Implementation of the Americans with Disabilities Act (ADA) and increased awareness of the abilities of disabled individuals in the work force will soon have an impact on nursing education and other professional and higher education programs. The ADA, signed into law on July 26, 1990, is a comprehensive mandate that prohibits discrimination against the more than 43 million Americans with physical and mental disabilities. In concert with the ADA, previous legislation expanding the rights of disabled Americans to education, employment, and accessible environments (???93-112; 93-516; 94-142) has resulted in a major impact on American society and the educational institutions which prepare individuals to join the work force. While case law has not clarified the extent of impact of the ADA on education, it is clear that the criteria for admission to professional educational programs must be stated in terms of the program's academic requirements, not in terms of the student's functional abilities. Nurse educators have watched ADA and other legislation with interest, but the time has arrived to take a proactive position toward planning for accessible, facultative, and flexible nursing education.
Nursing education must begin to address the needs of otherwise academically qualified applicants who may have visual, hearing, mobility, learning or other disabilities such as mental or chronic illness. Special needs students can be admitted to and accommodated by a nursing program which makes an effort to identify student needs and develop creative and flexible alternative teaching strategies. Traditionally, nursing education admission and progression criteria have been tied to the requirements for nursing licensure (Beeker, 1985; Swenson, Foster, & Champagne, 1991; Weatherby & Moran, 1989). These criteria may need a second look to plan for accommodation of students with special needs.
Review of the literature reveals that nursing education programs have had little experience with disabled students. While a number of hearing and learning disabled students have successfully completed nursing programs (Chickadonz, Beach, & Fox, 1983; TWminia & Weinfield, 1983), information on the scope of disabling conditions represented by students in nursing programs is not readily available. The major nursing organizations do not include information concerning disabled students or the services available to such students in their surveys of nursing education programs. Such data are essential for planning to address the integration of disabled individuals into the nursing profession. In this article, we present the findings of a study undertaken to describe the current status of the admission and progression of students with special needs in nursing education programs. We also explore some of the issues and implications that must be addressed by nurse educators and administrators as special needs students enter the student population.
A model developed by the Committee on the National Agenda for the Prevention of Disabilities, Institute of Medicine (IOM) (1991) guided this investigation. According to the IOM report, Disability in America:
Disability is the product of a complex interactive process involving biological, behavioral, and environmental (social and physical) risk factors and quality of life. Although disability always begins with a pathological condition, it is not inevitable even for people with incurable diseases or injury-caused conditions that carry the highest risks. There are usually, if not always, many points in the progression to disability at which to intervene and improve the quality of life for people with potentially disabling conditions (p. 10).
Elimination of societal, attitudinal and physical barriers can interrupt the disabling process and lead to enhanced quality of life for the functionally impaired individual (see the Figure). Schools of nursing, by taking positive measures, such as providing assistive technology for students or modifying worksites to accommodate students' limitations, can be effective in halting the disabling process. The long-term effects of these interventions will result in a positive outcome by allowing the future health professionals to contribute to society and the economy by maintaining independence and employment.
Design. The design of this research was a descriptive survey. The specific aims of the study were:
* To review the extent to which nursing schools have admitted students with visual, hearing, mobility, or learning disabilities;
* Ib characterize accommodations that have enabled students with special needs to successfully complete their nursing curriculum;
* To describe the types of special needs exemplified by students admitted to selected nursing programs; and
* Tb learn from specific case examples the strategies used by nursing schools in approaching the issues of nursing education of students with special needs.
A survey instrument with both closed and open-ended questions was mailed to faculty and admission officers of a stratified random sample of 200 baccalaureate and associate degree nursing programs in the U.S. Respondents were also invited to participate in telephone interviews to provide clarification or give additional information about specific student case situations. For the purposes of this study, special needs were identified as limitations or impairments of vision, hearing, mobility, mental status, or chronic illness in otherwise academically qualified students. According to Section 504 of the Rehabilitation Act of 1973 (PL 93-112), for the purposes of post-secondary education, a qualified individual with handicaps is one who meets academic and technical standards required for admission to or participation in the program (U.S. Department of Health, Education, and Welfare, 1977).
Figure. The Disabling Process and Quality of Life. Reprinted with permission from Disability in America: Toward a National Agenda for Prevention. Copyright by the National Academy of Sciences, Courtesy of the National Academy Press, Washington, DC.
