Ms. Dupler, Dr. Allen, and Dr. Fleming are Clinical Associate Professors; and Ms. Allen is Instructor, Washington State University College of Nursing, Spokane, Washington; Dr. Maheady is Adjunct Faculty, Christine E. Lynn College of Nursing, Florida Atlantic University, Boca Raton, Florida.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
Address correspondence to Alice E. Dupler, JD, APRN-BC, Clinical Associate Professor, Washington State University College of Nursing, P.O. Box 1495, Spokane, WA 99210; e-mail: email@example.com.
Faculty have reported a significant increase in the number of nursing students with disabilities (Ashcroft et al., 2008; Carroll, 2004; Kolanko, 2003; Maheady, 1999; Maheady & Fleming, 2005; Nelson, 2005; U.S. Census Bureau, 2005; Centers for Disease Control and Prevention, 2009); however, misinformation regarding legislated changes in the definition of a disability, as enacted in 2008 under the Americans with Disabilities Act Amendments Act (ADAAA), has contributed to faculty confusion when working with students with disabilities. Faculty who have a working knowledge of the law related to students with disabilities are more likely to identify successful teaching interventions to help students meet standards of practice (Kolanko, 2003; Kontash, Fletcher, Frain, & Winland-Brown, 2007; Madaus, 2008; Maheady, 1999, 2003; Marks, 2007, 2009; Owen & Standen, 2007). When this knowledge is integrated into a nursing program’s culture and curriculum, students with disabilities can achieve success in entry-level and advanced nursing education.
The purpose of this article is to address faculty questions regarding two issues. First, under what circumstances are nursing faculty legally required to provide reasonable accommodations for students with disabilities, as defined under the Americans with Disabilities Act (ADA) of 1990 and as amended in 2008? Second, what strategies facilitate successful completion of core requirements and demonstration of essential functions by students with disabilities?
Prior to enactment of the ADAAA in 2008, the ADA of 1990 and Section 504 of the Rehabilitation Act of 1973 provided legal guidance when working with nursing students with disabilities (Carroll, 2004); Helms, Jorgensen, & Anderson, 2006; McCleary-Jones, 2008; Sowers & Smith, 2004). These federal laws established the framework from which policies, procedures, and processes were developed to address the individualized needs of students enrolled in nursing programs (McCleary-Jones, 2005; Morris & Turnbull, 2005).
A student with a disability was a person who had or was regarded as having a physical or mental impairment that substantially limited a major life activity (Helms, Jorgensen, & Anderson, 2006; Rehabilitation Act, 1973). To meet this definition, the student was required to meet a two-part test. First, the student had to demonstrate a physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the body systems (Regulations to Implement the Equal Employment Provisions of the Americans with Disabilities Act, 2011, § 1630.2, i). This included psychiatric, emotional, and learning disorders; alcoholism; substance abuse; and HIV/AIDS and other diseases (ADA, 1990). Second, the student had to establish that this impairment substantially limited his or her capacity to provide self-care or to perform manual tasks such as the ability to walk, see, hear, speak, breathe, learn, or work (Regulations, 2011, § 1630.2, i).
Historically, the judiciary narrowly defined ‘disability’ and eligibility for protection on the basis of the disability. In Southeastern Community College v. Davis (1979), the Supreme Court signaled that although a nursing student may meet the definition of a disability, the law does not assume that a student with a disability is able to meet the requirements of an educational program; it requires only that an otherwise qualified individual not be excluded because of the disability. Subsequent judicial determinations further limited the application of statutory protection under the law due to the student’s inability to meet the restrictive definition as outlined by the courts. For example, students with diabetes, multiple sclerosis, acute or chronic depression, or epilepsy were more often than not excluded from protection under the federal statute even though their illness precluded them from work or school. The Court focused on the individual’s assertion of a disability rather than the organization’s response to a request for accommodation and potential for discriminatory harm against the person with a disability. Individuals were precluded from legal recourse under the ADA by the Court’s denial of “standing” to bring an action under the Statute. Because individuals could not meet the more rigid interpretation of being disabled, the Courts rarely reached the core issue of discrimination against those the statute was intended to protect (Neal-Boylan & Gullet, 2008a, 2008b).
