A collaborative approach to supporting nursing students with
disabilities
Alison Doyle
Declan Treanor
Disability Service
Trinity College Dublin
March 2011
1
Executive summary
This paper reviews a number of collaborative strategies between
College staff, services and professional practitioners to enhance the
academic and placement experiences of nursing students with
disabilities, including:
•
Disclosure and the Learning Educational Needs Summary
(LENS)
Clinical Placement Handbook for Nursing Students with
Dyslexia
Supporting students with disabilities on clinical placement:
guidelines for good practice
Development of the College Fitness to Practice Policy
Unilink Service – a specialist support
Academic support and assistive technology
•
•
•
•
•
It includes a small scale study (n=26) which examines student
perceptions of support during clinical placements. Findings
indicated student concerns with disclosure and attitudes towards
disability. Students were reliant on self-devised strategies for
managing placement as opposed to professional and academic
supports. Conclusions: links need to be extended and reinforced
between academic support provided within the college environment,
and clinical placement staff within health service providers. There is
still work to be done around improving confidence in disclosure and
request for reasonable accommodations.
As a result the following recommendations are considered to be the
most appropriate.

Implementation of placement workshops or a short placement
module as a collaboration between the School of Nursing,
CPCs and the Disability Service for 1st and 2nd year nursing
students. The emphasis of such a strategy would be
disclosure and reasonable accommodations.

Promotion of current HSE initiatives such as the online
learning and development tool. Provision of information and
resources with respect to disability and disclosure similar to
toolkits produced by the Royal College of Nursing (2010).
This would provide a greater transparency and confidence
amongst nursing staff and students.
2

Information on availability and examples of reasonable
accommodations provided by health service providers /
practice educators, to decrease student anxiety and promote
student confidence in the disclosure process.

Increased disability awareness training to clinical / practice
placement staff and more regular contact and collaboration
with Disability Service personnel.

Increase awareness of the College Fitness to Practice policy
with the College community is required. The policy section
relating to students with disabilities allows for the introduction
of practical reasonable accommodations in placements thus
allowing students to participate equally with their peers.
3
Introduction
The number of students with a range of disabilities undertaking
professional courses is increasing annually. On completion of the
degree course it is expected that students will work in a professional
capacity. At present there are 71 nursing students with disabilities
in TCD, although this figure relates only to those who have
disclosed a disability. Of these 58 have formally disclosed and
requested reasonable accommodations. Those electing not to
disclose were registered as students with mental health conditions
(7), medical conditions (4), hard of hearing (1) and physical
disabilities (1).
In order to effectively support this student group, practices and
strategies need to be integrated in a way which encourages trust
and confidence on the part of students, staff and practitioners.
Collaboration between practitioners
A number of strategies were undertaken between 2007 and 2010 as
a function of collaboration between the Disability Service, academic
and clinical placement staff:






Disclosure and the Learning Educational Needs Summary
(LENS)
Clinical Placement Handbook for Nursing Students with
Dyslexia
Supporting students with disabilities on clinical placement:
guidelines for good practice
Development of the College Fitness to Practice Policy
Unilink Service
Academic support and assistive technology
Disclosure and the Learning Educational Needs Summary
(LENS)
The Disability Rights Commission (DRC) in the UK found that
mandatory disclosure may result in a reluctance to disclose or seek
reasonable accommodations. It is strongly argued that generalised
health questions are not appropriate, nor do they provide adequate
or specific information. Using generalised health questions were
found to be more likely to lead to prejudicial views, resulting in an
increased risk of discrimination (DRC, 2007).
The DRC also draws attention to the increased likelihood of nondisclosure in the case of people with mental health issues. In some
circumstances non-disclosure may result in character judgements
4
being made if or when a crisis happens, and a student subsequently
needs to disclose their disability. The DRC recommend that a
decision not to disclose is not taken as evidence of bad character
(recommendation 16). Non-disclosure can also result in lack of
provision of reasonable accommodations which may improve an
individual’s ability to work effectively and safely. Non-disclosure is
understandable, but is not in the public’s best interest.
The Disability Service actively encourages disclosure from nursing
students. Every student who requests registration with the service
is provided with a needs assessment which identifies support
requirements that should be provided from Schools and
Departments, including examination accommodations, and those
that should be provided by the Disability Service. These are
captured in a document called the Learning Educational Needs
Summary (LENS). The LENS also contains a directive stating that:
‘The student should attend a meeting with their Nursing
Practice Development Co-ordinator to familiarise
themselves with the clinical placement setting, and to
discuss their requirement for reasonable
accommodations on clinical placement.’
A diagram of the LENS journey is provided in Figure 1. On
completion of the needs assessment a copy of the LENS is sent to
the student, and they are asked to confirm in writing their approval
for its circulation to their college tutor, the School Administrator,
the Head of School and the Clinical Allocation Officer. The student
is also asked to sign a Code of Practice which identifies the
recipients of the LENS. The Allocations Officer forwards the LENS
on the student’s behalf to their CPC at the commencement of each
placement.
5
Figure 1: The LENS journey
Clinical Placement Handbook for Nursing Students with
Dyslexia
The aim of the Clinical Placement Handbook was to provide advice
for students with specific learning difficulties, and centred on
constructing strategies for use on clinical placements and in the
future work place. In March 2009 drafts were circulated to
academic and clinical placement staff, and students, inviting them
to submit comments and additional material.
The handbook contains sections on planning a placement, general
advice and tips from students, calculating drugs, nursing
terminology, practical strategies, and assistive technology. The
booklet was designed to be both portable and functional and has
space for students to make notes and record contact details. The
section on practical strategies examines typical difficulties students
may experience as a function of their disability, together with
suggestions for effective management of such difficulties for both
the student and clinician.
The final version was published with funding provided by the School
of Nursing and Midwifery and was launched in December 2009 by
Sheila O’Malley, Chief Nursing Officer. A hard copy of the booklet is
provided to every nursing student on registration with the Disability
Service, and is available to download from the Disability Service
website at
http://www.tcd.ie/disability/docs/TCD%20nursing%20book.pdf
6
Supporting students with disabilities on clinical placement:
guidelines for good practice
Students with disabilities might experience challenges on placement
similar to those they encounter in an academic setting, but the
strategies and skills used in College do not necessarily translate to
the workplace. Nevertheless, such students are entitled to
‘reasonable adjustments’ in the workplace under the terms of the
Equal Status Act (2000). Professionals working with students in
higher education institutions are often concerned that support for
students with disabilities is not always in place on practice.
Challenges might arise when Nurse Practice Development
Coordinators / Supervisors are unfamiliar with reasonable
adjustments, and are not aware of how best to support the students
under their supervision.
In March 2009 a discussion document was initiated around
supporting students with disabilities on clinical placement, to
investigate how collaboration between stakeholders might enhance
this support. The content was based on guidelines proposed by
Stainer and Ware (2006) together with secondary research into best
practice. A draft was reviewed during a round table discussion
between the academic staff within the School of Nursing and
Midwifery, the Allocations Officer, Nurse Practice Development
Coordinators, and Disability Service staff.
The document considered the following issues:
•
How to ensure that there is effective communication between
the academic environment, practice settings and students.
•
How to ensure that mentors have sufficient support and
information to facilitate the learning experience of
students’.
•
How to support students to ‘translate’ strategies learnt in an
academic environment to a placement setting, and take
responsibility for their learning.
Further drafts were circulated with suggested amendments. Final
guidelines were forwarded to the School of Nursing and Widwifery.
7
Unilink Service
Unilink is a practical occupational therapy support service for
students who may be experiencing mental health issues related to
Bipolar Disorder, Depression, Schizophrenia and Asperger’s
Syndrome. The service was further expanded in 2007 to include
students with sensory, physical disabilities and dyspraxia and
physical disabilities.
Students with these conditions often experience difficulties in the
executive functioning skills. For example, they may experience
difficulty concentrating, planning and motivating themselves to
engage in their day to day activities such as going to lectures or
balancing work and leisure interests. The service offers practical
support on a one to one basis which is tailored to the individuals
needs and caters for these problems.
The aim of service is to enable students to develop practical selfmanagement strategies that assist them in the completion of their
college tasks and integration into college life. Unilink was officially
launched by the Minister of State at the Department of Education
and Science, Sile de Valera on 28th September 2006. Funding for
Unilink support is provided through the European Social Fund, and
applications for funding are administered by the Disability Service.
Students may be referred by the College Health Service, Student
Counselling Service and the Disability Service or College Tutor. The
majority of referrals to the service have been from Disability Service
and the Psychiatrists within the Trinity College Student Health
service. In September 2007 the Disability service adopted the policy
of referring all students disclosing a mental health difficulty.
Access to the service varies according to the need of the student,
and may range from a 10 minute ‘drop in’ on a daily basis, to a
weekly appointment for one hour. Some students wish to access the
service once a month and others need prolonged contact
throughout the duration of their course. Attendance may be regular
during the first year of college, but may be suspended until fourth
year, reflecting the course demands in these key years.
Interventions are provided from the perspective of academic tasks,
personal development, personal effectiveness and communication,
and health and well being. Strategies developed in each of these
areas are very pertinent to the area of clinical placement, which can
be a stressful element of the course for some students, and may
exacerbate existing difficulties.
8
Unilink is also provided as an outreach service to Dublin City
University and the National College of Ireland.
Development of the Fitness to Practice Policy
In January 2007 a working group was set up by the Dean of
Students in conjunction with Schools in Trinity College. The
objective of this working group was to develop guidelines around
Fitness to Practice that would both reduce the likelihood of
discrimination, and ensure that those graduating from professional
courses are fit to practice. Specifically a framework for such
guidelines would seek to:



protect students from discrimination on the basis of disability;
protect the College from liability arising from possible
discrimination;
ensure sound academic standards within professional
programs and for professional certifying bodies.
Compliance with equality legislation regarding ‘reasonable
accommodation’ is a fairly realistic goal while the student is within
the 3rd level educational environment, but placements and practice
education are more problematic.
Grey areas exist around exactly which competencies are regarded
as ‘core’ in any given profession.
Over an eighteen month period the working group met with
representatives from Schools offering professional courses and
other relevant. In 2009 the Disability Service submitted a position
paper on fitness to practice in response to the concerns of disabled
students with regard to possible discrimination, and an equal
concern from academics in terms of supporting students whilst
maintaining professional standards. Further research was
conducted to determine how other countries were dealing with this
complex issue, and it was concluded that a clear policy document
needed to be put in place to take account of relevant legislation
protecting disabled students from discrimination, and setting out
guidelines for reasonable accommodation, competency levels,
disciplinary procedures and disclosure of disability.
As a result the Fitness to Practice Policy was formally adopted in
April 2009 http://www.tcd.ie/about/policies/fitness-to-practicepolicy.php. The document contains guidelines for Schools and
Course Committees on the content of school/departmental fitness to
practice policies, together with recommendations on new
procedures for dealing with fitness to practice cases.
9
The adoption of this policy is a positive step and will protect
students who disclose a disability and seek reasonable
accommodations in placements as part of their professional courses.
The Disability Service continues to engage with relevant schools in
supporting them to identify problem areas in placements and in
understanding the reasonable accommodation process in work
based environments.
Provision of academic resources and assistive technology
During the period 2009 – 2010 the Disability Service investigated
new ways of delivering academic support to students with
disabilities, based on the premise of decreasing funding for students
with disabilities, and a recognition that students on professional
courses have restricted access to one-to-one human support whilst
on professional placement.
CPC staff were asked to provide a portfolio of blank forms
commonly used within the clinical context. These include nursing
care plans, biographical and health data, charts and reporting
forms, and are used during academic support sessions where
students identify a need to practice completion of documentation.
In addition CPC staff are encouraged to contact the Disability
Service in situations where they feel they may need guidance on
implementing reasonable accommodations. Individual Education
Plan templates are available for use by CPCs and students to
address areas for improvement in clinical placement in a structured
format.
A new web section was created for ‘Academic and Dyslexia Support’
http://www.tcd.ie/disability/services/AST/index.php providing
advice and guidelines on academic writing, and includes information
on clinical placement together with useful web resources for nursing
students. Examples of such resources are Re-usable Learning
Objects (RLOs) from the School of Nursing, University of
Nottingham and HSELanD.ie online resources for Learning and
Development.
In order to provide equity of access to technology, Texthelp has
been networked on every college computer including those off
campus in D’Olier Street and St James’ hospital. Texthelp Read and
Write Gold is a is a literacy support tool designed assist with reading
or composing text. It provides sophisticated text editing tools in
addition to a number of study skills applications. The toolbar sits
as the top of the screen in any application such as Word or
10
Powerpoint. It facilitates students with literacy difficulties, dyslexia
or English as a second language.
Student perspectives on clinical placement support
Fitness to practice standards and reasonable accommodations can
only be implemented where information regarding disability is
available, and is dependent upon disclosure. However it is widely
acknowledged that the perception of fitness to practice,
stigmatization and fear of discrimination are barriers to promoting
disclosure (Morris and Turnbull, 2007). The objective of this small
scale study was to investigate experiences of nursing students
during clinical placement with respect to provision of reasonable
adjustments, supports and disclosure.
Methodology
Registered undergraduate and postgraduate nursing students with
disabilities (n = 71) were invited to participate in a short survey on
college supports, disclosure and reasonable accommodations. This
invitation was distributed twice by email and included an outline of
the purpose of the survey. Both the email and the survey indicated
that responses would be anonymized before publishing. The survey
opened on 4th January 2011 and closed on the 4th February 2011.
As nursing students are completing placements at this time of the
year, in order to minimize the amount of time spent responding to
survey questions and to maximise the rate of response and
completion, the survey was limited to 10 questions covering:








Year of study
Disability category
Services used in college
Resources used in college
Disclosure
Reasonable accommodations on placement
Attitudes towards disability
Development of strategies
Responses were collected and analysed using software integral to
the survey programme.
Findings
There was a response rate of 37% (26) across all year groups (1st
to 4th year and postgraduate). Student profile indicated the
majority of respondents were 2nd years (34.6%) and the fewest
11
responses were from 3rd years (11.5%). Students with specific
learning difficulties made up 76.9% of respondents, with only four
other disability categories medical and mental health (23%) and
only one respondent from each category of ADHD, AS, Medical and
Sensory (visual).
Students identified supports they used in college as academic tutors
(12.5%), assistive technology (54.1%), Student Services (41.7%),
and the Disability Service publication ‘Handbook for Nursing
Students’ (62.5%). No respondents used the HSE online learning
and development centre.
With respect to disclosure, 56.5% of students had not disclosed a
disability to placement staff, stating that:
‘I don’t want it to seem like an excuse for needing extra
assistance or special treatment.’
‘I did not want to be stigmatized. I have seen other students,
particularly with dyslexia treated badly by CPCs and staff
nurses in the clinical setting. The clinical setting is not a
particularly friendly one, and can be very difficult for anyone
who is identified as having a learning disability. My impression
is that the staff nurses and CPCs don't understand, or think
you should be there, and I have seen a student definitely
discriminated against because of dyslexia’.
’no one understands’
‘with different staff members each day, and worried on how i
would be viewed’.
‘I think that it is better not to, a lot of clinical time is lost to
talking to CPCs about how it might affect things.’
Students were asked to describe the type of reasonable
adjustments they have requested on placement, with 61% stating
that they had not asked for any considerations. Of the remainder
26.1% requested extra time, 17.4% used assistive technology and
asked for practice in talking through procedures, 8.7% requested
time to practice completing forms, and 21.7% checking calculations.
Comments included:
‘I would be afraid to ask for any accommodations. I do not
want them to know. We were warned at college that the
nursing world is a small one, and if you get a reputation it will
follow you. My impression from placement is that you may
12
make it through your training, but you won't get a job
afterwards’.
‘I am wary of how I am affected on placement. As my scope
of practice grows, I feel I could possibly need reasonable
accommodations in the clinical area’.
Quality of support on placement from practice education staff,
nursing and academic staff was also rated, however most students
indicated peer support as beign most effective (excellent 13%, good
30.4%).
Finally students were asked who had assisted in the development of
specific strategies to cope with placement / disability issues. An
overwhelming majority stated that they relied on self-identified or
developed strategies (87%), followed by peer support (39.1%) and
family (30.4%).
Answer Options
Myself
Peers
Family
Nursing staff
Clinical placement staff
Academic staff
Disability Service
Nobody
Response Response
Percent
Count
87.0%
20
39.1%
9
30.4%
7
17.4%
4
17.4%
4
8.7%
2
13.0%
3
13.0%
3
Discussion
The profile of respondents (34.6% second years and 11.5% third
years) may be reflective of the fact that second year students are
13
engaged in longer and more demanding placements than in their
first year, whilst third year students may have acquired sufficient
experience and strategies for placement to be less stressful.
Students with specific learning difficulties (76.9%) accounted for the
majority of responses which is reflective of the proportion of this
disability category registered with the Disability Service, as does the
figure for students with Mental Health difficulties (23%).
Students are availing of practical supports provided by College in
terms of assistive technology (54.1%), Student Services (41.7%)
and Disability Service publications (62.5%), as opposed to
practitioner resources (0%). This indicates the need firstly for
continued and improved / innovative strategies for supporting
students with disabilities in professional placement provided by the
college, and secondly the need for development of resources in
collaboration with professional bodies and health service providers.
Despite a transparent chain of communication between the
Disability Service, academic and practice education staff, disclosure
remains an issue for students, with 56.5% electing not to disclose a
disability. Feedback highlights concerns with discrimination,
stigmatization and poor understanding of the nature of disability or
learning difference.
Such concerns are reflected in willingness to request reasonable
accommodations on placement, with 61% of students stating that
they had made no such request. Those students who did request
accommodations for the most part were seeking human support
with procedures, calculations and forms, including allocation of
extra time in which to do so. Again comments reflected fear or
uncertainty with respect to perceptions of professional competence.
Perhaps as a consequence of concerns around disclosure and
reasonable accommodations, 87% of students stated that they
relied upon self-developed strategies for dealing with practice
placement difficulties that might arise, closely followed by advice
and support from peers / friends (39.1%) and family (30.4%). This
suggests that students are wary of approaching practice
professionals, and that only limited strategic advice is provided.
Arguably this may be a function of lack of confidence on the part of
placement staff with regard to disability specific strategies. This is
reflected in regular requests for advice and guidance on supporting
students that the Disability Service receives from placement staff.
14
Recommendations and future initiatives
In the light of these findings the following recommendations are
considered to be the most appropriate.

