After completing the assigned readings and viewing the following YouTube video, Open the Door, Get 'Em a Locker: Educating Nursing Students with Disabilities discuss your response to the video and rel
Teaching Students With Disabilities
Betsy Frank, PhD, RN, ANEF
C ongress passed the Rehabilitation Act in 1973. This act states that any program or activity that receives federal funding cannot deny access or participation to individuals with disabilities. Section 504 of this act specifically addresses higher education and prohibits public postsecondary institutions that receive federal funds from discriminating against individuals with disabilities. Furthermore, almost 30 years ago Congress enacted the Americans with Disabilities Act (ADA, 1990). This act was further updated in 2008 and is now sometimes referred to as the Americans with Disabilities Act Amendments Act of 2008 (ADAAA). A summary of key provisions has been published to facilitate use of the act’s provisions (Equal Employment Opportunity Commission [EEOC], 2009). Because of these two laws, colleges and universities have experienced an increased number of students with disabilities admitted to their programs, including nursing programs
Nursing students with special needs present a challenge to nursing faculty in both the classroom and clinical settings. Students who have special needs include those who have a physical disability, such as a visual, hearing, or mobility impairment; a chronic illness; a learning disability; mental health issues; or a chemical dependency problem. Many nursing programs have had experience in meeting the needs of these students, and learning disabilities are among the most common type of disability reported. The majority of students do not disclose their disability before admission. Neal-Boylan and Miller (2017) found that some students with disabilities had to apply to multiple schools before being accepted.
This chapter addresses the issues related to the education of students with disabilities. It specifically focuses on common problems experienced by college students and nursing students: learning disabilities, physical disabilities, mental health problems, and chemical impairment issues. The Rehabilitation Act of 1973, the ADA as amended in 2008 (EEOC, 2009), and the significance of these acts to nursing education are also addressed.
Legal issues related to students with disabilities
Faculty should be aware of the legal issues associated with teaching students with disabilities. The ADA protects the rights of individuals with disabilities in the arenas of education, employment, and environmental accessibility. Higher education institutions must guarantee individuals with disabilities equal access to educational opportunities. Discrimination against individuals with physical and mental disabilities is prohibited by the ADA. However, the ADA does not guarantee that an admitted student will achieve academic success—only that the student has the opportunity to achieve academic success. A university or college has the obligation to maintain academic and behavioral standards for all students, disabled or not (Meloy & Gambescia, 2014).
The full effect of the ADA on professional education continues to be determined as more potential students with disabilities seek admission to nursing and other health professions programs. Focusing on stated program outcomes rather than on specific skills puts faculty in a better position to make decisions about what are reasonable accommodations for students who are disabled or have other special needs. The institution and faculty may be sued for failing to make reasonable accommodations. For example, a Missouri Appeals Court ruled that a nursing program had erred in dismissing a deaf nursing student because she needed accommodations in clinical practice (Wells v. Lester E. Cox Medical Centers, 2012). However, if the student does not request accommodation, the university is not required to provide such (Buescher et al. v. Baldwin Wallace University, 2015).
Implications for Nursing Education
Although many students with disabilities are enrolled in nursing programs, faculty often have reservations about their ability to deliver safe patient care. However, several authors have pointed out that no evidence exists that nurses with disabilities delivered unsafe care (Matt, Fleming, & Maheady, 2015; Neal-Boylan & Smith, 2016). Furthermore, all nursing students presumably are supervised by faculty or preceptors. Therefore their practice is continually monitored for safety issues. Matt et al. (2015) have stated that as the nursing workforce ages, many changes in the work environment can be made to make the environment accessible to practitioners and students alike.
Admitting nursing and other health professions students with disabilities to educational programs promotes cultural diversity (Shpigelman, Zlotnick, & Brand, 2016; Zazove et al., 2016). In 2016 the National League for Nursing emphasized this point in its vision statement Achieving Diversity and Meaningful Inclusion in Nursing Education. Admitting students that represent various groups within the population promotes a workforce that better reflects the population as a whole.
As more students with disabilities seek admission to nursing programs, and as those within the profession age, retaining nurses with disabilities in the workforce will be essential. If faculty and students don’t have an open attitude (Shpigelman et al., 2016) toward students with disabilities, much potential nursing talent may be lost when such students aren’t admitted into nursing programs.
By law, students have the responsibility to notify the institution regarding a disability and the need for accommodation (Walker, 2017). Although disclosure of disabilities is voluntary and not legally required, students who have a disability and require accommodation are encouraged to share this information with the institution’s office for students with disabilities. However, many students will not share information regarding their disabilities for fear of rejection.
Barriers to student success may be related more to faculty, fellow students, and practice partners’ attitudes than to student ability (Neal-Boylan & Smith, 2016; Shpigelman et al., 2016). Based upon faculty interviews, Ashcroft and Lutfiyya (2013) developed a grounded theory about nurse educators’ perceptions of working with students with disabilities. Their theory was named “producing competent graduates” (p. 1317). Subthemes within the theory included “let’s work with it” (the disability); “it becomes very difficult” (to accommodate); “what would happen if someone died?” (because of unsafe practice); a wary challenge; educator attributes, which included past experience in working with students with disabilities; and perceived student attributes or kind of disability.
Faculty negative attitudes can change. A study by Tee and Cowen (2012) demonstrated that a variety of strategies can enhance the ability of practice partners to work with students who have disabilities. Such strategies included having students tell their stories and developing a series of DVDs and interactive slide shows that practice partners, called mentors, could use to understand the issues faced by students with disabilities and how to appropriately accommodate those students. Education for faculty related to providing accommodations and understanding the possibilities for achievement among students with disabilities is key for students’ academic success.
When a student makes known the presence of a disability and gives permission to share this information with faculty, course faculty are notified about the disability that requires accommodation. Course faculty must keep this information confidential and are not to share this information with other faculty, as it is the student’s responsibility to decide when and where to disclose the presence of a disability. Students may choose not to disclose a disability in some courses. Even when student consent is given to share information with faculty, the nature of the disability is not disclosed to faculty unless the student decides to disclose it (Meloy & Gambescia, 2014). Box 4.1 is an example of a statement of services provided for students with disabilities. To receive accommodation, the student must disclose the presence of a disability before engaging in the learning experience; it is not possible to retroactively claim the need for accommodations after the student has already unsuccessfully engaged in the experience.
Box 4.1
Services for persons with disabilities
Disability Support Services provides reasonable, appropriate, and effective academic accommodations to students with known disabilities. This may include academic adjustments and services such as special testing arrangements. Note-taker services are available to qualified individuals. Services for persons with disabilities are based on individual needs and the university’s intent to offer appropriate accommodations according to the student’s documentation of need for same. These services are coordinated by the Student Support Services Grant Program. It is recommended that persons with disabilities visit Indiana State University before making a decision to enroll.
