White Paper on Inclusion of Students with Disabilities in Nursing Education Programs for the California Committee on Employment of People with Disabilities (ccepd)

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White Paper on Inclusion of Students with Disabilities in Nursing Educational Programs for the California Committee on Employment of People with Disabilities (CCEPD)

Beth Marks, PhD, RN

Director, HealthMatters Community Academic Partnership (HealthMattersProgram.org) Associate Director for Research, Rehabilitation Research and Training Center on Aging with Developmental Disabilities (rrtcadd.org)

Research Associate Professor, Department of Disability and Human Development, College of Applied Health Sciences

President, National Organization of Nurses with Disabilities (NOND.org) University of Illinois at Chicago 1640 West Roosevelt Road, Room 736

Chicago, Illinois 60608

Sarah Ailey, PhD, RN, CDDN APHN-BC

Associate Professor

Department of Community, Systems and Mental Health Nursing

600 S. Paulina #1080

Chicago, IL 60612


White Paper on Inclusion of Students with Disabilities in Nursing Education Programs for the California Committee on Employment of People with Disabilities (CCEPD)

Students with Disabilities in Nursing Education 2

Legal and Social Changes: Invigorating New Expectations 3

Employment Gaps: Expanding Opportunities through the Affordable Care Act 5

Nursing Shortage with a Twist: Fixing a Pipeline in Crisis 6

Barriers for Students with Disabilities 8

Historical Context: Concretizing Technical Standards 8

“What” Versus “How:” Understanding Essential Functions and Technical Standards 9

Technical Standards Today: Conflating Technical Standards and Essential Functions 10

Accommodations for Nursing Students 12

Standardized Technical Standards: Getting through “Clinicals” 12

Nursing Practice with Accommodations: Rethinking the Status Quo 13

Nursing in the 21st Century: Creating Technical Standards to Change Practice 13

Citations 19

Appendices 22

Appendix A: Model Technical Standard for Nursing Education Programs 22

Students with Disabilities in Nursing Education

Students with disabilities bring a unique perspective and set of skills that have the untapped potential to transform the nursing profession by enhancing culturally relevant and competent care to all patients. Just as racial and ethnic diversity is linked with quality of health care, students with disabilities can enhance culturally and linguistically relevant health care [1]. Within health professions, students with disabilities are often viewed from a deficit perspective; and, health educators, clinicians and researchers have not systematically considered how the acceptance of people with disabilities as health care professionals may also improve communication between health care providers and patients. This concordance may also result in greater patient involvement in care, higher levels of patient satisfaction, more preventive care, and better health outcomes[2-6].

By systematically considering the many ways in which significant innovators and leaders with disabilities, oftentimes by virtue of the challenges they faced, played critical roles in their ability to achieve greatness and transform societies[7], we can begin to view people with disabilities from an asset perspective. For example, President Roosevelt, though unable to walk, led the United States through the Great Depression and World War II. Albert Einstein, the father of relativity, experienced learning disabilities. And Beethoven, while considered the greatest composer of all time, could not hear. Florence Nightingale, often considered the mother of modern nursing, was physically disabled and largely confined to her bed for several years (with competing theories about the cause[8]. The founder of the American Red Cross Organization, Clara Barton, with her speech disability, achieved widespread recognition for her work with Susan B. Anthony in the woman’s suffrage movement and an activist for civil rights with Frederick Douglass. With the recent legal changes impacting people with disabilities, the nursing profession has another opportunity to pave the way for significant social change for people with disabilities.

The purpose of this report is to provide information framing the issues related to technical standards in nursing education and how the development of consistent standards can be inclusive of all students with and without disabilities and to provide recommendations on support of students with disabilities in admission, matriculation and graduation from nursing programs.

Legal and Social Changes: Invigorating New Expectations

Landmark laws. The passage of section 504 of the Rehabilitation Act of 1973 guaranteed access for people with disabilities to all federally-financed institutions, schools, hospitals, transportation systems, and federally-run programs and created an era of new expectations for people with disabilities. It had particular relevance to higher education as most institutions of higher education receive federal funding. Section 504 was the first law requiring that institutions receiving federal funds not exclude from their programs individuals with a disability who otherwise qualify. A special advisory panel of the Association of American Medical Colleges (AAMC) provided one of the early responses to the 1973 Rehabilitation Act to address technical standards (non-academic requirements listing the skills or experiences a student must have/meet to enter a program) for medical students.

Currently, in nursing education, many of the technical standards for programs in California and across the country are written in a manner that adversely impacts the equal participation of students with disabilities in nursing schools. The numerical impact of these standards is unknown, as the California Board of Registered Nursing does not collect disability demographic data for the Pre-Licensure Nursing Program Annual School Report or for the Biennial Survey of Registered Nurses.

By encouraging nursing education programs in California to adopt model technical standards based on nondiscriminatory language, partnering with the California Board of Registered Nursing (BRN) to ensure disability demographic data is collected as part of its regular reporting requirements and providing recommendation on supporting students with disabilities in nursing programs, the California Committee on Employment of People with Disabilities (CCEPD) aims to address this high impact barrier that is limiting educational and employment opportunities in California’s healthcare workforce for students and workers with disabilities. As we eliminate barriers that restrict students with disabilities from being admitted into health professions education and identify effective strategies for accommodating and ensuring equal educational options, we have an exciting opportunity to transform nursing practice, create more employment opportunities, and ultimately improve patient care.