With the passage of the ADAAA (2008), the definition of disability was significantly modified, from a legal perspective. Congress purposely rebutted judicial interpretation of a disability that had evolved between 1990 and 2010 (Parry & Allbright, 2010; Weiss, 2011). Notably, in the ADAAA (2008), Congress stated:
physical or mental disabilities in no way diminish a person’s right to fully participate in all aspects of society, yet many people with physical or mental disabilities have been precluded from doing so because of discrimination; others who have a record of a disability or are regarded as having a disability also have been subjected to discrimination. (§ 12101, a, 1)
Subsequently, the “definition…shall be construed in favor of broad coverage of individuals under this Act, to the maximum extent permitted by the terms of the Act” (ADAAA, 2008, 4, a, 4, C, 122 Stat. 3553, 3555). Thus, the ADAAA shifted the focus from whether individuals, including nursing students, were disabled to the institutional response to a person’s request for accommodation and whether that response was in fact discriminatory toward the individual.
Markedly absent in the 1990 ADA, the ADAAA (2008) statutorily defined that major life activities:
include, but are not limited to, caring for oneself, performing manual tasks, seeing, hearing, eating, sleeping, walking, standing, lifting, bending, speaking, breathing, learning, reading, concentrating, thinking, communicating, and working, [in addition to] the operation of a major bodily function, including… functions of the immune system, normal cell growth, digestive, bowel, bladder, neurological, brain, respiratory, circulatory, endocrine, and reproductive functions. (§ 4, a, 2, A, B, 122 Stat. 3553, 3555)
Although not an exhaustive list, linkages between impairments and bodily function are readily apparent. Examples include the presence of diabetes affecting the pancreatic endocrine system, lupus affecting the immune system, and cancer affecting normal cell growth.
Strikingly, Congress statutorily negated the judicial interpretation the ADA when limiting protection under the statute to those individuals whose disabilities prevented or severely restricted an individual from performing a major life activity. In the ADAAA (2008), Congress stated that the Court’s interpretation of “substantially limits” in this way required “a greater degree of limitation than was intended by Congress (§ 2, a, 7, 122 Stat. 3553). Under the amended statute, an “impairment that substantially limits one major life activity need not limit other major life activities in order to be considered a disability” (ADAAA, 2008, 4, a, 4, C, 122 Stat. 3553, 3556). This is believed to be the most significant change that Congress enacted when passing the ADAAA (2008). Nursing students may be protected under the ADAAA (2008) based on actual or perceived impairments, whether or not their disabilities limit a major life activity.
Now, mirroring language found in Title VII of the Civil Rights Act of 1964, the ADAAA protects individuals on the basis of disability (Weiss, 2011). In 2011, the Equal Employment Opportunity Commission (EEOC) published regulations interpreting the Amendments in the workplace (Regulations, 2011). In effect, implementing this dramatic shift, federal regulators have signaled their intent to focus scrutiny on whether an entity has complied with statutory obligations to protect individuals from discrimination and whether, in fact, discrimination has occurred (Regulations, 2011, § 1630.1, c, 4). This was specifically delineated in nine regulatory instructions for interpretation of “substantially limits” under the statute (Regulations, 2011, § 1630.2, j). They include the following:
- “Substantially limits” shall be interpreted broadly; it is not meant to be a demanding standard.
- An impairment is a disability if it substantially limits the ability of an individual to perform major life activities, compared with most people in the general population; it need not prevent or significantly restrict the individual from performing a major life activity.
- The primary focus of attention in ADAAA cases should be whether entities complied with statutory requirements and whether discrimination occurred, not whether an individual’s disability substantially limits a major life activity.
- Determination of whether an impairment limits a major life activity requires an individualized assessment.
- Usually, scientific, medical, or statistical analysis will not be required when comparing an individual’s performance of a major life activity with that performed by most people.
- Determination of whether an impairment limits a major life activity will be made without regard to ameliorative effects of mitigating measures. The exception to this provision is the ameliorative effect of ordinary eyeglasses or contact lenses.
- An episodic impairment or one that is in remission is a disability if it would substantially limit a major life activity when active.
- An impairment that substantially limits one major life activity need not substantially limit other major life activities to be considered a substantially limiting impairment.