Courtesy Indiana State University Undergraduate Catalog, 2017–2018. Retrieved from https://catalog.indstate.edu/content.php?catoid=32&navoid=860&hl=success&returnto=search#Center_for_Student_Success
Faculty are not allowed to inquire about the nature of the disability. In fact, decisions regarding whether accommodation is possible must be made after the student has been admitted, unless essential abilities are published and all students are asked before admission whether they possess the abilities needed for academic success (Aaberg, 2012). However, most lists of essential abilities focus, in part, on physical abilities such as lifting. Recent initiatives call into question such requirements (American Nurses Association, 2013). Although some schools publish essential abilities that students must achieve, faculty need to consider if they are truly essential to nursing practice. Levey (2014) conducted an integrative literature review on faculty attitudes regarding various aspects of working with nursing students who have disabilities and concluded that disclosure of disability status before admission can be a barrier for students, especially if essential abilities are published. Furthermore, Levey stated that essential functions are more related to employment, not student status. Neal-Boylan and Smith (2016) reaffirmed this position and also reinforced that published essential functions were barriers for students who wish to apply to nursing programs, even though they may otherwise be qualified.
When considering the standards that students must meet, Marks and Ailey (n.d.) and McKee et al. (2016) advocate for separating functional and technical standards. Functional standards for nursing include acquiring knowledge, developing communication skills, interpreting data, making clinical judgments, and using appropriate professional behaviors and attitudes (Marks & Ailey, n.d.). Technical standards such as being able to stand for long periods and working 12-hour shifts are standards that are meant to be used in the employment setting, not the educational setting (Davidson et al., 2016; Marks & Ailey, n.d.). Such technical standards as being able to hear can be met with assistive devices (Argenyi, 2016). Furthermore, just as physicians will not practice across all specialty clinical areas (Bagenstos, 2016), not all nurses practice in all health care settings (Neal-Boylan & Miller, 2017). Faculty have the ability to accommodate students when meeting program outcomes in a variety of ways and settings appropriate to meeting those outcomes, including simulation. Although not all those with disabilities can successfully complete a nursing program, technological advances open the door to wider opportunities for students and practicing nurses. Faculty must remember, however, that students are not required to disclose disabilities before admission. When considering the admission of a student who has a disability, admission committees in schools of nursing must consider the following questions:
■ Disregarding the disability, is the individual otherwise qualified to be admitted to the program?
■ What reasonable accommodations can the school make to enable the student to be successful in the pursuit of becoming a nurse who can deliver safe patient care?
Although institutions are not expected to lower or alter academic or technical standards to accommodate a student with a disability (Meloy & Gambescia, 2014), they are expected to determine what accommodations would be reasonable for a student who is disabled. According to Neal-Boylan and Miller (2017) most accommodations are determined by the campus offices that deal with students with disabilities and the nursing programs themselves.
Examples of reasonable accommodations include altering the length of test-taking times or methods, providing proctors to read tests or write test answers, allowing additional time to complete the program of study, providing supplemental study aids such as audiotapes of texts, providing note takers, or altering the method of course delivery, such as the use of simulation for some clinical practice (Azzopardi et al., 2014). Other accommodations include closed captioning (Neal-Boylan & Miller, 2017). The same considerations must be given to students who become disabled during their enrollment in a nursing program. Questions to be asked include:
■ Disregarding the disability, is the student otherwise qualified to continue in the nursing program?
■ What reasonable accommodations can be made to allow the student to continue?
Using concepts of universal design accommodates a variety of learning styles for all students, not just students with disabilities (Meloy & Gambescia, 2014). Dell, Dell, and Blackwell (2015) have stated that universal design in online courses, in particular, allows students with disabilities to have access without accommodation and students without disabilities can also gain access to course materials in a variety of ways. Universal design promotes course design that uses multiple ways to present course materials and multiple ways for students to demonstrate knowledge acquisition. Most learning-management systems allow faculty to use universal design in presenting their course materials. Technological advances such as lecture capture are easily incorporated into learning management systems (Watt et al., 2014).
In addition, the willingness to be flexible in teaching formats, having a tolerance for mistakes, and promoting a climate of acceptance of those with disabilities through such strategies as placing an accommodation statement in the syllabus is important for teaching online and in face-to-face classes (Levey, 2016). Whether one teaches online or in face-to-face environments, instructional design specialists should be part of the team that designs accessible distance courses and on-campus classes. See Box 4.2 for suggested universal design strategies.
Box 4.2
Universal design strategies
1. Have course materials available in audio and video format.
2. Design uncluttered webpages that don’t rely on color alone.
3. Provide accessible javascript.
4. Provide access to webpages that convert text to audio and audio to text.
Universal design is not just applicable to the classroom setting; it can also be applied in the clinical setting. Heelan, Halligan, and Quirke (2015) presented several case studies of universal design applied in clinical placements. For example, a nursing student with dyslexia used a Livescribe pen to take notes that were intelligible. General design principles included prioritizing learning outcomes into essential and optional, adjusting shift work to account for a student with fatigue caused by a chronic illness, and providing expected tasks to all students ahead of the clinical placement to allow students to practice ahead of time.
Even though many different teaching and learning strategies are a part of universal design (sometimes called inclusive teaching strategies), faculty and student attitudes toward the strategies can foster or hamper their use. Dallas, Sprong, and Upton (2014) studied faculty attitudes toward universal design; 381 faculty across a variety of disciplines including arts and sciences, education and human services, law, and medicine responded to a cross-sectional survey, the Inclusive Teaching Strategies Inventory (ITSI). This inventory measured attitudes toward instructional accommodations. Of note, was the fact that faculty in the colleges of education and human services, applied arts and sciences, and mass communication and media arts were more accepting of making accommodations using universal design strategies than were faculty in other colleges. Years of teaching and training were related to a more positive attitude toward using universal design principles.
Levey (2016) investigated a nationwide sample of nurse educators’ attitudes toward adopting inclusive teaching strategies using the Inclusive Teaching Strategies in Nursing Education (ITS-NE). This instrument was a modification of the ITSI used by Dallas et al. (2014). In contrast to Dallas et al., Levey’s results showed that more years of teaching experience negatively correlated with willingness to use inclusive teaching strategies. Social support was a positive indicator of willingness to use universal design principles in nursing courses.
Students also have a variety of attitudes about universal design principles. Black, Weinberg, and Brodwin (2015) conducted interviews with 15 students, 12 with disabilities and three without. All students desired success, wanted to communicate well with professors, and have ready access to course materials. Students valued the universal design principles such as providing slides before class, and a visually impaired student benefitted from the use of a screen reader. Providing a fully accessible classroom was another universal design principle valued by those with physical disabilities.
Gawronski, Kuk, and Lombardi (2016) compared 179 community college faculty and 449 students’ perceptions of universal design strategies using the ITSI and the Inclusive Teaching Strategies-Student (ITSI-S). Faculty and students alike perceived that accommodations, accessible course materials, multiple means of presentation, and inclusive lecture strategies were important. Students thought that course modifications such as allowing those with disabilities extra credit and inclusive assessments, such as having alternative assessments to demonstrate knowledge, were important—but faculty did not. One should note that 13% of student respondents identified as disabled, but disability status was not identified for faculty.