Sample. The potential sample included 100 National League for Nursing accredited baccalaureate degree programs and 100 accredited associate degree programs in the U.S. Up to two programs of each type were randomly selected from each state. If two or fewer programs of either type existed in a state, all programs of that type were included in the sample. The result was a sample of 86 returned surveys, just over half of which were received from BSN programs and half from ADN programs. The full sample demographics are described in the results section below.
Instrument. The instrument was designed to require minimal time to complete (estimated at 20 minutes based on the pilot study). A cover letter, directed to the program Dean or Director, provided information on the goals of the project and asked for program demographic information. Part 2 of the instrument was designed for a faculty member (designated by the Dean or Director) who had experience with a special needs student. This part asked for an indication of the number and types of students with special needs encountered by the faculty member. Narrative accounts of issues regarding students with special needs that were resolved either successfully or unsuccessfully were solicited. The third part of the survey was designed to be completed by the program admission officer. Part 3 contained questions directed at the number of students who had applied and been admitted to the program, and the admission criteria which applied to student applicants with special needs. The instrument was piloted with faculty and admission officers in the local area and by the office of special student services at a local associate degree program. Suggestions were incorporated into a revised survey instrument.
Packets containing all three portions of the survey were mailed to programs selected as described above. Approximately 10 days after the survey mailing, a reminder card was mailed and an opportunity provided to receive another survey. To prevent the exposure of a program to legal liability, all responses were kept confidential. The transmittal letter accompanying the survey noted that return of the survey would be assumed to indicate informed consent. Surveys were returned without identifying information except for the postmark indicating state.
Limitations. The voluntary nature of the survey precluded a guarantee of obtaining responses from a geographically balanced sample. Due to the nature of the question, more recently developed programs with newer buildings and equipment may have had more success in integrating disabled students. It was apparent, when responses were coded, that a number of surveys were completed entirely by one individual rather than by three different individuals as requested. This situation may have led to lower numbers of responses on Part 3 of the instrument which contained some questions that were also present in Part 2. A further problem identified was limited recordkeeping by schools of nursing on the numbers and progression of disabled students.
A total of 86 out of 200 surveys were returned, representing more than a 40% return rate. Narratives relating experiences with special needs students were received with 27 returned questionnaires. Six blank surveys were returned. Completed surveys represented schools in 44 different states as determined by postmarks; no determination of state was possible for nine surveys.
The schools ranged in size from 15 to 600 enrolled generic nursing students. Numbers of graduating students ranged from 2 to 270 per calendar year. Approximately half of the returned surveys (46.9%) were received from associate degree programs and half from bachelor's degree programs (51.9%). Nearly 90% of the schools responding are located on the main campus of a college or university. The remainder are located on a health sciences campus separate from the main campus. Seventy-five percent of the programs responding indicated that a student services office for students with special needs was available on campus.
The survey contained questions relative to the accessibility of the campus to students with different types of disabilities. The best access was reported for mobilityimpaired students (57.5% of the respondents answered "good" access) and learning-disabled students (57.0%). The poorest access was indicated for visually impaired students (51.9% answered "poor" access) and hearingimpaired students (39.7% answered "poor").
Sixty-nine faculty responded to Part 2, the faculty portion of the survey. Most faculty reported direct teaching contact with a student with special needs, the majority of whom were learning disabled. Contact with mentally impaired students (identified by the survey and faculty respondents as socially or emotionally disabled) was also reported frequently. Contact with students with chronic illness was reported less frequently; these problems were most frequently identified after admission. The lowest reported contact was with visual- and mobility-impaired students (see Table 1).
The types of accommodations which programs have made available to special needs students varied widely, as shown in Table 2. Most programs reported the availability of counseling for disabled students. Fewer reported having used equipment modifications, interpreters or other accommodations.
On Part 3 of the instrument, designed for completion by admission officers, 77.6% responded that their program had admitted a student with special needs in the past 5 years. The remainder responded that they had no disabled students, or they did not know if such students had been admitted. The number of disabled students admitted to programs with experience with special needs students ranged from 1 to 200, with an average of 13. Approximately half of those students admitted ultimately graduated. No admission officers reported that their schools maintained special admission criteria for students with special needs.
In summary, the results of the quantitative descriptive analysis indicate a high level of awareness of the potential for students with special needs, but limited experience and accommodation. Most programs that reported admitting students with special needs had experience only with learning-disabled students. Learning disabilities, chronic illness, and mental disabilities were hidden impairments, typically diagnosed during the student's program rather than prior to admission. Few schools had admitted students with hearing, mobility or visual problems. One of the narrative responses received gives a clue as to this lack of experience. The respondent, a faculty member who wears bilateral hearing aids, applied to two schools of nursing and was turned down when she told them about her level of hearing. The third time she applied, she did not volunteer information about her hearing loss and was accepted, graduated, and went on to graduate education and a career as a nurse educator.
