INTEGRATION of Disability-Related Content in Nursing Curricula
Smeltzer, Suzanne C., Dolen, Mary Anne, Robinson-Smith, Gale, Zimmerman, Vanessa, Nursing Education Perspectives
Despite evidence that health care professionals, including nurses, do not perceive persons with disabilities in a positive light and fail to attend to their health care needs, it is not known how nursing programs address the topic of disability. This descriptive study was conducted to examine the extent to which schools of nursing in the United States address disability-related issues and the strategies used to integrate disability-related content in their curricula. A 27-item investigator-developed survey was sent to a national stratified random sample of 1,000 schools of nursing. Questions pertained to curricular content, specific groups of persons with disabilities, and teaching methods and resources used to teach nursing students about disability. Respondents indicated that they included some content related to disability in their curricula. Nursing textbooks were the most common source of information used. Barriers to including disability-related content were lack of time and lack of faculty interest or expertise. These findings can serve as a stimulus to increase the extent and breadth of disability-related issues in nursing curricula.
Key Words Disability - Disability-Related Content - Disability Models - Nursing Curricula
IT IS ESTIMATED that 60 million persons in the United States have disabilities (1), and this number is expected to increase with the aging of the population. Many individuals with chronic illnesses and disabilities are living longer. In addition, many who would have succumbed to childhood illnesses or severe trauma in the past now survive and have normal or near-normal lifespans (2). Although disabilities are often associated with old age, national data demonstrate that they occur across the lifespan (3). * Despite these trends, there are indications that health care providers, including nurses, do not perceive persons with disabilities in a positive light and fail to attend to their health care needs (4,5). Further, it has been reported that the health care provided may promote negative stereotypical images and is seen as demeaning and disabling rather than empowering (6-8). * Factors contributing to negative attitudes on the part of health care providers may include inadequate attention to disability in the curricula and inadequate exposure to persons with disabilities during education and training. THIS ARTICLE REPORTS ON A STUDY DESIGNED TO DETERMINE THE EXTENT TO WHICH SCHOOLS OF NURSING IN THE UNITED STATES INCLUDE DISABILITY-RELATED ISSUES IN THEIR CURRICULA AND THE STRATEGIES SCHOOLS USE TO INTEGRATE SUCH CONTENT IN THEIR CURRICULA.
Review of the Literature The existing literature on disability in nursing and other health professions' education provides little direction about essential disability content. Most studies have focused on efforts to assess and change students' attitudes toward persons with disabilities.
Nurse researchers Lindgren and Oermann (9,10) attempted to improve attitudes of nursing students toward people with disabilities by providing content related to their care and through simulated disability experiences. In their first study, they assessed the attitudes of nursing students before and after participation in a one-day educational conference on health care strategies designed to empower patients with disabilities. The last session of the conference was presented by a person with a disability in a leadership position in a large health care foundation. One month after the conference, students' attitude scores were significantly more positive than preconference scores.
In a second study by the same researchers (10), some nursing students attended a special workshop on providing care to persons with physical disabilities. Students who attended the workshop had significantly more positive attitudes than students in a control group. The researchers concluded that a core of informed and interested nurse educators is needed to introduce and support rehabilitation nursing practice in the curriculum.
Thompson, Emrich, and Moore (11) used the Attitudes Toward Disabled Persons scale (12) to measure the attitudes of nursing students (n = 41) toward persons with disabilities at the beginning and the end of the senior year to evaluate the effects of a curriculum change focused on chronic illness and coping. Following clinical rotations in inpatient rehabilitation settings, units with patients with chronic illnesses, and rehabilitation or therapy areas and an all-day field trip to two rehabilitation centers, scores were significantly higher than preintervention scores.
Tanenhaus, Meyers, and Harbison (13) surveyed 30 schools of public health and reported that 85 percent offered courses dealing with disability. However, they also reported a lack of information about the Americans with Disabilities Act, measurement and classification of disabilities, independent living, and how assistive technology is organized and financed.