Faculty should consider that just because a student has a disability, he or she is not necessarily ill, and the type of support needed is not the type needed to cure an illness but to promote positive attitudes toward and the potential for growth of students with disabilities (Neal-Boylan & Smith, 2016). Whether a person’s limitations are viewed as a disability is defined by society rather than by the actual abilities of the person involved. Thus making the decision regarding what is a reasonable accommodation for a person with a disability is a complex process influenced as much by faculty and practice partner attitudes as by actual student abilities.
As the effect of the ADA—and now ADAAA—on nursing education continues to unfold in the courts and in the workplace, nurse educators must keep current with legal developments that relate to the education of individuals with disabilities who are pursuing degrees in the health professions. Some suggestions for increasing faculty awareness of the needs of students with disabilities include periodic continuing education sessions related to the legal implications of educating such students and the use of consultants who are experts in working with students with disabilities. Most institutions of higher education have an office dedicated to assisting and supporting students with disabilities who are enrolled on campus. This office can provide resources and expert advice to faculty and students. Another source of information may be individuals with disabilities who have successfully developed a career in nursing. These successful nurses can help nursing faculty understand the issues involved in educating students with disabilities, and they can serve as mentors to students with disabilities who are pursuing a nursing education. Practicing nurses with disabilities can serve as advocates for students and help nursing programs advocate for students who graduate and then seek employment.
Nursing faculty should begin to separate the truly essential components of nursing education from what has traditionally been included in nursing curricula. Nursing faculty should also use a variety of teaching strategies (Marks & Ailey, n.d.). In addition, nursing faculty need to consider such philosophical issues as whether nursing education might be extended to those individuals who will never practice bedside nursing in an acute care setting. Such nursing jobs might include staff development, infection control, case management, or a variety of jobs in the community settings where nursing care is delivered. A study of admission and retention practices of California nursing schools (Betz et al., 2012) showed that nursing faculty vary in approaches to dealing with disabilities. In making admission and progression decisions for all students, faculty need to balance student rights, safety, and abilities with issues of patient safety and university responsibility for providing appropriate accommodations according to the ADA. Faculty can use a variety of clinical settings to achieve the prescribed learning outcomes. Working with preceptors with disabilities in practice not only assists students in their educational process (Tee & Cowen, 2012) but could also demonstrate that disabled students can be successful as graduates by providing evidence of safe practice given by the students.
The nursing student with a learning disability
Learning disabilities are the most common type of student disability found on college campuses (National Center for Education Statistics [NCES], 2011). Despite a growing number of college students with learning disabilities, only about 17% seek help to be successful in their educational endeavors (Krupnick, 2014). The traditional definition of a learning disability is an incurable neurological disorder interfering with learning in a variety of ways. Approximately 15% of those in the United States have some form of learning disabilities. However, Tamboer, Vorst, and Oort (2016) studied 446 college students, including 63 with diagnosed dyslexia, and came to the conclusion that dyslexia may just be an alternative way of thinking that has evolved over time, because those without dyslexia often have similar learning characteristics to those without. Furthermore, Tamboer et al. (2016) stated that dyslexia may involve multiple cognitive difficulties. Clearly much more research is needed to understand the nature of dyslexia.
Students frequently begin college with learning disabilities undetected. In nursing education, learning disabilities are commonly uncovered when faculty notice striking differences between a student’s classroom performance and clinical performance. The student may display an adequate knowledge base and competent skills during clinical experiences but be unable to demonstrate the same degree of knowledge when taking tests in the classroom. Such disparities in performance can lead to much frustration and stress for the student even though their reading difficulties in many instances may not hamper their ability to complete their program of study (Olofsson, Taub, & Ahl, 2015). Because some students may need some assistance to complete their education, faculty should have an understanding of the characteristics of learning disabilities so they can refer students to the university or college office that works with students with various disabilities.
Characteristics of Learning Disabilities
Learning disabilities may manifest as a number of characteristics, each necessitating a different treatment and accommodation. Learning disabilities, including dyslexia, may involve reading and spelling difficulties; problems with mathematical abilities; difficulty with writing, auditory, and visual processing; and nonverbal processing such as intuition and holistic processing (LD Basics, 2018). Among those with diagnosed learning disabilities, 80% have trouble with basic reading skills (What is a learning disability, 2018). Students with learning disabilities may have difficulty following verbal instructions and difficulty organizing ideas in writing or may be unable to articulate ideas orally but able to articulate them in writing. Students may also have auditory processing deficits that may have an effect on their ability to recite from memory, although the diagnosis of auditory processing is not clear cut (de Wit et al., 2016). Prioritization is often a problem for those with learning disabilities (Locke, Scallan, Mann, & Alexander, 2015). In turn, time management may become problematic for the student.
Learning disabilities are highly individualized, and each student manifests a different grouping of characteristics. Some students without learning disabilities may experience the same difficulties as those with learning disabilities. In one study, Wray, Aspland, Taghzouit, Pace, and Harrison (2012) screened 242 British preregistration students using the Adult Dyslexia Checklist. Results showed that 28.5% of the sample achieved a score possibly indicative of a learning disability. For those students undergoing further evaluation, six students were shown not to have a learning disability. Tamboer et al.’s (2016) study confirms that those without dyslexia may also have some of the characteristics as those with dyslexia. Thus strategies to help students with learning disabilities may also help those without disabilities.
Being accurately diagnosed with a learning disability means students can make adjustments in their study habits and receive support. Support, which is sometimes difficult to get, is critical to their successfully meeting the academic standards.
Sanderson-Mann, Wharrad, and McCandless (2012) compared the clinical experiences of students with dyslexia to those without. Students with dyslexia rated reading and writing on patients’ charts, using care plans, and following a set of instructions more difficult than those without dyslexia. However, such tasks as change-of-shift reports, drug calculations, and time management were difficult for all students (Sanderson-Mann et al., 2012).
Evans (2014a) investigated how nursing students with dyslexia construct their identities. Twelve students enrolled in Irish nursing programs were interviewed. Students reported varying feelings regarding their dyslexia, including embracing their identity or having conflicting feelings. Some stated they had experienced being considered stupid by others. Students didn’t want their dyslexia to be used as an excuse for poor performance and recognized the need to uphold standards. In fact, many students don’t want to disclose their learning disability for fear of stigma (Evans, 2015; Nolan, Gleeson, Treanor, & Madigan, 2015). In another study, Evans (2014b) interviewed 19 nurse educators (lecturers) from two schools in Ireland using vignettes depicting students with various learning disabilities. Themes emerged related to faculty perceptions of students with learning disabilities. Lecturers stated that if students needed support in getting the work done, the students might be viewed as less capable. One lecturer acknowledged that “babysitting” students was problematic and some appeared reluctant to provide accommodations. Evans interpreted these and other similar quotes as indicative of the need for faculty development to help them understand the need and legal obligation to support students.
Accommodating Learning Disabilities
When faculty believe that a student may have a previously undiagnosed learning disability, the initial action is to refer the student to the campus office that assists students with special needs. After the diagnosis has been made, a plan for accommodation of the disability can be developed. Counseling may also help a student with learning disabilities gain self-confidence in the learning environment. As stated earlier, if the student chooses, the faculty can be made aware of the disability and what accommodations are required. Faculty members who are made aware of a student’s disability are not allowed to discuss that information with other faculty members unless the student gives permission.
