Dr. Temple is Assistant Professor, and Dr. Mordoch is Assistant Professor, Faculty of Nursing, University of Manitoba, Winnipeg, Manitoba, Canada.
The authors have disclosed no potential conflicts of interest, financial or otherwise.
The authors thank all of the nursing students who participated in the study. They also thank research assistant, Peter Mary, BN. This study was funded by the Faculty of Nursing Endowment Fund.
Address correspondence to Beverley Temple, PhD, RN, Assistant Professor, Faculty of Nursing, University of Manitoba, 483 Helen Glass Centre for Nursing, 89 Curry Place, Winnipeg, MB R3T 2N2, Canada; e-mail: Bev.firstname.lastname@example.org.
Nurses in general practice can expect to have increasingly frequent contact with people with intellectual disabilities as an increasing number are living in the community, are living longer, and have increased susceptibility to a variety of medical and psychiatric conditions. In addition, people with intellectual disabilities are less able to express their concerns or do so in a way that requires further assessment (Ouellette-Kuntz et al., 2005). To ensure that people with intellectual disabilities receive quality nursing care, nurses require a positive attitude toward this population and an accurate understanding of their health needs.
Ouellette-Kuntz et al. (2005) defined intellectual disability as “a significant limitation in both intellectual functioning and conceptual, social, and practical adaptive skills, originating before the age of 18” (p. S8). Individuals with intellectual disabilities comprise 1% to 3% of the Canadian population and are more likely to have physical disabilities, mental health problems, communication disorders, and hearing and vision impairments (Balogh, Hunter, & Ouellette-Kuntz, 2005). These characteristics, in conjunction with their cognitive and communicative disabilities, tend to make these individuals vulnerable to health disparities and poorer health as a result (Hogg, Lucchino, Wang, & Janicki, 2001). Health disparities are partially attributed to the knowledge base and attitudes of health care providers (Lunsky, Garcin, Morin, Cobigo, & Bradley, 2007; Ouellette-Kuntz et al., 2005).
Some studies have found that nurses feel more comfortable caring for people with physical disabilities than with intellectual disabilities (McConkey & Truesdale, 2000; Ten Klooster, Dannenberg, Taal, Burger, & Rasker, 2009). In comparison with other health care professionals, nurses score poorly on attitude tests toward people with intellectual disabilities (Au & Man, 2006; Packer, Iwasiw, Theben, Sheveleva, & Betrofanova, 2000; Ten Klooster et al., 2009). Traditionally, nursing students have little explicit education and clinical experience with this population. Nursing students often had poorer attitudes on attitude scales than other health care professional students, such as occupational therapy, communication disorders, and physical therapy students (Packer et al., 2000; Pfeiffer et al., 2003; Ten Klooster et al., 2009; Tervo, Palmer, & Redinius, 2004). Attitudes being measured often relate to valued status within society and the support for specialty services for people with intellectual disabilities (World Health Organization, 2001). Katz and Hayout (2002) provided a course on providing care for children with developmental disabilities and their families to hospital and public health nurses in Russia, improving the care nurses felt they were able to provide. Similarly, several other studies suggested that significant improvements in students’ attitudes were possible following theoretical courses and clinical experiences with individuals with intellectual disabilities (Chenoweth, Pryor, Jeon, & Hall-Pullin, 2004; McConkey & Truesdale, 2000; Webb, Tittle, & VanCott, 2000). No similar studies of nursing students’ attitudes are found in Canada.
Currently, disability studies professors are challenging health care professionals to rethink disability and shift from the traditional “medicalised” perspective to one that views disability as a social inequality issue (Lee & Scullion, 2001, p. 30). The medical model perspective views the cause of the disability primarily as the individual’s impairment, inferring disability is an individual problem. The social model of disability views society itself as having a disabling effect on the lives of people with a range of impairments. Barriers that are seen to impede the independence of people are viewed as the problem (Scullion, 2000). The perspective from which an individual views disability affects how the individual with the disability is perceived and informs policies and practices affecting care. In this article, we describe the results of a cross-sectional survey of second-year and fourth-year nursing students’ perceptions of disability, their perceptions of the nursing role with this population, and their preparation to provide care for people with intellectual disabilities.