A survey of health and social science faculty found that 63 percent of respondents did not teach about aging in people with preexisting disabilities (14). Nursing, physical therapy, and occupational therapy faculty members were more likely than other faculty to rate aging with a disability as an important topic.
Scullion conducted a qualitative study of disability content in one nursing program in the United Kingdom (6); six teachers and 10 nursing students were interviewed. Brief clinical vignettes that described individuals with disabilities were used to elicit students' responses about the subjects' ability to live independently. The instructors were interviewed to determine how they conceptualized disability. Students and faculty were found to consider disability to be a deviation from normal, synonymous with dependency, and an illness or medical condition. They described disability as a transient state that may be changed through rehabilitation and adaptation and demonstrated little understanding of simple definitions of disability, impairment, and handicap. Scullion stated elsewhere that little is known about how disability is presented in nursing curricula in the United Kingdom (15), but even less is known about the issue in the United States.
In a national study in the United States, Nosek and colleagues (5) called for information to be provided at undergraduate and postgraduate levels to health care professionals (e.g., nurse practitioners, nurse midwives, and nurses in general) about the reproductive health care needs of women with disabilities. Although the need to teach about these issues applies to men as well as women, this study specifically targeted women.
The literature clearly reinforces the notion that disability-related content is appropriate within the context of rehabilitation. However, the view that rehabilitation content is, or should be, the primary or only means of teaching about disability-related issues in nursing does not reflect the presence of persons with disabilities throughout society and in the health care system. Further, it is not known if improved attitudes demonstrated in these and similar studies have an impact on the quality of health care provided or interactions between health care professionals and persons with disabilities.
Method INSTRUMENT The Disabilities Questionnaire, a survey of disability-related content in nursing curricula, was developed by the investigators based on a review of the literature and their own experiences in the area of disability-related health issues. It was refined through a series of pilot questionnaires. Ten faculty from the investigators' college of nursing completed the first pilot questionnaire and provided feedback. These faculty represented medical-surgical, pediatric, psychiatric, introductory/basic nursing, and community health nursing specialties.
A revised questionnaire was pilot-tested by 19 faculty members from associate degree, diploma, and baccalaureate nursing programs not affiliated with the investigators' college of nursing. Their comments, additions, and suggestions were incorporated into the final questionnaire. Data from this pilot test were not included in the study.
The Disabilities Questionnaire used for the survey consisted of 35 items. Eight items pertained to the respondent's school. The remaining items asked about curriculum content related to disability, specific groups of persons with disabilities discussed, and instructional methods and resources used to teach about disability. The questions about specific content included 23 topics in five categories: 1) ethical and legal issues, 2) the effect of disability on access to health care, 3) growth and developmental issues across the lifespan, 4) definitions and epidemiology of disability, and 5) clinical care for persons with disabilities, including modifications required for nursing care and teaching.
Items were constructed as checklists about disability content, specific populations, models of disability (medical, rehabilitation, social [barriers], and interface models), and resources (textbooks, articles, films/videos, Internet resources/software, speakers, games, artwork, and popular books) used in the respondents' programs. All checklist questions allowed for the addition of other information.
Open-ended questions were used to ask respondents how well their nursing programs taught about the health promotion needs of men and women with disabilities and barriers and facilitators to incorporating disability content in the nursing curricula. Respondents were also asked to assess the effectiveness of their program in teaching about these issues. Forced-choice responses ranged from "very effective" to "ineffective" and "do not know." Respondents were also asked if they thought the amount of time spent on disability was adequate. Forced-choice responses ranged from "far too little," to "about right," to "far too much." A final series of questions asked what materials or methods might be helpful in integrating disability-related issues into nursing curricula.
Demographic items requested the title of the person completing the questionnaire, type of program (associate degree, diploma, or baccalaureate), the number of students who graduate each year, and the number of students with disabilities in the nursing program. Other items requested information about the presence of academic units and programs with disability courses within the school's larger institution.
