier Ltd. All rights reserved. Introduction There is an indisputable need for highly proficient, skilled nurses to meet the challenges of a modern, dynamic health service. However concerns have been persistently raised regarding the fitness for practice of newly qualified practitioners (Department of Health, 1999; United Kingdom Central Council, 1999; May and Veitch, 1998; Ross, 2002, Duffy, 2003, O’Shea and Kelly, 2007). Many nurses have been perceived as being unable to undertake certain practical skills unsupervised at the point of registration. These concerns were concordantly expressed by newly qualified nurses who reported feeling poorly prepared for their role as a qualified nurse (Ross, 2002; O’Shea and Kelly, 2007). Despite many revisions to nurse education curricula in response to the concerns raised (Roxburgh et al., 2008), the situation remains complex when it comes to supporting the skill and proficiency * Corresponding author. Tel.: +44 2380597980. E-mail addresses: s.r.tee@soton.ac.uk (S.R. Tee), ko4@soton.ac.uk (K. Owens), sp5@soton.ac.uk (S. Plowright), or@soton.ac.uk (P. Ramnath), srourke@soton.ac.uk (S. Rourke). 1471-5953/$ - see front matter Ó 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.nepr.2009.11.006 acquisition of the disabled student and the student with a learning difference in higher education (Higher Education Academy, 2006). The Disability Discrimination Act, 1995a,b (Amendment DDA 2006) requires education providers to ensure that support for disabled students is fair and equitable to that provided for other students and that, where necessary, reasonable adjustments are made. In concordance with this directive the UK professional regulatory body, the Nursing and Midwifery Council (NMC, 2006), stipulates that students, when qualified, must be able to respond safely and effectively to the challenges of modern healthcare. Service users expect to be nursed by competent people, (Darzy, 2008) and it is essential that all nurses practice at the requisite level of skill, demonstrating competence in the proficiencies determined by the NMC at the point of registration. Typically, adjustments enabling the acquisition of skill and proficiency of the disabled student will be determined by either Occupational Health (OH), Learning Differences Centre (LDC) or Disability Services (DS) associated with Higher Education Institutions (HEI). Academic adjustments can be quite straightforward, but, determining whether or not recommended adjustments are ‘‘reasonable” in practice settings can provide complex challenges. S.R. Tee et al. / Nurse Education in Practice 10 (2010) 216–221 To address these challenges and the potential lack of proper support in practice, an innovative proposal was implemented in one HEI School through a team of Student Practice Learning Advisors (SPLAs). The SPLA’s have a specific remit for supporting students with complex needs in practice and this paper reports on an analysis of their activity, detailing how recommended adjustments for disabled students were operationalised. It is anticipated that this work will be of value to other HEI’s and practice providers within the UK and across Europe who wish to increase their effectiveness in supporting disabled students in practice. 217 mentorship in nursing. The SPLA’s worked closely with students and their mentors to explore concerns, ensure the adequate implementation of recommended adjustments, determine learning needs and devise a plan of action to meet the required learning outcomes. Analysis of the literature revealed, there was little published work related to ‘reasonable adjustments’ in the practice setting. Developing the existing body of knowledge and sharing good practice in this area is therefore of potential value to a range of practice based disciplines and so this article reports on a 12 month, retrospective evaluative case study, which seeks to answer the question: Background literature To consider the genesis of the term ‘‘reasonable adjustments” and current practice with regard to disabled students in nurse education, a literature search was conducted using the BNI, CINAHL and MEDLINE databases. Search terms including disability, reasonable adjustments, competence, fitness, and practice, were combined in order to select relevant literature. In addition, government and regulatory body websites detailing policy and legislative changes were examined to explore the contemporary professional and legal context. There is a growing body of literature which has considered the practice learning support and adjustments made for students with dyslexia (Shular, 1990; Shellenbarger, 1993; Illingworth, 2005; Sanderson-Mann and McCandless, 2006; Morris and Turnbull, 2006, 2007; Royal College of Nursing, 2007) but a relative dearth of work related to other disabilities (Abbott, 2005; Oxtoby, 2005). Legislative changes, chiefly the Disability Discrimination Act, 1995a,b (Amendment DDA 2006) mean there is a likelihood that the number of disabled students will increase; requiring educators to enhance their understanding of special practice learning needs and the implementation of adjustments. Achieving competence in clinical practice has been a key focus and driver in healthcare evidenced by the introduction of the Knowledge and Skills Framework