- The effects of an impairment lasting or expected to last fewer than 6 months can be a substantially limiting impairment.
Given statutory intent and regulatory guidance provided by the federal agencies, it is clear that both the EEOC and the Office of Civil Rights will enforce the ADAAA with a focus not on the individual, but rather on the entity that is required to meet the individual’s requests for reasonable accommodation. Thus, the focal point is whether the response was indeed appropriate to meet the needs of an individual with a disability who has a statutorily protected right to be free of discrimination on the basis of that disability.
An educational institution most notably should reframe the discussion regarding its response to students who request accommodation on the basis of a disability (Table 1). Specifically, it is critical that institutional response be focused not on the issue of whether the student does or does not have a disability, but rather on the institution’s actual response to the student’s request for accommodation and whether that response assures that the institution is not discriminatory against a student on the basis of a disability.
Table 1: Institutional Considerations in Response to Accommodation Requests
Essential to this analysis is a clear delineation of institutional policy and procedures that include student notice (e.g., in syllabi or acceptance letters) and opportunities for the student to be heard. Typically, this function is delegated within the institution to an office or officer charged with assuring the organizational process is fair and statutorily compliant. Most universities publish the policies and procedures for requesting accommodation on their Web sites and provide contact information for the disabilities coordinator or office.
Prospective students are not required to disclose their disability and need for accommodation prior to admission, but they must do so upon admission if they desire an accommodation. The requirement for disability disclosure and an accommodation request is a change for a student who may have received accommodations without requesting them during their elementary and secondary school years. The responsibility shifts to the student in higher education. Therefore, notice of this requirement should be included in admission letters sent to all students with directions for accessing information regarding the process required by the university.
Nursing faculty integrate strategies to help students demonstrate competence throughout academic admission and progression procedures, theoretical course content delivery, and clinical placement assignments (Table 2).
Table 2: Faculty Considerations to Help Students Demonstrate Competence
Faculty integrate strategies intended to help students request accommodations to facilitate successful completion of course requirements. Initially, a statement should be included in each course syllabus that provides notice to all students who may request accommodation. Typically, statements specifically state that reasonable accommodations are available and provide adequate instructions to students about the process by which they can obtain approval for accommodations to meet their individualized needs.
When notified of approval of an accommodation for a student on the basis of disability, faculty are required to initiate and facilitate an academic accommodation upon admission to the program and throughout the student’s progression through different courses and clinical placements. Although faculty are not required to substantially modify essential requirements, such as excusing students from core classes required of all students, the law does clearly identify that consideration of available resources to address the student’s request are indicated. Accommodations in the course may include the use of auxiliary aids to facilitate the student’s progression through the nursing program (Dailey, 2010; Garcia, Paetzold, & Colella, 2005; U.S. Department of Education, Office of Civil Rights, 1998). These may include note takers, interpreters, videotext displays, Braille calculators, assistive listening devices, and telephone handset amplifiers. Schools may also need to equip institutional computers with screen reading, voice recognition, and other hardware or software. Assistive devices must effectively meet the needs of the student; however, faculty are not obligated to provide the most sophisticated aid available. Further, faculty are not required to fundamentally alter the nature of the nursing program or incur undue administrative or financial burdens; thus, although faculty may extend time given a student to complete a test, they are not required to change the content of the test to accommodate the needs of a student on the basis of a disability. Testing must measure the student’s knowledge, rather than the extent of the student’s disability (U.S. Department of Education, Office of Civil Rights, 2007).
In the clinical setting, some faculty may not be comfortable working with students with certain disabilities. A faculty champion who wants to work with the student will be most effective, especially for beginning students. These instructors, with support from administrators, can then help other faculty learn about and implement necessary accommodations. When possible, clinical faculty should meet with the student prior to beginning the clinical rotation.