Depending on the type of learning disability, a variety of accommodations may be appropriate for the student. Once diagnosed, some students may need some accommodation, such as permission to take tests in an alternate setting or more time to complete assignments. The use of color overlays to read text, voice-activated software, spellcheckers, completing work without distraction, and written contracts for completing assignments may also be appropriate accommodations (Locke et al., 2015). McPheat (2014) outlined other strategies that could be useful in both the clinical and classroom settings. For example, printing paperwork on colored paper and using 12- to 14-point Arial font can make text easier to read. Audio recordings of lectures also facilitate understanding of complex materials, which can be done easily with lecture-capturing software integrated into learning management systems (Watt et al., 2014).
Helping students understand their own learning styles helps them discover strategies that promote success. Box 4.2 lists universal design strategies that can guide faculty when teaching students with learning disabilities. The use of simulation is another strategy that can help students build self-confidence in their ability to develop clinical competence (Azzopardi et al., 2014).
Students may also benefit from the assistance of an in-class note taker, which is a generally accepted accommodation according to ADA. This allows students to concentrate on classroom discussion without the distraction of trying to take notes. Some students have difficulty processing multiple stimuli at once. Students who have difficulty reading, and as a result read slowly, often find this disability to be the greatest barrier to their academic success. Faculty can help students overcome this difficulty by providing an audio recording of textbooks and other readings and providing them with the required reading assignments early in the semester, or helping them identify the key sections of reading assignments.
Students with learning disabilities may also need accommodations for testing, because slow reading skills can affect the student’s ability to complete a test within the time allowed. Questions that are grammatically complex or contain double negatives, although difficult for all students, can be particularly challenging for students with learning disabilities and should be avoided. Providing the student with an extended testing time and a quiet room free of distractions may also be necessary accommodations. A test proctor who either reads the test to the student or writes and records the student’s dictated answers to the test questions may also be helpful.
An additional strategy that faculty can use to assist students with learning disabilities is to incorporate a multimedia approach, such as computer-assisted instruction. Again, use of universal design principles can help students with learning disabilities and the student body at large. These include providing copies of ancillary learning materials before class and placing visual cues within class notes. The use of smart phones with appropriate applications may also be helpful for all students but particularly those with learning disabilities. Another strategy that benefits all students, including those with learning disabilities, is to meet with students on a regular basis to ensure that learning goals are being set appropriately and are then being achieved.
Accommodation does not mean that academic standards are lowered but that multiple ways to achieve those standards are provided for all students, including those with learning disabilities. All classrooms contain students with multiple learning styles. By structuring classes to account for different learning styles and providing a variety of learning aids, nurse educators also help accommodate those with diagnosed learning disabilities (Tobin, 2013). When faculty consider that students have different ways of learning, they will design learning experiences that accommodate these diverse learning needs.
Salkeld (2016) developed the OPEL model with four components that can be used to work with students who have learning disabilities. These components are openness and transparency, planning and organization, evaluation and reflection, and learning and feedforward (p. 49). Students are encouraged to share concerns with clinical faculty and staff; students should regularly take time to discuss with clinical teachers and staff how to plan for successful achievement of clinical learning goals. Both students and clinical faculty and staff should reflect on how clinical learning was achieved, and at the end of the course, both students and faculty should reflect on what could be done in future clinical courses to promote successful learning. Specific learning strategies are helpful, but the model places them within a larger context of promoting success not only for those with learning disabilities but for all students. In fact, Hill and Roger’s (2016) study, which compared 353 medical, dental, nursing, and midwifery students who had nonspecified disabilities and those who didn’t, reinforced the need for such a model.
Campus Support Services
As previously mentioned, most institutions of higher education have established an office responsible for providing support services to students who identify themselves as learning disabled. Use of these services is voluntary, and they are usually available at little or no cost to the student. Services vary among institutions but typically include assessment and diagnosis of learning disabilities, identification of appropriate accommodations for the student, guidance counseling, and development of study and test-taking skills. Faculty education about students with learning disabilities is another service commonly provided by these offices. Campus teaching and learning centers can assist faculty with how to design courses in line with universal design principles.
Accommodations for the National Council Licensure Examination
Nurse educators need to be familiar with the accommodations provided students with disabilities in their states when taking the National Council Licensure Examination (NCLEX). Accommodations are offered to individuals with learning and other disabilities in accordance with the ADA. Each state determines the degree of accommodation offered to students on a case-by-case basis. Educators should investigate and verify the accommodations offered to students in their respective state and encourage students with disabilities to seek appropriate accommodations. One of the most common accommodations has to do with time allotted for the examination. Regulations do change, and the student and faculty are encouraged to check with the National Council of State Boards of Nursing (NCSBN) website (https://www.ncsbn.org) or the individual state board of nursing for further information. The student must provide documentation as to what accommodations have been made during his or her course of study before arriving at the testing center.
The student with physical disabilities
Thinking of physical disabilities as hindrances and environments that favor those without disabilities may limit opportunities for students and nurses with disabilities (Hargreaves & Walker, 2014). Required abilities that schools use to exclude students may include hearing, seeing, and lifting. Essential competencies for basic nursing programs may be different from those required in specialty graduate programs. For example, Helms and Thompson (2005) suggested that nurse anesthetists and nurse anesthetist students must be able to work in a fast-paced environment using complex information that is translated into immediate action. Nurse anesthetists must also be able to work closely with team members, so those who have any impairments that affect their ability to work in groups might not be suited for nurse anesthetist roles.
The US Supreme Court ruled more than 35 years ago that a prospective nursing student with a hearing impairment could be denied admission because of the potential for lowering educational standards (Southeastern Community College v. Davis, 442 U.S. 397, 1979). However, the ADA and ADAAA have clarified that such a student has the potential to succeed with reasonable accommodations. Published reports of students with hearing impairments who have achieved success in nursing programs and in subsequent employment do exist (Manning, 2013; Sharples, 2013). Many aids, such as sophisticated amplified stethoscopes, are now available, and an interpreter could be used for auscultation (Association of Medical Professionals with Hearing Losses, n.d.). Through the use of note takers and audio recorders, many students with hearing impairments have little difficulty participating in the classroom. Pagers and cell phones that vibrate may help students keep in contact with others in the clinical setting.
Much of the evidence regarding physical disabilities is case study evidence. Because nurses with visual impairments are active in the workforce faculty can assume that some students with impaired vision may be accommodated. Providing alternative learning environments and enabling students to work with preceptors may be accommodations that can reasonably be made. For example, a student with a visual impairment might need a magnifier to help with reading printed matter, larger font sizes on a computer, or a text-to-voice apparatus.
Students in wheelchairs may also be accommodated and go on to have a successful nursing career (Neal-Boylan & Smith, 2016). Such students might need to lower a bed or overbed table to deliver care. Practicing in the learning laboratory will help the student get accustomed to the accommodation before learning in the clinical arena (Neal-Boylan & Smith, 2016). Nurses with missing limbs have also functioned as staff nurses, including starting intravenous infusions (Maheady & Fleming, 2014).