to underpin qualified nurses’ clinical practice (Department of Health, 2003). Duffy (2003) identified that in some settings student nurses receive inadequate support to develop competence and that this support should be forthcoming. For those supporting students with a disability, it is not only an ethical and moral but also a legal obligation. The report, entitled Maintaining Standards: Promoting Equality (Disability Rights Commission, 2006, 2007) highlighted the positive contribution disabled people can make as teachers, nurses and social workers. However the report also highlights that there is much more to be done if we are to create a culture which promotes inclusivity and the provision of equal opportunities for all students. The Disability Discrimination Act, 1995a,b (Amendment DDA 2006) requires HEI’s to assess individual student needs and then to make reasonable adjustments to their programme. These obligations aim to ensure disabled students are supported to achieve their full potential in both practice and campus based learning environments and have implications for the preparation of mentors. Consequently the HEI must work in partnership with local healthcare practice experience providers and the associated Strategic Health Authority (SHA) to ensure commitment to students’ acquisition of skill and clinical competence. Student success is inevitably influenced by the quality of the practice supervision, the learning facilitation skills of the practice mentor and their understanding of the student’s individual learning needs; particularly when the student’s disability requires adjustments to be made to accommodate these needs. For this project four SPLAs were recruited from a range of practice backgrounds; each with experience of clinical teaching and What are the common reasonable adjustments typically made to support disabled students in healthcare settings? Method The overall purpose of evaluation, according to Clark and Dawson (1999), is as an action – oriented framework aimed at improvement. Thus the purpose of this study was to evaluate the impact of the SPLA service in terms of the nature of the support provided for disabled students and in particular the reasonable adjustments being addressed. An illuminative evaluation approach was undertaken which aimed to ‘discover and document’ (p. 7–10) what it was like to deliver the new SPLA service (Hamilton et al., 1977). The perspectives were those of the SPLAs themselves and so a case study design was employed which sought to explore in some depth their experiences of delivering the service to students with a disability (Polit and Hungler, 1995). In adopting this approach the aim was to give a multi-dimensional picture through the process of reviewing current literature and sampling, collecting and analysing a range of data in order to answer the question set out above (Yin, 2003). Data collection Evaluative data was gathered retrospectively after 12 months of operating the SPLA service. Three data collection methods were employed in order to provide a comprehensive picture of the SPLA service. These were: Method 1. Quantitative data provided background information on the students involved with the service and their length of engagement. This included:  numbers of students referred to the service as a percentage of the total student cohort;  nature of the presenting disability;  duration of contact with the service. Method 2. Detailed case summaries were purposefully sampled to reflect the common categories of disability encountered by the SPLA service which were then subject to more detailed analysis in order to ascertain precisely the adjustments made. Method 3. All SPLA’s (N = 4) who formed the service provided descriptive narratives of their personal experiences of supporting disabled students and their mentors in practice in order to articulate the mechanics of the service. Ethics The authors worked within ethical guidelines for evaluation (DoH, 2001) and the ethical procedures determined by the HEI. The data which was obtained from an evaluation report, has been anonymised to ensure case studies would not lead to identification 218 S.R. Tee et al. / Nurse Education in Practice 10 (2010) 216–221 Table 1 Student referral data. Total number of pre-qualifying students in the School Total number of referrals received from mentors Total number of referrals of disabled students as per DDA definition of disabled persona Number Percentage of total 1200 100% 46 27 3.83 2.25 a The Disability Discrimination Act defines a disabled person as ‘‘someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities (Disability Discrimination Act, 1995a,b http://www.direct.gov.uk 2009)”. of individual subjects. Students and SPLAs who participated in the development of this paper gave their informed consent to be named as contributors. Data analysis The three data collection methods generated a large amount of data which required detailed analysis. ‘‘The purpose of data analysis, . . .. . .. . . is to impose some order on a large body of information so that some general conclusions can be reached and communicated in a research report” Polit and Hunger (1995, p. 67). Initially the data was analysed in order to identify referral trends and patterns of usage of the SPLA service (Miles and