Nursing with the Hand You Are Given

Nursing students with disabilities are increasing in number throughout the United States, thanks in part to the passage of the Americans with Disabilities Act (ADA) in 1990.1 Although exact numbers are unknown, anecdotal reports of students with a wide variety of disabilities, including hearing loss, vision loss, paralysis, chronic illness, learning disabilities and mental illness, are documented in the nursing literature.2-10

The ADA, like the earlier Rehabilitation Act of 1973, was intended to level the playing field. The general mandate of the ADA is for students with disabilities to have the same access to educational programs as students without disabilities. But even though the ADA has been the law of the land for 15 years, many nursing schools continue to struggle with issues relating to admissions policies for students with disabilities, such as core performance standards, essential functions and providing accommodations.

Under the law, entrance requirements cannot include any criteria that would screen or appear to screen for disabilities. The ADA also mandates that educational institutions provide “reasonable accommodation” to individuals with disabilities.

Accommodation only ensures equal access to education; it is not a guarantee of success.

In the case of nursing students, criteria that would identify disabilities prior to admission are not only in violation of the ADA, they have no legitimate purpose. It is unfair to evaluate a nursing applicant in one brief session on his or her ability to perform skills that are intended to be developed over several years. Yet this is precisely what is happening today at all too many of the nation’s schools of nursing.

Jumping to Conclusions

A number of research studies have shown that when nursing educators find themselves caught between the legal requirements of admitting a student with a disability and their perceptions of what it takes to be a safe and competent nurse, the latter concerns often tip the scales toward discriminatory pre-judging of students. Additionally, when administrators and staff nurses are notified that a student with a disability will be part of a clinical group or will require accommodations, they often voice concerns and hold preconceived notions of success or failure before the student even steps onto their floor.

One study found that nearly 60% of nurse educators making admissions decisions “preferred” to assess the applicant’s disability and need for accommodation prior to making a decision as to whether the accommodations were viable or could be provided.11 This is in direct conflict with the mandate of the ADA. Students must be admitted to the program before accommodations are discussed.

The educators in this study failed to recognize that neither they nor the nursing applicant with the disability may know beforehand what accommodations will be needed. Developing accommodations is often an ongoing dynamic–a step-by-step process that evolves and changes as the student faces new experiences in the classroom and clinical settings.

One of the most commonly given reasons for denying admission to a nursing applicant with a disability is concern about patient safety. Even if the student is admitted to the program, faculty and administrators often continue to harbor these concerns. Yet a 2002 study by Sowers and Smith reports that there is no data to suggest that health care professionals with disabilities pose any greater safety risk to patients than those without a disability.12

Furthermore, in many cases nursing programs may be focusing on the physical attributes of some applicants with visible disabilities and be unaware of the “hidden” disabilities of other applicants. For example, students with undisclosed mental health issues may be a risk to patient safety but are admitted to programs without question.

Setting the Wrong Standards

Since the passage of the ADA, many nursing schools have adopted the practice of evaluating applicants with disabilities against a list of “technical standards” or “essential functions” deemed necessary for success in the program. For example, the Southern Regional Education Board’s Council on Collegiate Education for Nursing (CCEN) developed core performance standards for admission and progression, covering such areas as critical thinking, interpersonal skills, communication, mobility, motor skills, hearing, visual and tactile skills.13

In one study, eight nursing programs reported addressing essential functions by describing the physical requirements for each skill. Examples included hand washing techniques, sharps management, isolation techniques, range of motion, transfer and
computation of drug dosages and administration of medications.14

These types of guidelines were developed for nursing education programs to use in complying with the Americans with Disabilities Act. But ironically, they often have the opposite effect: Instead of eliminating barriers to admission for students with disabilities, they create new barriers.

Sowers and Smith argue that using physical attributes such as hearing, visual and communication skills as standards causes students who cannot hear, see or speak to be excluded from nursing programs. Instead, they recommend that essential functions and technical standards more appropriately focus on specific behaviors that nursing students will be expected to perform.