PROCEDURE Following approval from the investigators' Institutional Review Board, the questionnaire was mailed to a random national sample of 1,000 NLNAC-accredited schools of nursing stratified by type of program: 541 associate degree (AD), 48 diploma, and 411 baccalaureate (BSN) programs (including BSN completion programs). A cover letter requested that the person most knowledgeable about the undergraduate nursing curriculum complete the survey. Respondents were asked to return the completed survey by prepaid mail. A reminder postcard was mailed one month later.
Results Of the 237 questionnaires returned, 234 were usable. The overall return rate was 23.4 percent. Of the final sample, 48.7 percent were AD programs, 6.4 percent were diploma programs, and 41.9 percent were BSN programs. Seven programs four RN-completion, two direct-entry master's, and one unidentified program - were designated "other" and included in the analysis. Schools returning completed questionnaires represented all regions of the country.
Descriptive statistics were used to summarize the responses to the survey items. Chi-square analyses were used to determine differences in responses by type of school. Responses to open-ended questions were included in the results where appropriate.
DISABILITY-RELATED CONTENT Table 1 ranks topics for frequency of inclusion in the curriculum from most frequently included to least frequently included. Responses differed by type of nursing program on four of the 23 items: 1) the Rehabilitation Act and Americans with Disabilities Act, 2) effects of disability on ability to obtain health care, 3) discrimination by the health care system, and 4) epidemiology of disability in the United States. Significantly more BSN programs reported including this content than diploma and AD programs (Chi square range [df = 3] 10.5 26.1, range of p values = .01 - < .0001).
The mean number of content topics included in nursing curricula was 13.2 (SD = 5.6). Sixteen schools (6.8 percent) reported including all 23 topics in their curricula. Slightly more than one fourth (27.8 percent) taught 10 topics or less; 1.3 percent reported that they taught none of the topics. Significantly more topics were taught by BSN programs (F = 2.993 [df = 3, 226], p = .03). Content relating to pregnancy and parenting in the context of disability was included in the curricula by less than a third of the respondents.
GROUPS ADDRESSED Patients with cognitive disabilities, those at the extremes of age, and individuals with disabling psychiatric/mental health disorders were included in nursing curricula more often than other patient groups. Young adults, persons with learning disabilities, women and men with specific gender-related health issues, and people with disabilities from ethnic minority groups who often experience discrimination were included least frequently (see Table 2).
TEACHING STRATEGIES The use of textbooks to teach disability-related content was the major teaching strategy reported. Medical-surgical textbooks were reported by 94 percent and pediatric textbooks by 90.1 percent of the respondents. Few schools reported using videos, games, books, or disability experiences.
Types of clinical placements for experience caring for persons with disabilities were psychiatric settings (67.7 percent), general hospital units (56.2 percent), and nursing homes (53.1 percent). Disability-related content was mainly discussed in classroom teaching within pediatric, neurological, medical-surgical, geriatric, and rehabilitation nursing. The least frequent areas where such content was discussed were health assessment, health promotion, and women's health; fewer than 50 percent of respondents indicated that disability content was included in discussion of these three topics. The percentage of respondents who reported that their programs included specific health promotion content for men and women with disabilities was 46.1 percent and 57 percent, respectively. Simulated disability experiences, considered controversial and generally looked upon with disfavor by disability groups (7,16), were reported by 30.6 percent of the respondents.
DISABILITY MODELS Respondents were asked to indicate which of the models in Table 3 were used as the primary model to teach disability content. Many indicated that they used several models. Thus, 89 percent reported using the medical model and 77 percent reported using the rehabilitation model. The social and interface models were identified by 48 percent and 15.9 percent of respondents, respectively.
EFFECTIVENESS OF TEACHING ABOUT DISABILITY. The survey specifically asked if health promotion issues for men and women with disabilities were discussed in the nursing curricula and if the effectiveness of those efforts was assessed. Most respondents reported that their programs were not effective. More than half indicated that too little or far too little attention was given to the topic. Factors identified as barriers to increasing disability issues included "content that is more important would have to be deleted," "it is not a very important topic," and "if it is not tested [by NCLEX], we don't teach it."