The study was conducted in a mid-size Canadian city with study participants of a baccalaureate nursing program. The participants were from selected second-year and fourth-year classes of the program, with the aim of identifying differences in students’ perceptions throughout their education. The overall response rate was 30% (119 complete returns from 401 surveys distributed: fourth-year students, 52% response, n = 81 of 155; second-year students, 15% response, n = 38 of 246).
Ethical approval was received from the university’s Education and Nursing Research Review Board. Permission to access the student population was received from the dean of the Faculty of Nursing. The nursing students received advance notice of the survey by way of posters on bulletin boards and e-mails through the student council. Classes were selected that represented the majority of students in the second and fourth years of the nursing program and had no relationship to the professors conducting the study. With permission from the class professors, a research assistant with no connection to the students visited classes, gained written consent, and distributed surveys to those who consented to participate.
Data Collection Instrument
The authors developed the questionnaire based on factors identified in the current literature that demonstrated an effect on health care providers’ attitudes toward people with intellectual disabilities. The lack of psychometrics of this survey tool is a limitation; however, many of the questions have been previously used in other studies (Katz, & Hayout, 2002). The questionnaire consisted of three sections with a total of 23 questions, which took a maximum of 30 minutes to complete. The sections of the survey included two open-ended questions about students’ perceptions of disability, nine questions about their personal and work experiences with people with intellectual disabilities, and two scale questions about their confidence in caring for a person with intellectual disabilities. Using a 4-point Likert scale ranging from strongly agree to strongly disagree, students were asked to respond to three statements regarding care of a client with intellectual disabilities. They were asked if they would (a) feel confident in caring for this client, (b) feel that they had the required skills to provide care to this client, and (c) find it difficult to work with this client. Five statements pertaining to students’ beliefs surrounding the nursing role and demographic questions were also included.
Data from qualitative comments were read and, for verification, summarized for reoccurring themes by both professors (Creswell, 2007; Denzin & Lincoln, 2005). Scale data analysis was completed using SPSS® version 15 software. Descriptive statistics were used to describe the sample, and bivariate statistics were used to detect differences (de Vaus, 2002).
The mean age of the respondents was 25.7 years (range = 20 to 45 years). Gender was predominately female (n = 106), with 13 men responding to the survey. Prior to entering nursing, 49% of the respondents had completed some postsecondary education. The majority of students were single (68%) and Caucasian (68%). Most respondents were full-time students (57%) and many indicated that they were also employed full time or part time. The incomes of students’ households ranged from 33% in the <$29,999 range to 36% in the >$60,000.
Perceptions of Disability
In response to the question “When you think of disability what first comes to mind?” many students (48%) considered disability to be an individual’s problem. Students defined disability as “an inability to do things for oneself which leads to a need for assistance” and “a decrease or absence of a particular function or skill that is needed for everyday living.” Students identified disability as mainly physical and associated the wheelchair as a symbol of disability.
However, a few students understood a person with a disability may be “someone who is handicapped physically or mentally but may still be extremely intelligent and able to understand things.” Some students (6%) were sensitive to the stigma and obstacles associated with living with a disability. These students realized that people with disabilities have “something that interrupts one’s life” and were “not given the same opportunities as the rest of society,” recognizing “disadvantages to the individual with the disability” and their struggle with discrimination. A second-year student commented that all people are interdependent and that there is a universal need for interdependence: “we are all interdependent, [and] having a disability means you have a greater than normal reliance on others.” Students noted that societal obstacles hindered independence; one student commented, “society is not fully built for disabled individuals.”