Implementation of placement workshops or a short placement
module as a collaboration between the School of Nursing,
CPCs and the Disability Service for 1st and 2nd year nursing
students. The emphasis of such a strategy would be
disclosure and reasonable accommodations.

Promotion of current HSE initiatives such as the online
learning and development tool. Provision of information and
resources with respect to disability and disclosure similar to
toolkits produced by the Royal College of Nursing (2010).
This would provide a greater transparency and confidence
amongst nursing staff and students.

Information on availability and examples of reasonable
accommodations provided by health service providers /
practice educators, to decrease student anxiety and promote
student confidence in the disclosure process.

Increased disability awareness training to clinical / practice
placement staff and more regular contact and collaboration
with Disability Service personnel.
15
References
CHMS, (1999), ‘Guiding Principles for the Admission of Medical
Students’, available from http://www.chms.ac.uk/fastuds.html
Council of Heads of Medical Schools, (2005), ‘Recommendations on
Selection of Medical Students with Specific Learning Disabilities
including Dyslexia’
Disability Rights Commission, (May 2007), ‘Maintaining Standards:
Promoting Equality Professional regulation within nursing, teaching
and social work and disabled people’s access to these professions’,
available from
http://www.maintainingstandards.org/files/Maintaining_Standards_
Summary_Report.doc
Eversheds Solicitors, (July 2001),‘Fitness to Practise in the Medical
Profession’ – A Report to Universities UK and the Council of Heads
of Medical Schools available from
http://www.chms.ac.uk/fastuds.htm
General Medical Council, ‘Good Medical Practice’, General Medical
Council, (Third Edition, May 2001) available from
http://www.gmc-uk.org/global_sections/search_frameset.htm
Health Professions Council, (2005), ‘A disabled person’s guide to
becoming a health professional’, Consultation document London:
The Health Professions Council.
Medical Council, (2004), A Guide to Ethical Conduct and Behaviour,
6th ed. Dublin: Medical Council (Ireland)
Morris, D. K. and Turnbull, P. A., (2007), ‘The disclosure of dyslexia
in clinical practice: Experiences of student nurses in the United
Kingdom’, Nurse Education Today, Volume 27, Issue 1, January
2007, Pages 35-42
Nolan C., (2008), ‘Unilink – Supporting Students with Mental Health
Difficulties at Third Level’, Continuing education Workshops National
University of Ireland Maynooth.
Nolan C., (2008), ‘Unilink – A mental Health Occupational Therapy
service for Third Level Students’. In Proceeding of 42nd Annual
Conference of the Association of Occupational Therapists of Ireland.
Kilkenny. April 16th – 18th.
16
QAA, (2002), ‘QAA Subject Benchmark Statements: Medicine’, The
Quality Assurance Agency for Higher Education,
http://www.qaa.ac.uk/crntwork/benchmark/phase2consult.htm
Roberts, T., Butler, A., Boursicot, K., (2004), ‘The Higher Education
Academy, Special Report 4: Disabled students, disabled doctors –
time for a change?’
Royal College of Nursing, (2010), ‘Dyslexia, dyspraxia and
dyscalculia: a guide for managers and practitioners’
http://www.rcn.org.uk/development/publications/publicationsAZ#D
Stainer, L. and Ware, P., (2006), ‘Guidelines To Support Nursing
Learners With Dyslexia In Practice’, Bournemouth: Bournemouth
University.
Trintiy College Dublin, (2009), ‘Fitness to Practice Policy’, available
from http://www.tcd.ie/about/policies/fitness-to-practice-policy.php
Wray, J., Fell, B., Stanley, N., Manthorpe, J., Coyne, E. (2005),
‘Best Practice Guide: Disabled social work students and
placements’, Hull: The University of Hull
17