Lifting restrictions should not be a barrier, because many hospitals and nursing homes are striving for an environment that minimizes lifting. However, one barrier to promoting safe handling of patients could be what students observe in their clinical placements. Lee and Lee (2017) conducted a cross-sectional survey of 221 California staff nurses. Their results showed that a culture of safety in organizations included lift availability and nurses reported fewer musculoskeletal injuries when safe handling practices were promoted. If students are in clinical placements in an organization that doesn’t have a strong safety culture, they may engage in unsafe handling practices.
Students may become disabled during their time in school, and thus reasonable accommodations for students with physical disabilities may include time extensions for assignments and the assignment of an “incomplete” grade for courses that have not been completed on time. Smith-Stoner, Halquist, and Glaeser (2011) presented a case study of a baccalaureate nursing student who developed cancer. She continued in her classes but had to delay clinical experiences because of chemotherapy. The student also received extensions on assignment due dates to accommodate treatment. The student did graduate, albeit later than planned. Faculty need to be careful not to assume what a student is able to do when facing a physical limitation or illness and should consider ways to provide reasonable accommodations.
Students may have disabilities that are less readily apparent. Luckowski (2016) conduced a qualitative study of nursing students with disabilities in their clinical placements. Students with physical disabilities such as eczema and breast cancer persevered and were successful, although they often missed out on some experiences. For example, a student named Amanda was undergoing chemotherapy and couldn’t go into a setting where children might have respiratory syncytial virus (RSV). Leila, who had colitis, had to take frequent bathroom breaks when she had flare-ups. Others had to assist her with her care on those days (p. 257). Faculty can help students work in groups so those who need it can get a rest period. Furthermore, in some instances, providing alternative clinical experiences might allow a student to achieve the clinical objectives—just in a different setting.
Disabled military veterans are a special population that may require assistance from the veteran support office or the office that handles all students with disabilities. Five percent of veterans on campuses have disabilities, in contrast to 3% of all undergraduates (NCES, 2015). However, Aikins, Golub, and Bennett (2015) found that veterans with disabilities were more likely to attend college than veterans without disabilities.
Veterans enrolled in universities and colleges, including those in nursing programs, face challenges in the college environment but at the same time have strengths that are an asset to those enrolled in nursing programs (Dyar, 2016). Some of the barriers that veterans face are related to long and frequent deployments. They may have financial issues and family problems related to their deployments. Working with peers who are not as focused as they are may also be an issue, as are negative attitudes toward the military that some teachers and students may hold (Dyar, 2016). In addition, veterans are, for the most part, used to working in hierarchal structures, and learning independently may be difficult.
Veterans have many strengths, however, that promote success in a nursing program. If they have been medics, their skills can transfer into the clinical arena, despite their possible frustration with having to be closely supervised as a student. Working in teams and the ability to focus on the task at hand are strengths.
Returning to civilian life can a difficult transition for veterans. Therefore, having a veterans office on campus may ease the transition to college life for veterans, not just those with posttraumatic stress syndrome and physical disabilities.
When students with physical disabilities graduate, their successful employment may depend on nurse managers’ experience in working with nurses who are disabled. Matt et al. (2015) have stated that the work environment should be inclusive for all, not just those who identify as disabled.
The nursing student with substance abuse
Determining the number of nursing students who may be impaired by drug or alcohol use is difficult. However, the results of the 2016 National Survey on Drug Use and Health showed that 24% of full-time college students aged 18 to 22 had used illicit drugs in the past month (Substance Abuse and Mental Health Services Administration, 2017). This same survey showed that among persons aged 18 to 22, 38% reported binge drinking at least once in the past month. Binge drinking was defined as five or more drinks for males and four or more drinks for females at one time.
Other studies have confirmed the extent of substance abuse among college students. The college environment does provide students with easy access to alcohol and drugs, including prescription stimulants, such as Ritalin, and can expose students to situations in which alcohol and drug use is considered an acceptable activity. Bennett and Holloway (2017) performed a systematic review and metaanalysis on illicit prescription drug use in university students. Their results showed that students viewed their use of drugs as a means for self-improvement in academics, athletic performance, and physical and mental health. Contrary to popular belief, less than 50% used illicit drugs for pleasure such as getting high. Their review didn’t include use of alcohol, a legal substance.
Bennett and Holloway’s (2017) findings were confirmed by Arria et al. (2018). They conducted a nationwide study of 6962 full-time undergraduate students who didn’t have attention deficit hyperactivity disorder (ADHD). They found that 11.2% had used nonprescription stimulants in the past 6 months. Approximately 65% of this group believed the stimulants provided academic benefit. Even 63.7% of those who didn’t use the stimulants either strongly agreed, agreed, or were unsure about the academic benefit of nonprescription use of stimulants. Alcohol and marijuana use were correlated with the stimulant use.
Serowoky and Kwasky (2017) explored substance use and abuse among undergraduates at a small Catholic university. They used the CORE Institute survey from Southern Illinois University. Fourteen percent of 2175 undergraduates responded to the survey, which the authors stated was a typical response rate for surveys which use the CORE Institute survey. Of note, 46% of the survey responses came from nursing students. Mean alcohol use was 2.5 drinks per week, less than the national average of 4.4 drinks per week. Students also reported using nonprescription drugs for nonmedical reasons, including stimulants (4.2% using at least six times within the past year) and pain medications (2.8% in the past year). Alcohol and substance abuse was related to a number of negative consequences, including sexual assault, physical violence, and ethnic and racial harassment. Grades were negatively affected for 20% of those who abuse drugs and alcohol.
Another consequence of illicit drug use, particularly prescription stimulants, is academic dishonesty. Galluci, Martin, Hackman, and Hutcheson (2017) found in a study of 974 undergraduates that use of prescription stimulants for nonmedical purposes was associated with academic dishonesty, including copying homework and letting others copy off their homework and plagiarizing content from the internet.
All undergraduate college students experience academic pressures that may lead to substance abuse, but nursing students have additional stressors. Often nursing programs have retention and dismissal policies that put pressure on students to do well in their studies. Dealing with patients with a variety of complex health problems adds additional stress.
Boulton and O’Connell (2017) conducted a nationwide study of student nurses’ substance misuse. Their survey was conducted over the internet using the membership of the National Student Nurses’ Association. A five-question survey was used that was modified from the National Institute on Drug Abuse annual survey. Also used were the Student Nurse Stress Index (SNSI) (Jones & Johnston, 1999) and the Perceived Faculty Support Scale (PFSS) by Shelton (2003). Both instruments appear in numerous studies concerned with stress in nursing students. More than 4000 students nationwide answered the survey; 5% used illicit drugs and 61% used alcohol one to 40 times in the past year. Drugs included nonprescription stimulants, pain pills, and tranquilizers. As found by Arria et al. (2018), use of stimulants was primarily to enhance academic performance. Students who reported more stress experienced more substance abuse. High levels of faculty support did not ameliorate the correlation between stress and substance abuse.