When clinical assignments are made, students need to know that faculty will support them in achieving the required course objectives and support their specific accommodation needs. Faculty should allow students time to identify their needs in specific situations and to determine what works to achieve successful results. For example, a student with a limb difference may not know what, if any, kind of help is needed to perform a physical assessment skill until the content is presented and specific skills are described and practiced. For a student with a hearing impairment, access to a telephone with text messaging capability may be essential to assure the patient, student, and agency staff that as questions arise, the student will have direct access to faculty. Students are the experts on their needs; faculty are the experts on clinical expectations and requirements for safe practice. Collaboration among the student, faculty, and nursing students with similar disabilities facilitates identification of needed accommodations, rather than trying to guess what might be needed. Working together to develop creative approaches to meet the needs of the student, patient, and agency while achieving educational objectives results in a satisfying experience for all. As faculty encounter students with disabilities and develop skills in assisting students, a handbook of suggested approaches can be built and the necessary equipment obtained.
Accommodation levels the playing field, facilitates access to a program, and promotes progression through a nursing program; however, providing accommodations does not guarantee success.
Working with a student with a disability is usually a new situation for faculty and can result in unnecessary barriers that inhibit the student’s ability to successfully complete the program. To minimize this possibility, understanding legal requirements when working with students with disabilities and being aware of the available resources (Table 3) to help students with disabilities meet existing standards of nursing practice are crucial to success. When this knowledge is integrated into a nursing program’s culture and curriculum, students with sensory loss, paralysis, mental illness, learning disabilities, limb differences, chronic illnesses, or other disabilities can successfully complete nursing programs and move forward to provide excellent care to clients and serve the profession and their communities.
Table 3: Resources to Help Students with Disabilities
- Americans with Disabilities Act of 1990, 42 U.S.C. § 12101 (1990).
- Americans with Disabilities Act of 1990, as Amended, Pub. L. No. 110-325. (2008). Retrieved from http://www.ada.gov/pubs/adastatute08.htm
- Ashcroft, T.J., Chernomas, W.M., Davis, P.L., Dean, R.A.K., Seguire, M., Shapiro, C.R. & Swiderski, L.M. (2008). Nursing students with disabilities: One faculty’s journey. International Journal of Nursing Education Scholarship, 5, 1–15. doi:10.2202/1548-923X.1424 [CrossRef]
- Carroll, S. (2004). Inclusion of people with physical disabilities in nursing education. Journal of Nursing Education, 43, 206–213.
- Centers for Disease Control and Prevention. (2009). Number of U.S. adults reporting disabilities is increasing. Retrieved from http://www.cdc.gov/media/pressrel/2009/r090430.htm
- Dailey, M.A. (2010). Needing to be normal: The lived experience of chronically ill nursing students. International Journal of Nursing Education Scholarship, 7(1), 1–23. doi:10.2202/1548-923X.1798 [CrossRef]
- Garcia, M.F., Paetzold, R. & Colella, A. (2005). The relationship between personality and peers’ judgments of the appropriateness of accommodations for individuals with disabilities. Journal of Applied Social Psychology, 35, 1418–1439. doi:10.1111/j.1559-1816.2005.tb02177.x [CrossRef]
- Helms, L., Jorgensen, J. & Anderson, M. (2006) Disability law and nursing education: An update. Journal of Professional Nursing, 22, 190–196. doi:10.1016/j.profnurs.2006.03.005 [CrossRef]
- Kolanko, K. (2003). A collective case study of nursing students with learning disabilities. Nursing Education Perspectives, 24, 251–256.
- Kontash, L.G., Fletcher, I., Frain, M. & Winland-Brown, J. (2007). Work place issues surrounding healthcare professionals with disabilities in the current labor market. Work, 29, 295–302.
- Madaus, J.W. (2008). The role of school professionals in implementing Section 504 for students with disabilities. Educational Policy, 22, 363–378. doi:10.1177/0895904807307069 [CrossRef]
- Maheady, D. (1999). Jumping through hoops, walking on eggshells: The experience of nursing students with disabilities. Journal of Nursing Education, 38, 162–170.
- Maheady, D. (2003). Nursing students with disabilities change the course. River Edge, NJ: Exceptional Parent Press.
- Maheady, D. & Fleming, S. (2005, Summer). Degrees of success. Nursing with the hand you are given. Minority Nurse, 50–54.
- Marks, B. (2007). Cultural competence revisited: Nursing students with disabilities. Journal of Nursing Education, 46, 70–74.
- Marks, B. (2009). Jumping through hoops and walking on eggshells or discrimination, hazing, and abuse of students with disabilities?Journal of Nursing Education, 39, 205–210.