BARRIERS AND FACILITATORS TO TEACHING ABOUT DISABILITY Assessment of barriers to the inclusion of this content in existing curricula indicated that time, an overloaded curriculum, and lack of faculty interest or expertise were major barriers. Major facilitators were the interest and expertise of the faculty, access to local rehabilitation hospitals for clinical experiences, and the presence of faculty and nursing students with disabilities. The most frequent suggestions for integration of this material into the curricula were content in textbooks (52.19 percent), CD-ROMs (42 percent), and modules (40 percent).
Discussion Several interesting findings emerged from this study. First, many programs reported having some disability-related content threaded throughout the curricula. Second, respondents identified medical-surgical and pediatric nursing textbooks as their primary sources of information about disability and the primary methods used to teach disability. However, a review of a sample of undergraduate nursing textbooks conducted by the investigators (unpublished data) revealed little or no coverage of this content in these texts.
The ability to include disability in nursing curricula was found to be limited by time constraints and the need to teach content identified as "more important." Several respondents identified the need to prepare students for the NCLEX examination as a major factor that affected selection of content.
The groups of persons with disabilities most commonly identified in nursing curricula were the elderly, pediatric patients, and individuals with psychiatric-mental health disorders. Adolescents and young and middle-aged adults with physical disabilities were addressed less frequently. These findings may reflect the view that disability is common in the elderly. In addition, the impact of disability on the psychological and emotional development of children is hard to ignore. Lack of comparable attention to other populations may be a result of stereotyping.
The finding that few programs specifically discussed health promotion in adults with disabilities is consistent with previous studies (5,17,18). The findings of these previous studies suggest that persons with disabilities participate in health promotion activities infrequently and receive a lower quality of health care than those without disabilities. Without attention by health care providers to health promotion and health care for persons with disabilities, including those from specific groups, such as ethnic minority groups, their special health care needs are unlikely to be addressed.
The finding that sexuality and reproductive issues, such as pregnancy and parenting by persons with disabilities, are not addressed is consistent with findings of studies that have addressed health care of persons with disabilities (5). The failure to discuss these issues ignores the reality that pregnancy, sexuality, and parenting are common concerns among individuals with disabilities.
Many respondents indicated that they did not know if their nursing programs were effective in teaching disability-related content. Further, relatively few reported specific efforts to evaluate their students' knowledge about or attitudes toward persons with disabilities. While only half of the respondents indicated that the amount of time teaching disability content was "about right," the value they placed on disability as a topic for teaching was not determined.
Because data were obtained through self-report, the breadth and depth of disability-related content and the effectiveness of teaching were also not determined. Faculty interest and expertise in the area of disability, or lack thereof, were identified as factors related to the inclusion of disability content in curricula.
The overwhelming use of medical and rehabilitation models for addressing disability in nursing curricula requires comment. The medical model is based on the concept of disability as a medical diagnosis. Approaching disability from a disease perspective has been questioned by many individuals with disabilities and disability advocacy groups (7,19,20) as this approach does not cover the full spectrum of issues related to living with a disability. Further, it ignores the ability of many individuals to live independently and successfully, the impact of a disability on access to health care, and the need to modify how care is delivered (21). The medical model perspective is consistent with the belief that physicians and nurses are best qualified to make key decisions about health issues.
With the traditional rehabilitation model, it is assumed that with adequate effort on the part of the affected person, disability is temporary and can be overcome (21). This approach often fails to consider the reality of permanent disability. The findings in this study suggest that the models or approaches used in the typical nursing curricula would not be considered acceptable and empowering by individuals with disabilities.
Limitations The findings of this study must be interpreted with caution. First, the data were obtained through self-report. Thus, it is not known how accurately the responses reflect actual integration of disability content in nursing programs. second, because disability issues are not identified as core to nursing education programs and despite the inclusion of specific definitions in the data collection instrument, there may be differences in how the respondents and the investigators define disability and disability-related issues. Third, respondents may have defined disability, interpreted the questions, evaluated their own curricula, and completed the survey differently.