Graduate students also have substance abuse problems. For example, Bozimowski, Groh, Roouen, and Dosch (2014) examined the prevalence of substance abuse in nurse anesthesia students over a 5-year period, and 23 out of 111 programs responded to a survey. Of the data reported on 2439 students, 16 students were identified as having a substance abuse problem, and opioids were the most commonly abused substance. Of note was the fact that 23 programs had drug testing for cause and seven conducted random drug screening throughout the program.
Characteristics of Students With Chemical and Alcohol Impairments
The potential for substance abuse obviously exists among nursing students. Common signs of substance abuse include slurred speech, smell of alcohol, constricted pupils, sleeping during class, and frequent absences or tardiness. Other signs could include change in dress and convoluted excuses for behavior (Cotter & Glasgow, 2012; NCSBN, 2011). If not dealt with, substance abuse can affect a student’s professional practice upon graduation.
Cares, Pace, Denious, and Crane (2015) surveyed 441 past and present members of a peer assistance program to determine drug- and alcohol-related behaviors in the workplace and cues that would have facilitated identification of problems earlier, such as mental illness, feeling isolated (NCSBN, 2011), and barriers to seeking treatment. Sixty-nine percent responded to the survey. Respondents thought cues to drug use could have been identified earlier. Barriers to seeking help included fear and shame. By lowering barriers to treatment and recognizing cues to drug and alcohol abuse, nurses can get the help they need.
To help students deal with potential substance abuse problems that could persist after graduation, faculty need to have an understanding of this issue so they can assist students in receiving the appropriate professional support. Hensel, Middleton, and Engs (2014) investigated the relationship between professional identity—defined as self-concept—and drinking patterns in undergraduate nursing students. Three hundred thirty-three students across all 4 years of a baccalaureate nursing program were surveyed; 33% of the students were classified as heavy drinkers, or more than seven drinks per week for females and 14 drinks per week for males. Lower grades caused by drinking occurred in 5.1% of the sample.
Faculty also have a responsibility to ensure that students deliver safe patient care, which includes protecting clients from the actions of a potentially unsafe student whose clinical performance has been compromised. Faculty should be aware of the characteristics of students who may be chemically dependent, knowledgeable about the policies and procedures within their institution that relate to students who are chemically dependent, and familiar with the support services that are available to students who have a chemical dependency problem.
Faculty Responsibilities Related to Students With Impairments
What are the responsibilities of faculty if they suspect that a student is displaying characteristics that are indicative of chemical dependency? Faculty have ethical responsibilities toward the student and the student’s patients and therefore should not ignore or make excuses for such behavior. Although the ADA considers substance abuse a disability, unsafe clinical practice is not protected under the law (Menendez, 2010).
Mandatory drug testing of nursing students has become more widespread, probably in response to clinical agency requirements. Cotter and Glasgow (2012) discussed the legal and ethical implications of mandatory drug testing. They noted that faculty have the responsibility for seeing that students give safe care. Therefore monitoring for signs of substance abuse is a must. What is not clear is who has the right to know whether a student has tested positive for substance abuse. According to Cotter and Glasgow (2012), policies should be established that protect the rights of all involved, including students, faculty, administrators, and patients. For example, policies need to address whether students can be dismissed from the nursing program for substance abuse.
Before taking any measures, faculty need to understand clearly the policies and procedures that are in place within their institution for assisting chemically dependent students. Behavior must be documented and written policies followed (Cotter & Glasgow, 2012). A faculty member might have to take immediate action if, for example, a student appears impaired in the clinical area and remove the student from the clinical setting. In cases in which the student does not pose an immediate danger to clients but is suspected of substance abuse, an appointment might be made with the student for the purpose of taking appropriate action. In addition to the faculty, a second person, such as an administrator, should be present to ensure that the student is dealt with according to policy and that due process is not denied.
Written policies about chemical impairment that include the institution’s definition of chemical dependency, the nursing faculty’s philosophy on chemical dependency, and student and faculty responsibilities related to suspected chemical dependency should be clearly stated in the student handbook. Furthermore, adhering to the institution’s established policies helps ensure that the student’s right to due process is not denied and protects faculty from possible legal action by the student. The National Student Nurses’ Association (2017) supports policies that promote treatment and rehabilitation for students with substance abuse problems. In addition, the NCSBN’s (2011) “alternative to discipline policy” model includes student nurses. The Emergency Nurses Association and the International Nurses Society on Addictions also advocate for this approach (Strobbe & Crowley, 2017). Such a model includes attending Alcoholic and Narcotics Anonymous meetings, random drug screens, and treatment (Strobbe & Crowley, 2017). However, not all states include students in their programs for helping nurses with substance abuse. In fact, Nair, Nemeth, Sommers, and Newman’s (2015) scoping review found inconsistency in policies regarding students and practitioners with substance abuse problems. Whatever a school’s policy is, confidentiality in dealing with the student and promoting wellness are key.
Whether a school should institute a policy for random drug testing is controversial. Some even think that recognizing early symptoms of abuse is more effective than drug testing used to detect illicit drug use (Cotter & Glasgow, 2012). Although athletes are subject to random testing and most agencies have preemployment drug screening, the extent to which nursing students are required to undergo random screening is unknown. Although schools may not have policies requiring drug testing, students should be made aware that clinical agency policies may require blood or urine testing of individuals, including students, suspected of chemical dependency or as a requirement for engaging in clinical experiences within the agency. Nevertheless, some schools are instituting policies for drug screening before admission because of clinical agency requirements, and schools will require a drug screen if chemical impairment is suspected. Much more research is needed to determine the extent and nature of drug screening policies within nursing programs.
Many colleges and universities are attempting to deal with this problem by increasing student awareness of the effects of substance abuse through campus educational programming (Dittman, 2015). Strobbe and Crowley (2017) advocate for education for students and faculty on drug and alcohol abuse as a strategy to prevent abuse and to detect it earlier once abuse occurs so that treatment can begin.
Finally, faculty need to make sure that students applying for licensure disclose any substance use that resulted in criminal action, such as driving while intoxicated (DWI). Not disclosing such events can cause an application for licensure to be denied.
Nursing students with mental health problems
Mental health issues include anxiety, depression, eating disorders, obsessive compulsive behavior, and suicidal ideation. Some nursing students may have mental health problems before enrolling in nursing school, which may have led them to be attracted to a helping profession. Students who experience mental health problems may need assistance in identifying and addressing these problems. Undergraduate and graduate nursing students may have many fears and worries about their ability to succeed in their program of studies. Test anxiety is a special form of anxiety often experienced by nursing students. With the advent of high stakes testing, faculty should be on the alert to signs of extreme test anxiety (Røykenes, Smith, & Larsen, 2014).
Faculty who have close relationships with students may be the first to notice signs of stress and other mental health issues (Chernomas & Shapiro, 2013). Some indicators, either in the classroom or clinical setting are changes in behavior, eating disorders, sleep issues, back pain, and headache (Chipas et al., 2012).
Bartlett, Taylor, and Nelson (2016) compared stress in nursing students with the general student population. A total of 156 undergraduate nursing students and 76 other students answered the National College Student Health Assessment II (American College Health Association, 2011). Results showed that nursing students had more stress and stress-related symptoms such as sleep disturbances.