- McCleary-Jones, V. (2005). The Americans with Disabilities Act of 1990 and its impact on higher education and nursing education. The Association of Black Nursing Faculty Journal, 16, 24–28.
- McCleary-Jones, V. (2008). Strategies to facilitate learning among nursing students with learning disabilities. Nurse Educator, 33, 105–106. doi:10.1097/01.NNE.0000312187.28519.48 [CrossRef]
- Morris, D. & Turnbull, P. (2005). Clinical experiences of students with dyslexia. Journal of Advanced Nursing, 54, 238–247. doi:10.1111/j.1365-2648.2006.03806.x [CrossRef]
- Neal-Boylan, L. & Gullet, S. (2008a). Registered nurses with physical disabilities. Journal of Nursing Administration, 38, 1–3. doi:10.1097/01.NNA.0000295630.95592.ae [CrossRef]
- Neal-Boylan, L. & Gullet, S. (2008b). Work experiences of RNs with physical disabilities. Rehabilitation Nursing, 33, 67–72.
- Nelson, R. (2005). Nurses with disabilities. American Journal of Nursing, 105, 25–26. doi:10.1097/00000446-200506000-00018 [CrossRef]
- Owen, S. & Standen, P. (2007). Attracting and retaining learning disability student nurses. British Journal of Learning Disabilities, 35, 261–268. doi:10.1111/j.1468-3156.2007.00439.x [CrossRef]
- Parry, J.W. & Allbright, A.L. (2010). The ADA Amendments Act of 2008: Analysis and commentary. Retrieved from http://apps.americanbar.org/abastore/products/books/abstracts/4410202update_abs.pdf
- Regulations to Implement the Equal Employment Provisions of the Americans with Disabilities Act, 29 C.F.R. § 1630.2 (2011).
- Rehabilitation Act of 1973, 29 U.S.C. 791 § 504 et seq. (1973).
- Southeastern Community College v. Davis, 442 U.S. 397, 99 (1979).
- Sowers, J. & Smith, M. (2004). Nursing faculty members’ perceptions, knowledge, and concerns about students with disabilities. Journal of Nursing Education, 43, 248–252.
- U.S. Census Bureau. (2005). Selected disability measures by selected age group: Table 1. Retrieved from http://www.census.gov/hhes/www/disability/sipp/disable05.html
- U.S. Department of Education, Office of Civil Rights. (1998). Auxiliary aides and services for postsecondary students with disabilities. Retrieved from http://www.ed.gov/about/offices/list/ocr/docs/auxaids.html
- U.S. Department of Education, Office of Civil Rights. (2007). Students with disabilities preparing for postsecondary education: Know your rights and responsibilities. Retrieved from http://www.ed.gov/about/offices/list/ocr/transition.html
- Weiss, R. (2011). ADAAA Congress reacts to Courts’ restrictive interpretations of the ADA. Washington State Bar News, 65(9), 9–16.
Institutional Considerations in Response to Accommodation Requests
|What is the actual institutional response to the student’s request for accommodation?
|How was notice provided to the student?
|How was the student afforded an opportunity to be heard?
|Is the response discriminatory against a student on the basis of a disability?
Faculty Considerations to Help Students Demonstrate Competence
|Admission and progression procedures
| Notice of accommodation availability in admission documents
| Facilitate access to and approval of requests for accommodations
| Clearly delineate and adhere to approved accommodations
| Reevaluate and modify accommodations as students progress
|Theoretical course content delivery
| Course syllabus
| Notice of accommodation availability
| Access to procedure to obtain approval
| Contact person information
| Upon approval of accommodation
| Initiate accommodation in a timely manner
| Note takers
| Extended testing time
| Provide auxiliary aides as indicated
| Videotext displays
| Braille calculators
| Telephone handset amplifiers
| Screen reading on institutional computer
| Voice recognition and other hardware or software
|Clinical placement assignments
| Identify a faculty champion
| Allow students time to identify their specific needs in clinical situations
| Facilitate student, faculty, patient, and clinical agency collaboration
| Provide assistive devices with texting capabilities for direct faculty access
Resources to Help Students with Disabilities
|Association of Medical Professionals with Hearing Losses
|Disabilities, Opportunities, Internetworking, and Technology
|Job Accommodation Network