The passage of the Americans with Disabilities Act (ADA) in 1990 was landmark civil rights legislation for people with disabilities. Congress noted that people with disabilities are a unique minority and extended the intent and protections of Section 504 with a sweeping mandate to end discrimination on the basis of disability in employment, state and local government, public accommodations, commercial facilities, transportation, and telecommunications. The passage of the ADA [9] changed the landscape of American society through increased architectural, transportation, and communication access for people with disabilities and greater accommodations for students and workers [10]. While the ADA was a symbolic victory for transitioning from a medical definition of disability to a social constructed view of disability, public representations of disability and federal courts' treatment of disability created another story [11]. Many of the law's strengths and weaknesses manifested themselves [12-15] through series of decisions made by the United States Supreme Court; and, the lower courts that narrowed ADA’s scope of protection and excluded from coverage individuals that the Act was originally designed to protect, including people with epilepsy, diabetes and muscular dystrophy [16].

The Americans with Disabilities Act Amendments Act (ADAAA) of 2008 [17] signed into law (S.3406) by President George W. Bush on September 25, 2008 rekindled the spirit of the ADA of 1990 and provided an increased impetus to more actively address the attitudinal issues that continue to impede people with disabilities from achieving President George H.W. Bush’s vision with the ADA of 1990 of a bright new era of equality, independence and freedom. Specifically, the bipartisan effort aimed to reverse several controversial Supreme Court decisions that limited the original intent of the ADA. Effective January 1, 2009, the ADAAA bolstered and extended the original ADA civil rights legislation[18]. The ADAAA was passed "to carry out the ADA's original objectives as a national mandate for the elimination of discrimination by “reinstating a broad scope of protection to be available under the ADA” – the intended spirit of the ADA [19], which followed the broad scope of the Rehabilitation Act of 1973/Section 504. The ADA Amendments Act (ADAAA; 2008), made significant changes to the ADA's definition of "disability" that broadens the scope of coverage under the previous acts. In education, the ADA and Section 504 essentially required colleges and schools to provide reasonable accommodations to students with disabilities so that programs are accessible to them. The ADAAA shifts the focus away from whether a student has a disability and making accommodations to ensuring equal educational and employment opportunities [19].

March 24, 2014 marks the most recent “very important day” for people with disabilities, as the revised Section 503 Office of Federal Contract Compliance Programs (OFCCP) 7% rule became effective. The OFCCP now require employers with federal contract to take affirmative action to recruit, hire, promote, and retain individuals with disabilities For the first time, a single, national utilization goal for individuals with disabilities is now mandated for federal contractors and subcontractors to set a goal of having 7 percent of their employees be qualified individuals with disabilities in each job group of the contractors’ workforce. This essentially requires that healthcare institutions who are federal contractors and subcontractors demonstrate that their nursing workforce include at least 7% individuals with disabilities.

The ADAAA and the new OFCCP regulations afford an opportunity to rethink the environmental factors, including physical characteristics built into the environment, cultural attitudes and social behaviors, and the institutionalized regulations, policies and procedures, and practices of public organizations and private entities that are barriers to individuals with disabilities entering and remaining in the nursing profession. We can now direct our activities away from questioning whether people with disabilities have a place in the nursing profession to actively developing strategies that will eliminate the many barriers for people with disabilities in nursing education[14]. The ADAAA also shifts the focus for educators, regulators, and employers away from focusing on whether a student nurse or a practicing nurse has a disability to making accommodations and ensuring equal educational and employment opportunities[1].

Disability studies and nursing education. Within the field of disability studies (a relatively new field akin to minority studies, gender studies), scholars continue efforts to study and shift our view of disability from a purely medical perspective (e.g., being disabled is a deficiency/ abnormality residing in the person), to a greater understanding disability as a social construct (disability is a difference with disabling qualities residing in the environment), disability can be framed as a difference rather than a biologically absolute reality.

The discussion of the role of nurses and nursing students with disabilities in advancing the diversity of the nursing workforce is not new. In 2003, Rush University held a symposium entitled Rush University College of Nursing Symposium on Nursing Students with Disabilities. This symposium raised the issue that “persons with disabilities have generally been overlooked in serving the health care field” and called for “perspective on how to effect change.” At that conference the National Organization of Nurses with Disabilities (www.NOND.org) was formed.

The entrance of students with disabilities into nursing education programs has largely remained unchanged; and, the persistent educational and employment gap for people with disabilities continues[20]. As frontline health care professionals, adopting an understanding of disability from a social model perspective can have tremendous potential on ensuring access to acceptable and accessible health services and can have a positive impact on how people with disabilities view themselves with a sense of disability pride[14]. In order for this to happen, the barriers to people with disabilities entering the health professions need to be removed.

Affordable Care Act. The Affordable Care Act provides a platform for change within health care for both employees with disabilities and patients with and without disabilities receiving care. Several titles of the act address potential reforms in the areas related to health care workforce and the provision of care for people with disabilities. Title V, Health Care Workforce, Sec. 5307, notes the need to address cultural competency, prevention, and public health and individuals with disabilities training. Title III, Improving the Quality and Efficiency of Health Care and Title VII, Improving Access To Innovative Medical Therapies Sec. 311, addresses the need for options to finance long-term services and care in the event of a disability. Increasing the numbers of health care providers with disabilities can enhance the potential for creating innovative community support services for education, employment, recreation and managing health across the lifespan. Recruiting students with disabilities into health professions and incorporating a social model within educational curricula may have a favorable impact/outcome on research, education and practice to guide systemic changes.

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