In addition to the more quantitative descriptive analysis which reflected limited experience with disabled students, a qualitative analysis of narrative data was performed. These data provided a richer, experiential perspective unattainable in the descriptive analysis presented above.
Results of analysis of narrative data revealed three themes relating to faculty experiences with special needs students: lack of awareness, creative problem solving, and problems and failures.
Lack of Awareness. A distressing number of respondents indicated that they were not aware of any students with special needs and did not keep records of such students. In addition to reporting a lack of recordkeeping, one respondent said, "If they meet our technical standards and possess academic qualification, they are admitted.* Another respondent reported that unless a student's disability was "noticeable," the student was not identified as impaired.
Creative Problem Solving. Many of the faculty providing narrative description told of the creativity and caring used to help students complete their education. Stories were told also about how accommodation to diversity in the student population enriched the program and created a "success story" for both the student and the school. In one situation, a respondent recalled: "We had a student with a learning disability .... He particularly encountered difficulty with charting and taking written examinations. A faculty member who had a child with a learning disability, I believe, helped me and other faculty to evaluate the problem and to look at alternative solutions. We allowed the student to take oral examinations, and we assisted him with his writing skills. The computer helped him to improve his writing skills."
Two stories involved operating room (OR) experiences for students who used canes for ambulation and balance. Despite initial opposition by the OR staff, the faculty arranged for the canes to be either decontaminated or wrapped in gauze. One of these students later participated as a scrub nurse without the assistance of her cane. These learning opportunities would not have been available to the student if the faculty members had not intervened.
One school enrolled a student with an amputation of an upper limb. In the faculty member's words: "We had a student with only one arm, so she had difficulty doing skills. We were able to help her arrange for a batteryoperated arm. She learned how to use the arm and was very successful." When another student with a similar amputation applied, the faculty already had problem solved many accommodations. Another program recalled two students with different types of brain tumors; although the students had different needs and abilities, a faculty attitude of helping and problem solving facilitated their progress. Both schools reported successfully meeting the challenges of working with these students.
Nature of Disabling Conditions in Nursing Students with Whom Faculty Have Had Contact
Accommodations Which Have Been Made for Special Needs Students (% of respondents indicating availability)
Another example involved a visually-impaired student: "Both faculty and student adjusted [to the student's limited vision]. Additional time was necessary for the person to 'see' and to read. Readers were available from the Blind Center to read texts. Special equipment was available to her. Extra time was provided at examinations. Tests were in dark black ink on white paper. For state board examinations, a reader was requested."
Problems and Failures. Several respondents noted that the issues of disability can become overshadowed by other issues. Specifically mentioned were disabled students who were perceived as manipulative. For example: "A student who was very loud, demanding, and manipulative was handled with counseling and strict limitations placed on her behavior. Unreasonable demands made by her were denied. She has now been in the [nursing] major three semesters. Little change in her behavior has occurred." Also mentioned were overwhelming problems which could not be overcome, for example: "This student was a marginal student before the accident [which led to a mobility impairment]. Following rehabilitation, [she] was able to physically do most assignments, but never mastered nursing process and failed."
Although, in many cases, faculty were able to accommodate the needs of learning-disabled students by such means as adjusting reading assignments, eliminating time testing, and providing quiet places for examinations, other barriers external to the school precluded the students moving on to successful nursing practice, for example, these students sometimes were unable to complete NCLEX examinations due to lack of accommodation by the state nursing board.
In summary, although problems and failures and a lack of awareness of special needs students was identified in the qualitative analysis, the creativity and sensitivity of nurse educators in facilitating education of special needs students was gratifying and worthy of recognition.
One in seven Americans (approximately 36 million people) has a disabling condition which interferes with life activities (Institute of Medicine, 1991). A functional limitation does not necessarily result in disability, but in the context of a society in which that limitation is not accommodated, disability can occur. To intervene in this process, it is important that nurse educators face the multiple issues of special needs students who seek enrollment, progression, and graduation from their programs (Strader, 1983).
Nursing is reemerging as a highly regarded field of study due to multiple economic and social factors. The desire of students with special needs to find work in a respected profession in which salaries are improving and jobs are available are not unlike those of the general population. This situation will surely result in additional applications to nursing schools by students with varied needs and abilities.