Huberman, 1994). The qualitative data was subjected to categorisation to determine reoccurrences of particular disabilities and associated reasonable adjustments. The SPLAs descriptions of their experiences were interrogated to identify common themes. The findings from the data presented reflect the three methods of data collection. unaware of the disability and it had presented for the first time after staring the programme. The patterns of referral appear to suggest that more students in their third year required support with their disability. This may reflect the increasing demands and the level of functioning expected of the final year student. The figures reflecting contact time compare students referred to the SPLAs who had a disability and those that did not. The criteria for referral to the SPLA service were that students, irrespective of disability, were in need of additional support with achieving their practice competencies and were likely to be at risk of failing their practice assessment. Disabled students required on average 20% more contact time than their non-disabled counterparts. Case study examples The following four summaries reflect the identified needs of students with a range of common disabilities and learning needs in the practice environment. Students whose disability was already know to the School would have adjustments in place prior to placement but students referred were those who continued to have difficulty despite initial adjustments. To ensure anonymity is maintained, potentially identifying features have been removed or modified. A brief thumbnail sketch of concerns cited by the mentor is followed by an account of the adjustments made. Case study 1: dyslexia – year two student Box 1: Concerns cited by mentor as reason for referral  apparent lack of knowledge;  difficulties organising and prioritising care;  difficulties in record keeping communication difficulties. Student, SPLA and mentor joint assessment of learning needs Student needs to be able to Findings The initial data set provides details of overall usage of the SPLA service in the first year of operation. Table 1 indicates the total number of students referred and the number that had a disability. It can be seen that almost 60% of students referred were disabled. Table 2 breaks down the disabled student data in more detail. Of the twenty seven students referred only five had revealed their disability on application to the programme of study. The working definition of hidden disability adopted was that either the students knew about their disability and had not disclosed or that they were Table 2 Student disability data. Number As a percentage of all referrals (%) Total number of referrals of disabled 27 58.7 students Number revealed disability 5 10.9 Number hidden disability 22 47.8 Stage of programme Year 1 (new students) 8 17.4 Year 2 (new students) 7 15.2 Year 3 (new students) 12 26.1 Postgraduate diploma 0 0 Average number of contacts for all students receiving SPLA support Disabled 5.1 Non-disabled 4  structure information in a comprehensive manner;  structure thought processes to give order to communication;  develop efficiency in memory and recall. Strategies employed to address adjustments  Ensure adaptations and adjustments recommended by LDC are communicated to mentor and are implemented in practice (e.g. coloured overlay), monitor effectiveness.  Provide student with ways of structuring common tasks such as assessment e.g. using ABCDE and devising cue cards as an aid. Provide detailed learning contracts which structure learning into small manageable parts, and encourage repetition and sequencing, building from basic to complex. Advice to students:  access support from LDC;  write cue cards or mind maps about the physiology, signs and symptoms and nursing interventions for common conditions that they will meet in practice;  ask for blank copies of practice documents to take home to practice usage;  take dictionaries (English and Nursing) to placement; S.R. Tee et al. / Nurse Education in Practice 10 (2010) 216–221  keep a notebook to record questions, reminders, etc.;  complete paperwork in a quiet area;  read what they have written aloud in a private place to check sentence construction;  use simple words in records in the first instance to ensure intended communication is clear and accurate (e.g. low blood pressure rather than hypotension);  ask mentor to proof read draft notes;  make notes as a visual representation of the tasks when managing/ prioritising care rather than relying on memory. Case study 2: dyspraxia – year three student Box 2: Concerns cited by mentor as reason for referral Difficulty demonstrating:        professional behaviour; predictable behaviour patterns; punctuality with regard to all aspects of time-keeping; confident communication with the multi-disciplinary; team (MDT); acquisition of new skills; remembering new information. 219  Disclose requirements of others necessitated by their hearing difficulties.  Build confidence.  Address practical problems with hearing difficulties in practice.  