Another issue is the low response rate (23.4 percent). It is not known if failure to respond reflects lack of interest in this issue or its importance for nursing curricula. It is also not known how representative the responses actually received were.
Implications for Nursing Education The fact that nearly one fourth of the American population currently lives with disabilities is an indication that this topic is important and needs greater attention. It is clear from this study that greater consideration should be given by nursing faculty to increasing the depth, scope, and focus of disability-related content in nursing curricula. Further, the approaches used to teach about disability should incorporate concepts considered most important and relevant by persons with disabilities.
Use of the social model (19,22) or interface model (21) is recommended if nurses are to be prepared to provide care that is empowering. In this way, students will be encouraged to view persons with disabilities as capable and responsible individuals able to function effectively despite having a disability. Further, use of these models may encourage students to become advocates for the removal of barriers to health care and to examine how society and health professionals contribute to discrimination by constructing disability as an abnormal state.
It is important to ask faculty with expertise in disability to contribute to the integration of disability-related content and related issues in nursing curricula. Efforts of less experienced faculty to learn more about disabilities should be supported through continuing education activities.
Nursing students require information about persons with a variety of disabilities - physical and developmental disabilities, alcohol and drug abuse, and emotional illnesses - and they need clinical experiences with these groups. They also need contact with individuals who are fully functional and making major contributions to others' lives, as well as exposure to the complex issues and barriers to health care encountered when an individual with a physical disability also experiences emotional or psychological sequelae.
Raising students' awareness of the issues and biases encountered in society by those with disabilities is an important first step. Specific strategies for addressing these issues may include having nursing students evaluate the accessibility of health screening facilities, such as gynecologic settings and mammography, for women with disabilities. Asking students how they would modify their nursing care if their patient has a disability is one approach to help them begin to examine the health issues and care needs of patients with disabilities.
The Americans with Disabilities Act of 1990 and Healthy People 2010 (3) have focused attention on health care disparities among persons with disabilities. The growing awareness of disability in the United States can serve as a stimulus for nursing faculty to consider strategies to include these issues in their curricula. The goal would be for nurses to be better prepared as advocates in their interactions with persons with disabilities of all types across all settings and age groups.
THE SURVEY SPECIFICALLY ASKED if health promotion issues for men and women with disabilities were discussed in the nursing curricula and if the EFFECTIVENESS OF THOSE EFFORTS WAS ASSESSED. Most respondents reported that their programs WERE NOT EFFECTIVE. More than half indicated that too little or FAR TOO LITTLE ATTENTION WAS GIVEN TO THE TOPIC.
THE ABILITY TO INCLUDE DISABILITY in nursing curricula was found to be LIMITED BY TIME CONSTRAINTS and the need to teach content identified as "MORE IMPORTANT." Several respondents identified the need to prepare students for the NCLEX examination as a MAJOR FACTOR that affected selection of content.
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About the Authors Suzanne C. Smeltzer, EdD, RN, FMN, is a professor and director of nursing research at Villanova University College of Nursing, Villanova, Pennsylvania. Mary Anne Dolen, DrPH, RN, CHES, is a professor and the interim chair at Thomas University, Division of Nursing, Thomasville, Georgia. Gale Robinson-Smith, PhD, RN, is an assistant professor and Vanessa Zimmerman, MSN, RN, is an administrative research associate at Villanova University College of Nursing. This study was funded by the Research seed Fund of the Health Promotion for Women with Disabilities Project at Villanova University College of Nursing with a grant from the Bristol-Myers Squibb Foundation. For more information, contact Dr. Smeltzer at email@example.com.…
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Publication information: Article title: INTEGRATION of Disability-Related Content in Nursing Curricula. Contributors: Smeltzer, Suzanne C. - Author, Dolen, Mary Anne - Author, Robinson-Smith, Gale - Author, Zimmerman, Vanessa - Author. Journal title: Nursing Education Perspectives. Volume: 26. Issue: 4 Publication date: July/August 2005. Page number: 210+. © 2009 National League for Nursing, Inc. Provided by ProQuest LLC. All Rights Reserved.
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