Nursing Role and Educational Preparation
The majority (61%) of students had some personal experience with a person with an intellectual disability. Approximately one quarter (22%) of the students had some experience volunteering with people with intellectual disabilities. Almost all (98%) of the students agreed or strongly agreed that nurses have an important role to play in meeting the general health needs of people with intellectual disabilities but felt that nurses who specialize in intellectual disabilities should have the main role in caring for people with intellectual disabilities.
Students had a wide range of responses to questions about their emotional and cognitive reactions to people with intellectual disabilities. When asked about their feelings of awkwardness when encountering people with intellectual disabilities, students from both years indicated they occasionally (42%) or rarely (39%) felt awkward. When asked about feeling afraid when encountering people with intellectual disabilities, responses ranged from occasionally (14%) to rarely (39%) to never (47%).
A greater (82%) number of students in the second year, compared with those in the fourth year (63%), reported they did not receive any information in their nursing program about how to interact or care for people with intellectual disabilities. But 77% of second-year and 84% of fourth-year students agreed or strongly agreed they feel confident in caring for people with intellectual disabilities who have medical needs. Students agreed or strongly agreed (57%) that people with intellectual disabilities have more health needs requiring assessment or intervention from nurses than does the general population. Almost all (96%) of the students did not believe that people with intellectual disabilities should be a lower priority for health care.
The main limitations of this study are the small sample size, the limited response rate, and that it was conducted at one site. This limits the generalizability of the study findings, although it does contribute to a greater understanding of students’ perceptions of people with intellectual disability.
Most students’ conceptualizations of disability were consistent with the medical model, which emphasizes physical deficits and focuses on providing care based on physical needs, despite a nursing curriculum that attempts to focus on holistic care of the individual, family, and community. Second-year students indicated a greater lack of understanding of communication methods they could use to interact with people with intellectual disabilities.
Nursing education has the opportunity to build on societal changes toward inclusion and to reflect inclusion in education and practice building on the social model of disability. Students have been helped to change their conceptualization of disability from a focus on personal physical deficits to the inclusion of environmental structural and social barriers using targeted educational programs, including preparatory disability educational programs, and by incorporating the perspectives of family of children with intellectual disabilities (Chenoweth et al., 2004; Webb et al., 2000; Wilson & Merrill, 2002).
Although students agreed that a clinical nurse specialist was needed to care for people with intellectual disabilities, paradoxically they stated that they felt competent to look after people in this population. This may indicate that they do not fully understand the needs of the population and perhaps have only limited encounters in more acute settings where they were focused on medical problems, but they felt their knowledge was transferable. This may be coupled with limited clinical situations and opportunities that provide quality role modeling of care. To improve their attitudes about people with intellectual disabilities, nursing students must be educated based on improving positive direct experiences and a self-awareness of personal perspectives through self-reflection (Fitzsimmons & Barr, 1997; Werner, & Grayzman, 2011). Without initiatives to educate nursing students to value people with intellectual disabilities and the related holistic nursing role, students may graduate without adequate exposure to this population’s needs or to professional role modeling of optimal nursing care, thus limiting future intentions to include caring for people with intellectual disabilities in their career choices (Werner & Grayzman, 2011). Students must be taught the societal role in placing people with intellectual disabilities at a disadvantage in order to be able to understand the principles of inclusion and move from a focus on physical needs only to a holistic view of nursing.
The fact that many nursing students viewed disability in terms of functionality concurs with models of health upheld by diverse health care providers and demonstrates that the biomedical model remains the dominant view of health. To begin to view individuals with intellectual disabilities within a more inclusive model of health, a discussion of diverse models of disability must be included within nursing curricula (Hubbard, 2003; Seccombe, 2007). We are encouraged by the thoughtful and reflective comments that some of the students contributed. To foster these more inclusive attitudes, nursing education must provide educational experiences that encourage students to develop diverse understandings of intellectual disabilities (Katz & Hayout, 2002).
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