Demonstrate the use of initiative. Strategies employed to address adjustments  facilitate Occupational Health(OH) and Disability Services (DS)referral and involvement with student;  liaise with DS to ensure implementation of recommended adjustments and effectiveness of equipment subsequently supplied;  advise mentor on practical issues such as allowing the student to sit/stand facing the person speaking in hand over/ wards rounds;  consider the level of background noise when explaining and teaching procedures to the student;  ensure student is allocated patients whose care they are responsible for to encourage them to identify care needs independently and develop their initiative. Case study 4: mental impairment – year three student Box 4: Concerns cited by mentor as reason for referral Student, SPLA and mentor joint assessment of learning needs Student needs to be able to acquire and develop:     time management skills; skills in organising and prioritising tasks; confidence and competence in practicing clinical skills; confidence in communicating with members of the MDT.  level of practice below that expected at the stage of programme;  impaired recall of new learning;  ineffective inter-professional communication;  difficulty in engaging in practice experiences. Strategies employed to address adjustments Learning contract to include:  supervised practice and organised repetition of identified skills;  strict timeframe for progression from participation to initiation and management of care;  use of notebook and handover sheet to plan care;  student and mentor agreeing shift rota every week and clarifying expectations re time and place of next shift at the end of each shift;  ‘Prioritisation and planning’ skills rehearsal away from practice area with SPLA. Case study 3: hearing impairment – year one student Box 3: Concerns cited by mentor as reason for referral Difficulty demonstrating:  Motivation;  interest e.g. does not ask questions and appears slow to learn;  initiative. Student, SPLA and mentor joint assessment of learning needs Student needs to be able to: Student, SPLA and mentor joint assessment of learning needs Student needs to be able to:  maintain concentration;  build confidence;  address disturbed sleep pattern. Strategies employed to address adjustments  facilitate OH and DS referral and involvement with student;  encourage student to use Counselling and Mentorship services;  initiate programme adjustment and extension of practice experience to allow time off when required; – negotiate shift pattern with placement in order to: – avoid long shifts; – allow later starts; – minimise night shift requirements;  initiate a learning contract detailing weekly targets for achievement;  use learning contract to enable development of levels of activity and independence. Analysis of the descriptive summaries enabled identification of common strategies for all student support (see Box 5) 220 S.R. Tee et al. / Nurse Education in Practice 10 (2010) 216–221 Box 5: Common support strategies for all students  encourage student to visit placement prior to commencement to learn about the placement and be able to identify potential problems;  support students in disclosing issues affecting their practice learning;  ask mentors to schedule regular, honest and constructive feedback sessions;  encourage mentor and student to regularly assess learning needs, set objectives and use a learning contract;  advocate regular progress meetings with SPLA, student and mentor to facilitate feedback and revise learning objectives/ learning contract;  facilitate effective liaison between practice staff, student, HEI and support services. The SPLA experience The following reflections from SPLAs highlight four key areas of practice which have been critical to the success of the role: Working with other services ‘‘Many students referred to the SPLA were dyslexic and already supported by the HEI, LDC. LDC support focuses on academic skills and whilst some strategies can be transferred into practice, such as the use of coloured overlays to assist with reading, many students had difficulty with recall and learning the sequences required for specific clinical skills. This demanded individual assessment and management.” ‘‘Supporting dyslexic students demands an individualised multiservice but coordinated approach. The SPLA service works closely with DS and OH to ensure that reasonable adjustments are implemented and supported by both the student and practice staff.” ‘‘. . . those working within the DS are not from healthcare backgrounds which make it difficult for them to recommend appropriate adjustments relevant to specific practice situations.” Practical measures ‘‘An example of this is the student with impaired hearing. It was identified that the student found it impossible to determine blood pressure using a sphygmomanometer and stethoscope and was therefore given the recommended electronic stethoscope.” ‘‘In skills rehearsal . . . it was identified that the stethoscope could not be used to measure blood pressure and was intended for identifying heart sounds. We were able to liaise with DS to select a more appropriate aid that would be appropriate for the student and for the intended purpose.” Individualised support ‘‘The team have used learning contracts and skills rehearsal with these students in an attempt to overcome these difficulties.” ‘‘Support is tailored to individual need and the student is often used as a resource for potential coping