Recent passage of the Americans With Disabilities Act has again focused the attention on the abilities of people with special needs. While our research showed that the level of integration of students with special needs is limited at this time, it is clear that the changing nature of the social climate will encourage such students to seek nursing education.
What barriers exist for the nursing profession and in nursing educational programs which might limit the admission of students with special needs? Speculation and imagination inform the following issues:
While nursing programs are characterized by the provision of professional education, nurse licensure requirements remain largely vocational in content and scope. Many nursing education programs have traditionally tied graduation requirements to the licensure examination required for practicing nurses. The licensure process implies, but doesn't test, the ability to provide the physical aspects of nursing care. Does potential exist in nursing for the provision of nursing education to those who might never practice bedside nursing? While practicing nurses who become disabled often take on nursing responsibilities which do not involve physical care to patients, could these roles be envisioned for students who, on admission, are unable to practice in the traditional manner? These questions indicate that several philosophical issues need further consideration.
What types of accommodations might make nursing education more accessible to disabled or special needs students? The best source of information is the student himself or herself Ideally, the student has access to an Office of Disabled Students which can provide advice and support. Interaction with students who are well informed and appropriately demanding of accommodation will tax nursing programs which have rigid curricula and scheduling. How much flexibility in the design and implementation of nursing education are nursing programs required and willing to provide? Regulations accompanying the ADA that pertain directly to health professional education programs are as yet unwritten. Nurse educators are encouraged to participate in development of appropriate and reasonable policies.
Disabled students who are successful in post-secondary education often attribute their success to professors or instructors who are willing and able to meet their needs (American Council on Education, 1991). How might nursing faculty learn to deal more effectively with students with disabilities while maintaining high standards required by nursing, state, and national accrediting bodies? In addition to seeking assistance from a campus office for disabled students, a number of resources are available. Table 3 is a list of publications which may provide valuable information to nursing faculty and administrators preparing to admit special needs students.
Awareness programs can help faculty and students alike understand the visible and invisible disabilities of special needs students. A consultant from the university office for disabled students or city or state commission on the handicapped may assist faculty to raise awareness and develop strategies to ensure successful integration of these students. Offices of vocational rehabilitation at the state or county level may also provide valuable consultation. Nurses who have experienced disabling conditions or chronic illness should be invited to talk with faculty or to serve as ad hoc members of curriculum or admissions committees during discussion of these issues. These nurses could be invited to mentor students with special needs during their nursing education.
As the nursing profession continues to struggle with the identification of essential knowledge for nursing practice, nurse educators must identify essential and congruent aspects of nursing curricula and education strategies. Although sorting the essential from the traditional or habitual aspects of nursing education is troublesome and emotionally charged, the time has arrived for nurse educators to take on this challenge and facilitate the education of enthusiastic and capable future nurses.
Resources for Nurse Educators
- American Council on Education Health Resource Center. (1991). Resources for adults with learning disabilities. Washington, DC.
- Beeker, B. A. (1985). Helping students succeed despite learning disabilities. Nursing and Health Care, 6(10), 558-561.
- Bueche, M.N. (1983). The student with hearing loss: Coping strategies. Nurse Educator, 8(4), 7-11.
- Chickadonz, G.H., Beach, E.K., & Fox, J.A. (1983). Educating a deaf nursing student. Nursing and Health Care, 4(6), 327-333.
- Institute of Medicine. (1991). Disability in America: Toward a national agenda for prevention. Washington, DC: National Academy Press.
- Strader, M.K. (1983). Schools of nursing and the handicapped applicant: Status of the law. Nursing and Health Care, 4(6), 322-326.
- Swenson, L, Foster, B.H., & Champagne, M. (1991). Responses of schools of nursing to physically, mentally, and substanceimpaired students. Journal of Nursing Education, 30(7), 320-325.
- Tumminia, PA., & Weinfield, AM. (1983). Teaching the learningdisabled nursing student. Nurse Educator, 8(4), 12-14.
- US Department of Health, Education, and Welfare. (1977). Nondiscrimination on basis of handicap. Federal Register, 42(86), 22676-22702.
- Weatherby, F, & Moran, M. (1989). Admission criteria for handicapped students. Nursing Outlook, 37(4), 179-181.
Nature of Disabling Conditions in Nursing Students with Whom Faculty Have Had Contact
Accommodations Which Have Been Made for Special Needs Students (% of respondents indicating availability)
Resources for Nurse Educators