For example, an essential function may be “detecting a heart murmur.” A student who is hard of hearing may be able to detect a heart murmur using an amplified stethoscope and a deaf student may use a stethoscope that provides visual output. These students cannot “hear,” but they can perform the essential function with a reasonable accommodation.

When core performance standards and/or essential functions are used to make admissions decisions, it is all too easy to exclude students with disabilities by making premature assumptions about their skills. At this stage of the process it is very difficult to accurately predict the skills a student may or may not be able to achieve over time. This approach fails to level the playing field for students with disabilities, limits equal access to the educational experience and violates the Americans with Disabilities Act.

A Personal Case Study

The following case study illustrates how putting too much emphasis on standards and functions can result in discrimination against students with disabilities. Susan Fleming, one of the authors of this article, was born without a left hand; she wears a prosthetic hand. Susan worked as a nurse’s aide in high school and was passionate in her desire to become a nurse. She completed the prerequisites and applied to a nursing program, where she was given a skills test. This test evaluated skills that a graduate nurse would be expected to perform, such as mixing IV fluids, giving injections and donning sterile gloves.

Susan was denied admission to the program because she was unable to demonstrate some of the skills on the test. She was told that she would “endanger a patient’s life.” This test was created exclusively for her and was not administered to any other applicants. This constitutes singling out of certain students for “special testing” and discriminates against applicants with disabilities.

On admission to a nursing program, most students do not yet know how to perform skills such as these using appropriate techniques. These skills are practiced in the nursing lab and in clinical settings, and are mastered over time. Some students may master these skills sooner than others. The same scenario applies to nursing students with disabilities. All students need time to practice and hone nursing skills.

Many students with disabilities are able to find accommodations that will work for their particular needs. Faculty, administrators and staff nurses cannot “assume” that a student with a disability, such as having only one hand, will be unable to achieve a particular skill. Patients with hemophilia routinely learn to start IVs on themselves quite competently with one hand.

Susan was aware of her legal rights but chose not to fight the nursing school’s decision. The lack of time, resources and energy to pursue a discrimination case in the courts is common to many students with disabilities. Often, they are driven away from nursing forever.

But Susan focused her energy on moving forward. She applied to another nursing program, where she was accepted. While in nursing school, she worked in a busy emergency room in order to gain more clinical skills. Susan was successful in her nursing program and recalls that she did not discover all of the accommodations she needed until she had almost completed the program.

The primary accommodations Susan required in nursing school were large gloves, special scissors and a hemostat. Today, she still uses these accommodations after many years of successful practice as an RN. She is able to draw blood, start IVs, work in labor and delivery, and work as the baby nurse in the OR during cesarean sections. She is a respected and valued member of the team.

An Equal Chance to Succeed

Nursing educators need to be mindful that their next star student may be a person with a disability. This case study of a student with a disability who learned to perform nursing skills over time, with a little help from reasonable accommodations, serves as an example of the resourcefulness and compensatory abilities that students with disabilities often possess.

On admission, students with disabilities should not be required to demonstrate skills that nursing students routinely demonstrate and master over time. Rather than pre-judging them, nursing educators, administrators and staff nurses should offer them a welcoming hand. We should honor the spirit and true intention of the ADA by helping these minority students become successful and productive members of the nursing profession.

Today, the career paths open to nurses are immense and wide-ranging–from floor nursing and intensive care unit nursing to telephone triage and pharmaceutical sales. In a profession that offers such a diversity of opportunities, students with disabilities can bring valuable skills to the table, such as empathy, sign language and lip reading, as well as personal experiences that both colleagues and patients can learn from.

Nursing students with disabilities need the support of the nursing “village” in order to be successful. They may “play their hand” differently, but at the end of the day they bring value to the nursing profession and to patient care. Together, we can give more of these students the chance they deserve.