strategies.” Promoting student well-being ‘‘Some mentors have expressed concern upon first meeting with a disabled student that they will not be fit for practice. Sometimes, such concerns have been manifest by reluctance in implementing adjustments; some mentors who are less experienced express concern that patient safety may be compromised.” ‘‘It is gratifying when SPLA input creates positive change in attitudes towards disabled students.” Discussion Previous studies have found that student nurses with disabilities may have difficulties with communication, consistency, documentation and the acquisition of clinical skills (Sanderson-Mann and McCandless, 2006; Morris and Turnbull, 2006). This study highlights the need for effective and coordinated support for disabled students but reveals that additional time may be required to learn, rehearse and become proficient in clinical skills. Providing reasonable adjustments in practice can be challenging due to the potential diversity of practice experiences, the limited time that mentors have to support learning and the distance from the HEI (Duffy, 2003). Whilst academic institutions have well established systems in place for supporting disabled students within the academic environment these may not be mirrored within the practice setting (Wright, 2000; Sanderson-Mann and McCandless, 2006). The creation of the SPLA role portrays an attempt to address the need to provide regular and frequent support for both the student and their mentor in practice, wherein the efficacy of recommended adjustments can be assessed and further support provided. This study reinforces the long established need for regular meetings between the HEI and the practice provider to ensure that arrangements are satisfactory for each individual (Selekman, 2002). This study set out to determine the common reasonable adjustments typically made to support disabled students in healthcare settings and what is clear is that the process of determining adjustments and then confirming that recommended adjustments are reasonable involves a number of agencies including OH, DS, LDC and practice providers. The SPLA team, using their knowledge of nursing, have been the conduit through which all agencies have been able to ensure increased and more appropriate support, both to the disabled student and their mentor. Where specific problems are encountered the SPLA’s are able to liaise with expert services at the HEI to consider equipment and techniques that could be used to help the student overcome their disabilities. Reactive solutions to students needs are often too late to be effective (Sanderson-Mann and McCandless, 2006) but the SPLA team has now become much more proactive in engaging students early in their student life-cycle in order to anticipate and address any potential problems in practice which includes mentor’s lack of knowledge about disability and, perhaps more worryingly, inadvertent and naive prejudice toward disabled students. SPLA’s were careful that professional fitness to practice standards were not compromised, but within these parameters the team have been able to develop their awareness of successful strategies for supporting students with a range of diverse needs to achieve professional competence and proficiency. The various stakeholders seemed to have benefited from the commitment and investment in this role. Although student evaluations were not incorporated in this evaluation, students involved in this study have reported finding the support provided gave them confidence not only in practice but also in discussing their disability more openly. Significantly, mentors showed greater appreciation of their role and their obligations in supporting disabled students. The HEI were seen to be proactively fulfilling their legal responsibilities and contributing to the student-centred culture within the HEI. Whilst this project evaluated a specific local development within one institution, there are important lessons to be learnt particu- S.R. Tee et al. / Nurse Education in Practice 10 (2010) 216–221 larly around the need for institutions to find suitable mechanisms enabling collaborative dialogue with support services including OH and the DS to ensure students continue to receive the support they need. Conclusion This study sought to explore the common reasonable adjustments typically made to support disabled students in nursing programmes. However it became clear that the SPLA role was pivotal in translating adjustments into practice. Adjustments recommended by OH, LDC and DS reflect the first stage of a dynamic process. Adjustments were subsequently reconfigured, reduced or more typically added too, by the SPLA in consultation with the mentor, the student and always as a result of the lived experience. The learning that occurred as a result is being used to inform and develop support services to provide information and intelligence for those who must determine adjustments for practice for disabled nursing students in future. The Disability Rights Commission report (2007) highlights the positive contribution disabled people can make as nurses. It further emphasises the requirement to create a culture which promotes inclusivity and equal opportunities for all students. 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