Not only do students experience stress in the classroom, but clinical practice presents an added stressor. Cowen, Hubbard, and Hancock (2016) examined stress in students at the beginning and end of their first nursing course in an upper division baccalaureate program. Seventy-two students completed author-designed questionnaires at both the beginning and the end of the semester. Confidence in physical assessment skills did improve over the semester, but fear of making mistakes in patient care was a primary concern. Not knowing what to do was another concern, as was fear of lack of course success. Cowen et al. (2016) recommended learning activities such as simulation to help alleviate fears and build skill levels before patient care. However, Cantrell, Meyer, and Mosack’s (2017) integrative review on the effects of simulation on stress revealed that simulation can cause a great deal of stress—in some cases even more than actual clinical practice. Even so, students valued the high-fidelity simulation experiences.
Suen, Lim, Wang, and Kowitlawakul (2016) explored stress in 285 students from Singapore. With regard to the clinical environment, students preferred clinical learning that was individualized for their needs. One interesting finding was that students’ stress increased as they progressed during the program. Students had higher expectations for clinical placements, and if reality didn’t match the expectations, students had more stress. Financial problems also increased the stress levels for students.
Graham, Lindo, Bryan, and Weaver (2016) found that 106 second-year Jamaican nursing students from two schools had stress associated with clinical placement, fear of harming the patient, interactions with staff, and financial difficulties. Alsaqri (2017) studied stress levels in Saudi nursing students and also investigated their coping methods. The Perceived Stress Scale (Sheu, Lin, & Hwang, 1997) and the Coping Behavior Inventory (Sheu, Lin, & Hwang, 2002) were used to measure stress and coping. Major stressors, similar to other studies, were related to assignments, knowledge and skills, taking care of patients, and working with staff, on top of daily stressors in their life. Furthermore, problem solving was the primary coping strategy.
Students in specialty areas encounter some unique stressors, but stressors encountered are comparable to what other studies have shown. Galvin, Suominen, Morgan, O’Connell, and Smith (2015) interviewed 12 students in mental health nursing. One important finding was that academic work on top of clinical placements was overwhelming to them. Galvin et al. (2015) made a strong case for reducing the academic workload during clinical placements. They also recommended that health support services be available to students outside of the usual work day.
Most studies of mental health issues have been descriptive, using a variety of instruments to collect data. Despite multiple data-gathering methods, the results have been consistent—nursing students universally experience stress. Description is not enough. Interventions to ameliorate stress and anxiety are important if nursing students are to be successful in their programs of study.
Two systematic reviews outlined several interventions to deal with test anxiety. Shapiro (2014) conducted a systematic review on test anxiety. She found that such interventions as aromatherapy and hypnotherapy have the potential to decrease test anxiety. Because the sample sizes were generally small, no definitive conclusions could be made regarding interventions to decrease test anxiety. Quinn and Peter’s (2017) systematic review confirmed that some interventions may help decrease test anxiety. Their review validated that such interventions as music, biofeedback, animal therapy, music, essential oils, guided reflections, and progressive muscle feedback might contribute to decreased test anxiety. However, sample sizes were small. To promote student success, faculty have a key role in helping students deal with test anxiety. Using some of the interventions mentioned in the two systematic reviews might help students.
Mindfulness and meditation have promising possibilities for helping students handle stress. van der Riet, Rossiter, Kirby, Dluzewska, and Harmon (2015) conducted a descriptive, qualitative pilot study with 14 first-year undergraduate and midwifery students designed to evaluate the effects of a 7-week stress management and mindfulness program. From the themes identified, van der Riet et al. determined that the program helped students sleep better, have fewer negative thoughts, and promoted better patterns of concentration. However, challenges were encountered during the program, primarily students’ inability to attend all sessions because of class commitments.
Alsaraireh and Aloush (2017) randomly divided 181 students nearing graduation into two groups, with 91 in the exercise group and 90 in the mindfulness meditation group. Results indicated that depression decreased in both groups, but more so in the mindfulness meditation group. The authors suggested that their study be repeated by using this same design but collecting data over time as opposed to just one point.
Burger and Lockhart (2017) also conducted a randomized control trial with 52 undergraduate students. Students who meditated had a moderately stronger ability in executive function and had reduced stress and increased mindfulness. Although reducing stress may improve clinical performance, having better executive function promotes better critical decision making, and mindfulness may allow students to be more aware of actions to promote safe patient care (Burger & Lockhart, 2017).
Incorporating mindfulness training into nursing education may be a worthy endeavor, but doing so requires a time commitment on the part of faculty and students. Hutchison, Cunningham, and Millar (2016) conducted a 9-hour mindfulness training workshop for students. Students gave very positive feedback, but no long-term feedback was reported.
Mindfulness training can also be conducted asynchronously online. The ability to deliver training online is important because many undergraduate and graduate nursing programs are online. Spadaro and Hunker (2016) provided an 8-week mindfulness program to all undergraduate and graduate nursing students at one university, and 26 students participated. As a result of their participation, stress was reduced, anxiety decreased, and cognition or the ability to concentrate and shift attention improved.
In addition to mindfulness, two other strategies may help students reduce stress and anxiety. Chueh, Chang, and Yeh investigated the use of auricular acupressure delivered for 4 weeks via magnetic pellet to 36 RN-BSN students in northern Taiwan. This quasi-experimental, pre and postdesign, study showed that this intervention has the ability to improve sleep quality and decrease anxiety and depression. Limitations were the small sample size, and lack of generalization of findings to students in Western countries who may not find this type of intervention useful.
Mental rehearsal is another strategy that may hold promise in its ability to help students deal with stress (Ignacio et al., 2016). Eighteen third-year Singaporean nursing students used mental rehearsal before a simulation using a standardized patient who was rapidly declining. The mental rehearsal involved classroom presentations on the technique itself, a video on handling a patient who is declining, and relaxation techniques. Then students practiced mental rehearsal on their own. Eighteen out of 103 senior students participated in this quasi-experimental study. Before and after the mental rehearsal, students were exposed to a deteriorating standardized patient. Stress did not appear to decrease post-intervention as indicated by vital signs and anxiety levels as measured by the State Trait Anxiety Inventory. However, performance during the simulation did improve. A five-person focus group was conducted 5 months after graduation to assess the effect of the mental rehearsal. The graduates acknowledged that the mental rehearsal and using standardized patients allowed them to have realistic expectations of clinical practice.
Although some interventions have shown promise in helping students deal with stress and anxiety, students’ willingness to participate in interventions may be influenced by their attitudes toward prevalence of stress in themselves and others and their willing to seek help. Galbraith, Brown, and Clifton (2014) gathered data from 219 British nursing students regarding willingness to seek help for stress-related conditions. Descriptive analysis of the data demonstrated that 74.9% of the students had experienced stress. Most students (87.2%) would disclose their stress to family and friends. Few would disclose to colleagues or professional institutions because they believed families could best offer advice. Only 11.4% would seek professional help. Students revealed that they would not lose confidence in colleagues who had stress.
Volunteer sample sizes in the previously discussed studies may give credence to the fact that students are reluctant to explore new ways to deal with stress. If research-based interventions were offered on a regular basis to nursing students, would students be willing to avail themselves of the opportunity to engage in stress- and anxiety-reduction programs?
Faculty Responsibilities Related to Students With Mental Health Problems
All faculty have the obligation to provide an educational climate that promotes strategies to mitigate stress and promote student success (Alsaqri, 2017). Instituting interventions early on can help ameliorate stress and anxiety experienced by nursing students. However, when students’ performance is adversely affected by stress, anxiety, or other mental issues, the process used to assist students with suspected mental health problems is similar to the approach used with any student whose academic progress is jeopardized by unsatisfactory performance. First, the ADA/ADAAA prohibits discrimination against individuals who are mentally impaired. Second, all actions taken by faculty must be congruent with existing institutional policies and afford students the due process that is their right.
When mental health issues interfere with student behavior, faculty must deal with this behavior in a manner that is consistent with institutional policy. According to Cleary, Horsfall, Baines, and Happell (2012), policies must include confronting the student with evidence of problematic behavior, and the faculty member needs to facilitate reduction of the problematic behavior before action is taken. Students should be made clearly aware of the behavior adversely affecting their academic performance and what they need to do to correct this behavior. A learning contract may be used in this instance to indicate what the student needs to do to improve the behavior and the time frame in which this must be accomplished. Many campuses have student codes of conduct to guide policy development. According to Cleary et al. (2012), policies should delineate procedures for assessing, documenting, reporting, intervening, and referring students for treatment. Many university campuses offer counseling to students free or for a reduced fee.
If despite these interventions the behavior does not improve and the student is unable to perform effectively or patient safety is compromised, administrative withdrawal or dismissal from the program may be necessary. As always, the student who is administratively withdrawn or dismissed has the right to pursue the grievance and appeal process in place within the institution.
Criminal background checks
In addition to mental health issues, which can compromise patient safety, the student who has a record of criminal activity can also compromise patient safety. Patient safety is a major concern for state boards of nursing and health care accreditation agencies. The Joint Commission (2017) states, “Staff, students and volunteers who work in the same capacity as staff who provide care, treatment, and services, would be expected to have criminal background checks verified when required by law and regulation and organization policy” (para 1). Therefore nursing programs often require criminal background checks. Furthermore, most states require criminal background checks for licensure, only six states did not require a formal criminal background check for licenses: Colorado, Hawaii, Maine, New York, Vermont, and Wisconsin. A search of individual state boards of nursing websites will provide students with information regarding background checks before licensure.
The number of nursing programs requiring background checks has increased, although recent data on the number of programs is not readily available. Regardless of whether a school requires a criminal background check before admission, faculty have a duty to warn students that although they may have successfully completed the nursing program, licensure could be denied if a student has a criminal background. Additionally, as noted earlier, clinical agencies may have requirements for background checks and may refuse clinical placements based on the results of the criminal background check. An example of a criminal background check policy is found in Box 4.3.
Box 4.3
Example of criminal history check policy
At the time of your application, you were required to submit a current national level criminal background check, which was part of the criteria used to determine your eligibility.
Criminal background information will be maintained in your student nursing file, is considered confidential, and no results will be released. The student is responsible for notifying the Department Chairperson of any new charges or additions to one’s criminal history promptly. Failure to report new charges may result in dismissal from the program.
Used with permission from Indiana State University Nursing Program Department of Baccalaureate Nursing. Retrieved from https://www.indstate.edu/health/bn-student-handbook
Denying admission based on the results of a criminal background check requires careful consideration. Decisions need to be made in line with state law and clinical agency policy. Guidelines for making decisions need to be readily available to all faculty and students. When admission decisions are made, faculty need to consider the nature of the criminal conviction and how long ago the offense occurred and afford due process for those denied admission. Philipsen, Murray, Belgrave, Bell-Hawkins, Robinson, and Watties-Daniels (2012) have questioned the value of criminal background checks for students, as students are under close supervision of faculty. Nevertheless, they acknowledge that faculty must follow the policy in place for the clinical agency. They also note that the results of the criminal background checks must be evaluated on a case-by-case basis.
Evidence does support that criminal background checks before admission may help identify students who may commit crimes while enrolled as a student (Smith, Corvers, Wilson, Douglas, & Bienemy, 2013). Of the more than 3000 applicants RN licensure, in one year's time, in the state of Louisiana, 14.7% had a criminal history (Smith, et. al., 2013). One should note that the Louisiana Board also required a criminal background check before enrollment in clinical courses. Because of a large difference in sample size, a matched-pair cohort was constructed for analytic purposes. Among the findings was the fact that 10% of those who had a criminal record before enrollment had subsequent criminal activity, whereas only 2.3% of those without a prior criminal record did.
Requiring criminal background checks of international students before admission necessitates special consideration (Genovese, Schmidt, & Brown, 2015). If a student is coming directly from a country outside the United States, the visa application process should have included a criminal background check. For students who have resided in the United States for some time before admission, a criminal background check should be conducted if required of all students (Genovese et al., 2015).
The areas of criminal background checks and drug testing continue to evolve, and nursing faculty will need to keep apprised of changes in health care agency policies and state laws. The NCSBN has published a position paper and a resource packet, including model statutory language for state boards of nursing to use in crafting laws regarding criminal background checks (NCSBN, 2015).
Summary
This chapter has provided information about the legal and educational issues related to educating students with disabilities and other special needs. The needs of students with learning disabilities, chemical dependency, and mental health problems are presented along with faculty responsibilities associated with teaching these students. Interventions are identified for assisting students to cope with a disability or impairment that can be used for all students to promote academic success.
Nursing faculty are responsible for creating a learning environment that supports the teaching–learning process for all students. Working with students who have disabilities or impairments brings special challenges to the student–faculty relationship. No specific rules say what level of disability or impairment prevents admission to a nursing program. However, faculty will find themselves capable of meeting these challenges in a caring, facilitative manner when they are knowledgeable about the legal issues related to students with disabilities or impairments, their institution’s and school’s policies and procedures related to students with these special needs, and the interventions designed to help students maintain their self-esteem and be successful. Viewing disabilities not as hindrances but as differences may help faculty better make appropriate accommodations for students while still maintaining academic standards.
Furthermore, if faculty are open to working with students who have disabilities, students might be more inclined to disclose, without fear of adverse consequences, that they have a need for accommodations. Developing strong partnerships with clinical agencies may also be a key to successfully integrating students with disabilities into the nursing program.
Thinking broadly about how to achieve program objectives and the use of technology and universal design will promote a more inclusive learning environment for all students, not just those with disabilities. Conducting large-scale studies of nursing students and staff with disabilities and will provide more evidence regarding what accommodations support safe and effective nursing care.
Those with disabilities will continue to seek enrollment in nursing programs. Faculty may need to consult resources that give guidance on how to accommodate those with disabilities. In addition to the resources available on individual campuses, the following websites contain much information regarding how to accommodate students with disabilities:
