enhancement of pre-registration nursing (sceprn) well ... · 4.7.5 mental health related disability...

Geoffrey L Dickens, Richard Craven, and Nutmeg Hallett 6/20/2016

FINAL REPORT for The Scottish Collaboration for the Enhancement of Pre-Registration Nursing (SCEPRN)

WELL ADJUSTED?

A systematic, integrative review of empirical research about making ‘reasonable adjustments’ in clinical practice placements to support pre-registration healthcare students who have a disability

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TABLE OF CONTENTS

Page

Table of Contents 2

List of Tables and Figures 3

List of acronyms 3

About the authors 4

1. Executive summary 5

2. Introduction 7

2.1 Background 7

2.2 Prevalence of disability 8

2.3 Specific legislative requirements 9

2.4 Aims of the current study 10

2.4.1 Profile 10

2.4.2 Access 10

2.4.3 Best practice 10

2.4.4 Evidence and future development 10

3. Methods 10

3.1 Review protocol 10

3.2 Search strategy 10

3.3 Study selection 11

3.4 Inclusion/ exclusion criteria 11

3.5 Data extraction and synthesis 11

3.6 Study quality 12

4. Results 12

4.1 Characteristics of included studies 12

4.2 Study quality 14

4.3 Study aims 14

4.4 Disability related need in studies 14

4.5Underlying values and assumptions 14

4.5.1Stakeholder engagement 15

4.5.2 Commitment to a formal process 15

4.6 Integrated approaches to reasonable adjustments in clinical practice 16

4.7 Standalone interventions/ reasonable adjustments 16

4.7.1 Start of the course 16

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4.7.2 Before individual placements 17

4.7.3 On placement 18

4.7.4 Dyslexia 18

4.7.5 Mental health related disability 19

4.7.6 Hearing impairment 19

4.7.7 Visual impairment and physical disability 20

4.7.8 Dyspraxia 20

4.8 Student-Centred Reasonable Adjustment Model (SCRAM) 20

5. Discussion/ Conclusions 20

5.1 Summary of main findings 22

5.2 Strengths and limitations 22

5.3 Future research priorities 23

5.4 Recommendations 23

6. References 46

List of Tables and Figures Page

Figure 1: Flow diagram of literature search modified from 13

the PRISMA flow diagram (Moher et al. 2009)

Figure 2: Student-Centred Reasonable Adjustments Model (SCRAM) 21

Table 1: Full text papers excluded with reasons 24

Table 2: Critical appraisal of quantitative studies 25

Table 3: Critical appraisal of qualitative studies 26

Table 4: Critical appraisal of mixed method studies 27

Table 5: Critical appraisal of case studies 28

Table 6: Characteristics of included studies 29

Table 7: Study results and implications for practice 35

Table 8: Integration of study results: example 41

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Acronyms used:

DDA Disability Discrimination Act

DRC Disability Rights Commission

EHRC Equality and Human Rights Commission

HEI Higher Education Institution

NES NHS Education Scotland

NMC Nursing and Midwifery Council

ODI Office for Disability Issues

ONS Office for National Statistics

PICOT Population, Intervention/Focus, Comparator, Outcome, Timescale

PRISMA Preferred Reporting Items for Systematic reviews and Meta-Analyses

QMPLE Quality Management of the Practice Learning Environment

SCRAM Student-Centred Reasonable Adjustments Model

UK United Kingdom

About the authors

Geoff Dickens: Geoff is Professor of Mental Health Nursing at Abertay University. His primary

research interest lies in risk assessment for violence and other adverse outcomes in mental health

patients. He also specialises in systematic reviews and meta-analyses.

Richard Craven is Lecturer in Mental Health Nursing at Abertay University. He is lead for the pre-

registration nursing programme and is a member of the Scottish Collaboration for the Enhancement

of Preregistration Nursing (SCEPRN).

Nutmeg Hallett is currently a PhD student at the University of Northampton where she is writing her

thesis on violence prevention in psychiatry. She has been employed as a Research Assistant at

Abertay University.

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1. EXECUTIVE SUMMARY Since 2010, HEIs and healthcare providers in the United Kingdom have been required to

make reasonable adjustments to working conditions to support pre-registration nursing and other

healthcare students who have a disability while they are on clinical practice placements. In this

paper, we identify and synthesize the available published evidence about current and best practice

related to reasonable adjustments for pre-registration healthcare practitioners on clinical practice

placements. The overall aim is to identify how those with a declared disability can be best supported

and thus how pre-registration training can be most inclusive.

We conducted a systematic review of the worldwide empirical literature in accordance with

the PRISMA (Moher, Liberati et al. 2009) guidelines. Multiple electronic databases were searched

using comprehensive terms. Included papers described empirical studies related to making

reasonable adjustments using any quantitative, qualitative or mixed-methods design. Acceptable

study designs were observational, exploratory, or experimental/pseudo-experimental. We included

well-reported case study designs where the main data source was the authors' experience of

implementing related change. There were no exclusion criteria relating to study participants, who

could be students (with or without disabilities), educators, or clinically-based staff, as long as the

study focused on reasonable adjustments for students on placement. Excluded studies were

opinion-editorial comment and other non-empirical papers, and those not written in English

language. Relevant papers were retrieved, assessed against inclusion/exclusion criteria, and

subjected to critical quality review against appropriate guidelines. Framework analysis was used to

structure extraction and integration of individual study findings.

Our comprehensive search identified 16 relevant empirical studies conducted in four

countries and involving n=188 people who were students with a disability; the most common

condition was dyslexia (n=35; 18.6%). Some studies drew their sample from university faculty,

placement mentors, field program directors, and other unidentified persons. Half (n=8; 50%) of

studies were conducted in the UK since the Equality Act 2010, the relevant legislation requiring

reasonable adjustments in the UK, came into force. Included studies were descriptive and involved

quantitative survey, qualitative, mixed-method, and case study approaches whose aim was largely to

identify good practice. Study quality was variable. Our framework analysis revealed that reasonable

adjustments manifest as specific interventions, procedures, or arrangements, but may also usefully

require adherence to an overall process. Reasonable adjustments can occur prior to, during, and

following the placement and involve commitment from HEI tutors, clinical placement mentors and

other staff, and healthcare students themselves. Different disabilities may require different solutions

and approaches. Studies emphasise the centrality of the students’ role as an active participant

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including as the expert in relation to their own disability-related needs. The underlying assumptions

and values behind reasonable adjustments initiatives included the need for stakeholder engagement

and the commitment to a formal process.

Most of the studies of reasonable adjustments for specific conditions examined the support

in clinical practice of students with dyslexia; little is known about specific support for students with

other conditions such as those with a mental health problem. There is no good empirical evidence

from large-scale evaluative studies about which specific interventions, or other supporting elements,

are most effective in terms of a range of outcomes including placement success, inclusion,

satisfaction, or patient experience.

We tentatively propose a Student-Centred Reasonable Adjustment Model (SCRAM)

representing a combination of process-driven, person-related, condition-specific, and student-

centred approaches to supporting disclosure of disability, identifying needs and possible reasonable

adjustments, and maintaining the integrity of a competency and professional conduct based training

in order to drive professional registration of the future healthcare workforce based on equality of

access. We view this model as evidence-based, but also flexible and dynamic since all reasonable

adjustments should be constantly reviewed to identify whether technological or other advances can

now facilitate even greater inclusion.

Future research should aim to provide trial evidence for a supporting model of adjustment,

and produce more evidence to support guidance on supporting people with conditions other than

dyslexia. Better information is needed about the proportion of pre-registration healthcare students

who have a disability, and about the nature of that disability, in order that efforts to implement

more inclusive practices can be evaluated. More needs to be known about the practices and policies

of a range of healthcare placement hosts, HEIs, and about the experiences of students themselves,

and of service users who might be affected by these practices and policies. To achieve these aims it

will be necessary to conduct in-depth studies with people with conditions other than dyslexia to

determine their needs and satisfaction/experience of support given. Additionally suitable target

outcome domains should be identified and work undertaken to determine whether appropriate

measures exist to capture improvement.

Geoff Dickens

Professor Mental Health Nursing, Abertay University

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2. INTRODUCTION

2.1 Background

Nursing represents the largest single, professional occupational group in the UK by some

margin with 680,858 registrants in 2014 (NMC, 2014). Nurses are part of a total NHS workforce

numbering over 1.6 million people, with more employed providing education in HEIs, and care in the

independent sector. The scale and scope of the Nursing profession, lying as it does at the heart of

one of the world’s most substantial workforces, is significant given its important role in respect of

public trust and safety (NMC, 2015). The profession also plays an important role as a barometer, and

hopefully as an exemplar, of attitudes and practice with regard to the professional preparation and

subsequent employment of people with disabilities. In this context we can usefully and legitimately

ask how ‘the caring profession’ itself promotes inclusion, cares for, and promotes the wellbeing of

protected groups within its ranks – notably those with a disability - in terms of meaningful

employment and training opportunities.

Historically, developments in disability legislation, while somewhat erratic, were essentially

incremental, reflecting a developing view of disability as a social rather than medical concern.

Successive Employment, Education, Welfare and Race, Sex, and Sexual Orientation Equality Acts

culminated in the Disability Discrimination Act 1995 (DDA) and its 2005 successor, punctuated in

2000 by the establishment of the Disability Rights Commission. A rich vein of reports and academic

literature informs the Equality and Human Rights Commission’s (EHRC, 2010) report: ‘Disability,

Skills and Employment: A review of recent statistics and literature on policy and initiatives’ which

describes the complex, interconnected political, social, economic and related factors which affect

the experiences of disabled people in the UK. Following these developments, the civil rights of

people with disabilities were distilled through the Equality Act 2010 in which disability is listed as

one of nine protected characteristics. The Act promotes the rights of people who belong to one or

more of these ‘protected groups’ defined by age , gender reassignment, marriage and civil

partnership, pregnancy and maternity, race, religion and belief , sex, sexual orientation, and

disability.

Disability is defined as physical or mental impairment with substantial long-term effects

which have an adverse impact on day to-day living (EHRC, 2010). Like the DDA before it, the Equality

Act imposes a legal responsibility on employers to mitigate the potential impact of disability on an

employee’s ability to carry out their duties by making ‘reasonable adjustments’ to the work and the

working environment. This legal requirement, and a definition of its terms, will inform subsequent

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discussion of the extent to which profession-based disciplines have made adjustments to reflect

recent changes, and what has been learned about the impact of any adjustments.

2.2 Prevalence of disability

Estimates of the prevalence of disability in the general population have been confounded by

use of different definitions, changes in individual status over time linked to health status or age, and

under-reporting due to concerns about stigma (EHCR, 2010). Recent ONS (Department for Work and

Pensions and Office for Disability Issues, 2014) self-report data compares rates of ‘long-standing

illness or disability’ defined as ‘anything that someone has considered to have troubled them over a

period of time’ (36% in 2013) and ‘limiting long-standing illness or disability’ (20%). The most recent

available figures from Scotland indicate that 45.6% of people defined as disabled were in

employment compared with 70.7% of people not defined as disabled. The same figures reported by

the EHCR using data from 2008-09 were 47% and 81.5% respectively, suggesting that disabled

people are disadvantaged in the labour market with regard to employment, pay, and status or

promotion.

While the size of the nursing profession is well documented, and the presence of disability in

the general population relatively so, little is known about the prevalence of people at the

intersection: nurses with a disability. Noting issues linked both to quality and completeness of its

data, both of which are currently under review, the NMC (2015) reports that, of those 686,782

nurses on the register, 12% reported a disability of some kind whilst 41% reported they had no

disability; the remaining 47% are recorded as ‘unknown’ or ‘prefer not to answer’. The previous

years' figures in the same category were 10%, 56% and 34% respectively signalling incremental

change possibly as a result of improved reporting mechanisms (NMC, 2013). A conservative

estimate of more than 80,000 nurses and midwives reporting disability at any one time is therefore

warranted. This figure can be called into question as a serious underestimation of the true rate of

disability in the profession simply with reference to the reported rate of one condition, dyslexia, in

the general population at 8-10% (and 12% for student nurses) (Evans, 2015).

In summary, issues including age, definition of disability, stigma, reporting mechanisms, and

data collection methods all contribute to an incomplete picture of the extent and nature of disability

within the nursing profession, a situation that likely extends to other professions. These factors are

arguably compounded in a climate where it has been suggested that standards which regulate ‘good

health’ and ‘physical and mental fitness’ in nursing and related professions are linked primarily to

unsubstantiated concerns about public protection (DRC, 2007).

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Those considering a career in nursing may reasonably question how their current or future

disability is likely to be managed and supported, or whether it will act as a barrier to career progress.

Currently, the climate seems to be one where significant challenges have been identified but

progress towards meeting them remains partial. Whilst the profession is reportedly fully committed

to further tackle the inequalities faced by people with disabilities (NMC, 2014), evidence to support

progress is sparser. However, if the depth of literature concerning disability and nursing could be

said to be limited, the same could not be said for its breadth. A wide range of articles and reports

have illuminated aspects of the role of disability amongst nurses. Other authors have noted a lack of

empirical studies (Storr et al, 2011) and this remains a consistent theme alongside more structural

themes linked to the nature of disability, its identification, and the interface between social attitudes

and the still relatively novel legal framework which informs practice. Looking ahead, nursing –

alongside other professional healthcare occupations - could possibly advance its attempts to address

issues in training and practice through systematic identification and appraisal of the available

research evidence in order to provide the basis for recommending future priorities for development

and research.

2.3 Specific legislative requirements

The United Kingdom 2010 Equality Act delineates the responsibility of HEIs to make

reasonable adjustments for their students as first described in the 1995 Disability Discrimination Act,

the main disability discrimination law, which bans discrimination by employers against disabled job-

seekers and employees, and by service providers against disabled service-users, in order to ensure

that they can participate as fully as possible in educational opportunities. It is most notable for

imposing a duty on employers and service providers to make reasonable adjustments for disabled

people to help them to overcome barriers that they may face in gaining and remaining in

employment, and in accessing and using goods and services. The main activities covered by the DDA

are: employment, including access to employment; access to and use of goods, facilities and

services, including access to public buildings, shops and leisure facilities and to healthcare, housing

and transport; certain other functions carried out by public bodies, such as policing and issuing

licences; membership of private clubs and use of their facilities. The legislation requires public

bodies to promote equality of opportunity for people with disabilities. It also allows the government

to set minimum standards so that people with disabilities can use public transport easily.

Of unique relevance to pre-registration healthcare students with a disability is the need to

consider what ‘reasonable adjustments’ within the practice learning environment can be made to

accommodate their needs. Despite some work in this area, there remains a need to assess the

impact of reasonable adjustments on access to the profession, issues in practice, teaching and

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learning, the experience of students themselves, nurses and other stakeholders. The current

literature review will act both as a barometer to assess the impact of a key element of the Equality

Act (2010) on the practice-based learning of pre-registration healthcare students in practice, and as

an informative supplement to other aspects of policy and strategy including, for example, Quality

Standard for Practice Placements (2008), the NHS Education Scotland (NES) Quality Management of

the Practice Learning Environment (QMPLE) project, and Setting the Direction (NES, 2014).

2.4 Aims of the current study

The specific aims of the review relate to:

2.4.1 Profile. To raise the profile of the relevant UK Equality legislation and improve

knowledge of the details of the legal framework within which nurses and other healthcare

professionals are required to practice

2.4.2 Access. To address the concerns that have been raised about access to nursing and

other healthcare careers by people with disabilities (SKILL, 2010)

2.4.3 Best practice. To make recommendations about what constitutes best and effective

practice in this arena.

2.4.4 Evidence and future development. To highlight gaps in the current evidence base and

prioritise key future research and development questions.

3. METHOD

3.1 Review protocol

We conducted a systematic literature review in accordance with the relevant sections of the

PRISMA guidelines (Moher et al., 2009).

3.2 Search strategy

The aim of the literature search was to identify empirical studies about reasonable

adjustments, or terms used to represent equivalent interventions in non-UK jurisdictions, made to

facilitate the participation of pre-registration nursing and other healthcare students on clinical

placement as part of their course of preparation for registration. The search was conducted between

February and March 2016. We devised a PICOT (Riva et al., 2012) approach combining terms related

to the relevant Population (student nurs* or medica* or physiotherap* or occupational therap* or

psycholog* or social work* or pharmac*), Intervention (reasonable adjust* or reasonable

accommodation or individual accommodation or reasonable modification), Comparator (Any),

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Outcome (Any), and Time period (1995 to present). Multiple computerised databases (CINAHL,

DynaMed, Health Business Elite, MEDLINE, LISTA, PsycINFO, Medline, Biomedical Reference

Collection: Comprehensive, Web of Science, ASSIA, Cochrane Library, EMBASE, ProQuest [including

Dissertations/Theses], and Google Scholar) were searched. Hand searching of references lists from

included studies was conducted to identify further records. Titles and abstracts were reviewed by

GLD and RC and the full text version of any paper that described a potentially relevant empirical

study was retrieved.

3.3 Study selection

Full text papers identified by the search were independently reviewed by all three authors.

Elimination of papers at the full text review stage was achieved by consensus.

3.4 Inclusion/exclusion criteria.

In order to be included a paper needed to describe an empirical study which reported on

reasonable adjustments for healthcare students while on clinical placement. We took a broad view

of what constituted empirical work and, as a result, included practice-based case studies where

descriptions of relevant projects were presented. The physical setting of studies was not limited, for

example studies could be conducted in HEIs, but the focus of the study must have been about

adjustments made in the clinical practice setting. Participants could include students themselves,

university faculty, clinical placement mentors, or any other relevant people or groups including their

data. Non-English language studies were excluded.

3.5 Data extraction and synthesis

Information from studies identified as meeting inclusion criteria were extracted and

tabulated by NH under the headings: author, date, title, country and setting, aims and objectives,

sample studied, disability or condition involved, design/data collection, instrumentation used,

results and implications for practice. Results were integrated using a process of framework analysis

(Ritchie & Lewis, 2003) which requires data to be ‘cut up’ and organised into useful piles of data

about the same thing. Data was organised both in terms of ‘cases’ (in this review particular or

general classes of disability including physical disability, dyslexia, dyspraxia, mental impairment and

so on) and in terms of reasonable adjustments made (including specific interventions or alterations,

approaches, processes, at what stage, who by, and with what effect). This was undertaken initially

by GLD; subsequently, the emerging data categories were discussed and agreed by the three

authors. Further consideration of study data within this framework of which actor (student, HEI and

tutor, placement provider, mentor, regulatory body), can undertake or facilitate what action or

process (identify a disability, identify a possible reasonable adjustment), at what point (pre-course,

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pre-placement, on placement, post-placement), with reference to which disabilities or conditions

(e.g., dyslexia, hearing impairment, mental impairment) was used to develop a student-centred

reasonable adjustment model (SCRAM).

3.6 Study quality

The quality of the qualitative studies was assessed using a 14-item checklist adapted from

two sources (Critical Appraisal Skills Programme, 2013 and Tong et al., 2007). The quality of the

quantitative studies was assessed using a 12 item checklist adapted from two sources (Greenhalgh,

2006 and University of York Centre for Reviews and Dissemination, 2008). Quality of the mixed

method studies was assessed using a 16-item checklist (O'Cathain et al., 2008 and Pluye et al., 2011).

Finally, the quality of case studies was assessed against a 14-item checklist (National Institute for

Healthcare and Excellence, 2012).

4. RESULTS

4.1 Characteristics of included studies

The literature search strategy (see Figure 1) yielded a total of 232 papers (including four

papers identified from hand searching) published between 1992 and 2014. After removal of

duplicates, 217 were retained for screening at abstract/title level by RC and GLD following which the

full text versions of 54 papers were retrieved (see Fig 1). Of these, 16 papers were judged (NH and

GLD) to meet inclusion criteria (see Figure 1), and 38 were excluded (see Table 1). Characteristics

and main findings from included studies are presented in Tables 6 and 7.

Included studies were conducted in four countries (UK n=8; Ireland n=3; US n=4;

Canada n=1) Most (n=14) studies were conducted in university or health school settings; n=1 study

was conducted in clinical practice setting and n=1 in both university and practice settings.

Participants in studies included students with disabilities (nursing students in n=9 studies; social

work n=2; medical n=2, and a range of student health care professionals including from dentistry,

optometry, physiotherapy in n=1 study), university faculty (n=3 studies), practice mentors (n=2), and

expert advocacy groups, field directors, chief student support officers, and learning needs support

officers (all n=1); one study used data from 247 nursing programs. Since some studies did not report

the number of participants, for example attendees at workshops or other data collection events, it

was not possible to ascertain total numbers of participants; however, at least N=188 (median n=12,

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Figure 1: Flow diagram of literature search modified from the PRISMA flow diagram (Moher et al.. 2009)

Range 1 to 63) students with disabilities (or their data) were included in studies. Of these, the most

common disability was dyslexia (n=35; 18.6% participants reported to have dyslexia). The precise

number of students with specific conditions was not possible to ascertain but included people with

mental health problems, visual impairment, hearing impairment, specific learning disabilities,

ambulatory disabilities, and physical illness. Seven studies were qualitative in design and all of these

employed semi-structured interviews to capture data; other studies used case study (n=5),

quantitative (n=3), and mixed methods designs (n=1).

Number of records identified through

database searching: 228

Number of records identified through

other sources: 4

Number of records after duplicates

removed: 217

Number of records screened: 217

Number of records excluded at

title/abstract level with reasons (N=163)

Not about reasonable adjustments 130

Not about healthcare 19

Could not obtain paper 1

Not empirical 13

Number of full text records assessed

for eligibility: 54

Number of studies included for quality

appraisal and inclusion in review: 16

Number of full text records excluded

with reasons:

Not about reasonable adjustment 10

Not about healthcare students 7

Not empirical 18

Not about clinical placements 2

No separate healthcare data 1

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4.2 Study quality

Five of seven qualitative studies met the majority of the 14 quality criteria (range 3-14,

median =10); common limitations were inadequate description of data analysis and lack of

information about the relationship about the independence of the researchers from the

participants; see Tables 2,3,4, and 5). The single mixed-methods study included in the review met

the majority of quality criteria but only two of the five case studies; all quantitative studies met half

or more of the 12 quality criteria but none met more than two thirds (range 6-8, median=7) and

common limitations included lack of validity and reliability of instrumentation and lack of

information about study funding.

4.3 Study aims

Most studies aimed to ascertain what measures students, mentors, or other

stakeholders reported as being helpful regarding making reasonable adjustments in clinical practice

placements; these studies were largely exploratory in nature. Three papers (Griffiths et al, 2010;

Howlin et al, 2014ab) described the development and evaluation of two different clinical needs

assessment models which aimed to incorporate the identification of specific issues and potentially

supportive interventions within a process that linked educational and clinical placement settings.

Both studies described the implementation of their assessments in the context of small numbers

(n=1 and 4 respectively) of students with a disability and were evaluated qualitatively.

4.4 Disability-related need in the pre-registration healthcare student population on clinical

placement

Very little is known from the empirical research literature about the number or proportion

of people enrolling on pre-registration healthcare professional courses who declare a disability.

Watson’s (1995) survey of 247 US nursing programmes revealed that 45% admitted new students

with disabilities; most commonly dyslexia, learning disability, and then people with physical mobility

issues. In the UK, Tee et al (2010) found that 27 (2.3%) of the nursing student population met the

relevant legislative criteria of a disabled person. All other studies in the review which sampled

students with a disability did so purposively and thus presented no data about the proportion of

student nurses declaring a disability.

4.5 Underlying values and assumptions behind approaches to reasonable adjustments

Framework analysis revealed two main categories of values and assumptions expressed in

the included papers which were believed to be key to success in terms of successfully supporting

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students with a disability through implementation of reasonable adjustments for clinical practice

placements: stakeholder engagement and commitment to a formal process.

4.5.1 Stakeholder engagement. This theme suggested a need to recognise that all relevant

parties including HEI faculty, students, mentors and other clinical placement staff, and placement

providers should have the necessary information about disability and reasonable adjustment. This

was felt to be deliverable through education for all of these groups (Howlin et al, 2014a), dialogue

and clear communication (Howlin, 2014a; Reeser, 1995), provision of information for prospective

students during the recruitment and application process (Watson, 1995). Identified as central to

success was the valuing of individual students as the expert in their own disability and their

associated needs (Wright & Eathorne, 2003), which was echoed in findings about the need for

targeted supportiveness and interventions to be individualised (Tee et al, 2010), and for those

working with students with a disability to retain flexibility (Griffiths et al, 2010). It was felt important

that healthcare students find disclosure of disability to be challenging and potentially high risk in

terms of career progression (Howlin et al, 2014a), and that the process of disclosure needed to be

supportive and discrete (Cook et al, 2012; Morris & Turnbull, 2006; Ridley, 2011). Barriers to

engagement are likely to include lack of flexibility and discrimination (Griffiths et al, 2010).

4.5.2 Commitment to a formal process. This theme encompassed issues about the

underlying rationale for a shared approach to the issue of reasonable adjustments for students with

a disability on clinical placement including understanding of, and sympathy with, the equality-

inspired aims of relevant legislation (Cook et al, 2012; Solan & Heiberger, 1995). Central to this

commitment was the need for a commitment to a model of professional competence and conduct

for practitioners rather than the somewhat imprecise and subjective previous model of ‘fitness to

practice’ or ‘good health’ (Howlin et al, 2014a). Some researchers have noted that this is more

credible where it is clearly understood that students with a disability need to reach the same

educational standards and requirements as their peers without disability, and that, in this context,

there is a risk that reasonable adjustments may be viewed as being the partner of reduced

educational standards and students with a disability somehow viewed as less able and competent

(Reeser, 1995). Conversely, making adjustments could be seen as empowering for students with a

disability, raise confidence in their potential and ultimately facilitative of a more representative

workforce (ibid). Further, all students, including those with a disability, need to be exposed to and

experience a range of clinical settings; however, rather than a adopting dogmatic approach

mandating that disabled students should be able to attend the same placements as their peers

White (2007) advised that HEI staff should recognise that some placements are more suitable than

others for students with a disability and use their judgement appropriately. Also related to this

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theme was the need for formal accountability of placement sites through regular monitoring of

practice, and the development of formal policies and procedures around reasonable adjustments

(Reeser, 1995). Finally, Reeser (ibid) suggested a level of realism among her sample of US social work

field studies directors that some people may have disabilities that are sufficiently severe that, even

with all available reasonable adjustments, the student may not be capable of achieving competence.

4.6 Integrated approaches to reasonable adjustments in clinical practice

Two papers have proposed and described the operation of an operationalised process for

identifying and supporting healthcare students with a disability and subsequently implementing

appropriate reasonable adjustments. Griffiths et al (2010) described a 6-phase model comprising i).

Disclosure: identifying and assessing need(s); ii) Establishing support systems and processes in

practice iii) Mid-placement review; determination of alternative strategies iv) Development of

detailed plans and models of support; establish critical information base; v) End of placement

review; evaluation vi). Revise support strategy In line with critical success factors identified above

the researchers reported that the model relies on engagement of the practice team, practice

partners, and the disability service, all working student-centrically. The model was demonstrated

using a case study description on one student with Myalgic Encephalopathy.

Howlin et al (2014a) proposed and evaluated (2014b) a 5-phase Clinical Needs Assessment

(CNA) based on domains of competence and containing background information in the form of a

questionnaire to assist a detailed history of the individuals' disability; presence/absence of any

aggravating factors, and a list of reasonable adjustments outlining the responsibilities of the

University, clinical site and student. i). Students with an academic/examination needs assessment

and registered with disability services are invited to meet a member of Disability Learning Team

(DLT) to discuss and agree reasonable adjustments for forthcoming clinical placements and

requested to bring any supporting information, letters, or reports. ii) The role of the DLT and

purpose of CNA is explained; focus on individual student needs and identification of strategies used

successfully in other settings. The ‘reasonableness’ of reasonableness is explained (defined as

practical effective measures that do not cause excessive cost or disruption to the placement or

employer). iii) Examples of specific supports are offered; these may require revision to ensure they

remain suitable throughout the program. iv) Disclosure of information about the individuals’

disability in the CNA is discussed with the student. The students’ legal right to non-disclosure, except

for issues of patient safety which contravene the right, is explained, also the benefits of disclosure

including that reasonable adjustments can then be offered. Consent/non-consent provided in

writing by the student. v) The student is invited to liaise with Clinical Contact Person to discuss their

reasonable accommodations. Evaluation of this model was conducted through qualitative interviews

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with four students with a disability. All students disclosed disability on placement to an extent. CNA

was used to highlight students’ accommodations to clinical staff on placement. Issues raised

included: communication (e.g., issues from CNA not passed on to clinical staff), negative staff

attitudes, and need to improve provision of reasonable adjustments. Reasonable adjustments were

identified as the responsibility of the undergraduate team, the clinical area, or the student. The

authors concluded that CNA 'bridges the gap' between HEIs and clinical placements. Disclosure is

challenging and requires education for clinical staff and students, and preceptors to support student

in practice by implementation of accommodations. Communication needed to ensure student has a

positive experience of support. Regulatory bodies need to provide better guidance for all.

Elsewhere, while not proposing integrated processes for disclosure and reasonable

adjustment, Solan and Heiberger (1995) have identified the need for an appropriate adjustments

policy because it is linked to provision of support to students in clinical settings and a need for

student education to be more personal and have modifications made on a case by case basis.

4.7 Standalone interventions/ reasonable adjustments

A number of papers described interventions aimed at supporting reasonable adjustments at

discrete points from the start of the pre-registration course through to clinical placements and

beyond. These were presented as standalone interventions and were not presented as part of an

integrated overall approach such as those described by Howlin et al. (2014a) and Griffiths et al

(2010).

4.7.1 At start of the course. Ashcroft et al (2008) described how nursing students were asked

to meet individually with clinical course leaders to discuss the course objectives, placements, and

learning activities to allow them to identify accommodations, strategies, and resources that may

help the individual student to complete the course (Ashcroft et al, 2008). In Watson’s (1995) survey

of US nursing schools, post admittance strategies included explaining about process for disability

needs assessment, identification by observation and remedial action, written notices, inclusion of

declaration of disability forms in orientation packs. (Watson 1995)

4.7.2 Before individual placements. Reeser (1995) reported a range of issues were

considered by field directors when making placement decisions including their own perceptions of

the special needs of those with particular disabilities, and on those of everyone with disabilities; the

skills, abilities, and experience of particular students of which students’ acceptance of their

disabilities; clients’ acceptance of the student, the sensitivity of placement staff, time flexibility,

whether the placement itself serves persons with disabilities, assessment of the violence risk of the

client population, geographic and physical accessibility of the placement, the special needs of

18

persons with disabilities, and the skills, abilities, and experiences of individual students were thought

important.

Cook et al (2012) found that provision of an individualised student support card, detailing

the disability and necessary adjustments, gave credibility to requests for reasonable adjustments in

clinical settings. Tee et al (2010) a range of interventions that could be employed to support

reasonable adjustments including encouraging students to visit the clinical placement prior to

placement commencement to learn more about the setting identify potential problems; supporting

students in disclosing issues affecting their practice learning; asking placement mentors to schedule

regular, honest, and constructive feedback sessions; encouraging both mentor and student to

regularly assess learning needs, set objectives, and use a learning contract; advocate regular

progress meetings between the placement learning advisor, student and mentor to facilitate

feedback and revise learning objectives and the learning contract; facilitation of effective liaison

between practice staff, the student, the HEI and support services; finally, ensuring that the student is

allocated patients whose care they are responsible for to encourage them to identify care needs

independently and develop their initiative.

4.7.3 On placement. Wright and Eathorne (2003) identified a range of support mechanisms

that mentors could enact for students on clinical placements including: encouraging students to

disclose their disability in a non-discriminatory environment; listening to students as experts on their

own learning needs, provide clear instructions and expectations, and discuss how these can be met;

asking the student to repeat or write down instructions or expectations where necessary;

encouraging the student to keep a book for notes; offering the opportunity for testing new skills

before using with patients; making time to discuss new learning and ongoing practice; and being

flexible and innovative.

4.7.4 For dyslexia. Studies identified a range of specific reasonable adjustments that could

be offered; these were largely specific to particular conditions. For dyslexia, possible reasonable

adjustments that could be made by placement mentors and other staff included: extra time for

writing in and reading patients’ notes, additional checking of notes with placement mentor,

additional time to write down telephone information; additional support for the organisation and

management of patient care; demonstration of nursing skills rather than explaining verbally to the

student; provision of written information on skills in advance of demonstration; use of a template

for nursing handovers; provision of a list of common abbreviations; additional check of calculations

for medicines/fluids (Howlin et al, 2014b); provision of a pre-prepared drug calculation tool; use of

capital letters on drug charts and other patient documents (Morris & Turnbull, 2006); implement

adaptations (e.g. coloured overlay) and monitor effectiveness; provide student with ways of

19

structuring common tasks such as assessment e.g. using ABCDE and devising cue cards as an aid.

Provide detailed learning contracts which structure learning into small manageable parts, and

encourage repetition and sequencing, building from basic to complex (Tee et al, 2010). Some clinical

placements were viewed as more appropriate for students with dyslexia, some of the characteristics

included a small, close knit team; open, friendly, relaxed atmosphere; small numbers of patients

with infrequent patient turnover; clear protocols or structured routines; minimal report writing or

sufficient time to write reports. Planning with mentors to achieve learning outcomes was seen as

helpful, as long as the mentor considered the student’s needs rather than setting tasks that were too

daunting or challenging (White, 2007). Adjustments that could be made by the student included use

of a note book to record difficult words/medication names, use a highlighter pen in patient notes;

use of a medical dictionary and calculator; use of a SMART pen and electronic paper for handovers

(Howlin et al, 2014b). Meanwhile, the undergraduate team could provide learning disability

awareness training; and additional practice time for clinical skills (Howlin et al, 2014b).

4.7.5 For mental health-related disability. For mental health related disability, for their own

part, students should continue with own self-care and medication use but no specific adjustments

were identified for the clinical practice area. (Howlin et al, 2014b). Other approaches could include

facilitation of Occupational Health and Disability Service referral and involvement with student;

encouraging the student to use counselling and mentorship services; initiation of programme

adjustment and extension of practice experience to allow time off when required; negotiation of

shift pattern with placement in order to avoid long shifts, allow later starts, and minimise night shift

requirements; initiation of a learning contract detailing weekly targets for achievement, and

subsequent use of the learning contract to enable development of levels of activity and

independence.(Tee et al, 2010).

4.7.6 Hearing impairment. For hearing impairment, possible technological adjustments

included special stethoscopes, hearing aids, adapted telephones, beepers that vibrate, audiotape

recorders (Maheady 1999; Watson, 1995); adjustment of the degree of telephone work, and

provision of a quiet office (Reeser, 1992); facilitation of Occupational Health and Disability Services

referral and involvement with student; liaison with DS to ensure implementation of recommended

adjustments and effectiveness of equipment subsequently supplied; advising mentor on practical

issues such as allowing the student to sit/stand facing the person speaking in hand over/wards

rounds; considering the level of background noise when explaining and teaching procedures to the

student; and ensuring that the student is allocated patients whose care they are responsible for to

encourage them to identify care needs independently and develop their initiative. (Tee et al, 2010).

20

4.7.7 Visual impairment and physical disability. For visually impaired physical accessibility,

adjustments could include provision of magnified print (Watson, 1995) and consideration of public

transport availability (Reeser, 1992). The latter should also be considered for those with a physical

disability, and other practical adjustments could include provision of a parking spot, with any gates

always open on arrival, an electronic pad to open doors (Maheady 1999; Reeser, 1992); and

provision of lifting assistance (Watson, 1995). It was considered important by field directors to

consider physical accessibility, specifically that work involving transitions between floors/storeys or

involving home visits might be unsuitable for people with a physical disability (Reeser, 1992)

4.7.8 Dyspraxia. Students with dyspraxia were thought to be helped through supervised

practice and organised repetition of identified skills; provision of a strict timeframe for progression

from participation to initiation and management of care; use of notebook and handover sheet to

plan care; the student and mentor agreeing a shift rota every week and clarifying expectations about

the time and place of the next shift at the end of each shift; provision of ‘prioritisation and planning’

skills rehearsal away from practice area with the disability team (Tee et al, 2010).

4.8 Student-Centred Reasonable Adjustment Model

Based on our framework analysis we constructed a model (see Figure 2) which represents our

attempt to diagrammatize the stakeholders (green) and processes (black) involved in successful

approaches to reasonable adjustments together with the values and assumptions that are reported

to have driven those approaches. In addition the relationships (grey) required between stakeholders,

and the specific conditions for which a range of reasonable adjustments might be made are

included. The aim of the model is largely as an aide memoire to those working with students with

specific disabilities (blue).

5. DISCUSSION AND CONCLUSIONS

We have systematically identified, appraised, and integrated the empirical evidence about

supporting healthcare students in practice by making reasonable adjustments in clinical practice

placement settings. The studies identified were all descriptive in nature, including qualitative,

quantitative and case-study designs, and, while the power of this evidence may be questioned, it

does capture a deal of expertise from student, placement, and HEI stakeholder perspectives about

the issues and processes involved in identifying the need for, and supporting those students who

need reasonable adjustments. At the same time, the integrated body of work can only be said to

22

represent an amalgamation of descriptive level evidence and, as a result, recommendations made do not

represent best-practice as established through trial methodology.

5.1 Summary of main findings

Research into the provision of reasonable adjustments for healthcare students is in its infancy. Given that

specific legislation to require such adjustments to be made was only enacted in 2010 this is perhaps

unsurprising. Developments thus far have been in pockets; however, we imagine that many of the innovations

described in papers in the current review have been implemented elsewhere since we are aware of this from

our own contacts with clinical placement settings. While this is welcome, it is important that good practices are

shared nationally and even internationally to ensure equality of access to opportunities for students with a

disability so that they may participate in the widest possible range of practice settings. Spreading good practice

would assist those working as mentors and managers in clinical services to think in the broadest possible terms

about their own practice setting and how it might be reasonably modified procedurally, environmentally, or in

other practical ways to further aims of equality of access. The limited amount of available research has usefully

explored what those with disabilities find helpful, and how university faculty and practice mentors have

achieved advances. The contribution of the current report is to have systematically identified and appraised the

literature and to integrate findings to produce a matrix describing what various stakeholders can contribute

prior to, during and following a clinical placement that has been reported as helpful in empirical literature. This

integration leads us to make a number of recommendations which we list in the final section.

5.2 Strengths and limitations

As with any review the strengths lie ultimately in the quality and depth of the original research. The inherent

limitation is the volume and quality of the existing research in this area. The absence of trial studies means that

we cannot make conclusions about the robustness of concepts identified from a psychometric perspective.

Neither can the current review answer with great confidence questions regarding the relative appraisal of

different means of adjustment due to the lack of accurate measures used. Despite the range of assessed quality

of the included papers we have not excluded any findings from the integration of results, since an inclusionary

approach seemed warranted at this stage. While this retains the virtue of comprehensiveness it further adds to

our inability to discriminate between good or poor, or best and good, practices. Since what is described is what

has been interpreted by researchers as 'good' or 'helpful' interventions we think it is correct to take this at face

value. However, in making recommendations we are aware that the weight of evidence for some adjustments

falls short of pronouncing that mentors, university faculty, and students themselves must or should act in some

prescribed way. Nevertheless, the current review is systematic, includes studies of all healthcare professions

rather than focusing on one narrow group, includes studies from the perspective of anyone involved whether

student, mentor, or tutor, and cast its net across the whole of the relevant worldwide empirical literature.

23

5.3 Future research priorities

Potential future projects could include a national and representative survey of practice relating to making

reasonable adjustments, including respondents from HEIs, practice, students, and patients/service users.

Second, further development of models of best practice is required, for example utilising Delphi methodology to

establish consensus. These models could be operationalised and manualised, implemented, and subject to

rigorous evaluation from multiple perspectives including student outcome, economic, and other. In order to

achieve this it will be necessary to develop appropriate outcomes measures to capture views from service,

student, mentor, and HEI perspectives. Further information is required about the full range of conditions for

which reasonable adjustments are made in practice. Finally, the paucity of prevalence data regarding disability

in the healthcare professions also suggests potentially fruitful lines of activity and enquiry looking ahead.

5.4 Recommendations

Based on the current position, nursing and other healthcare professions run the risk of developing a skew in the

evidence base on disabilities and reasonable adjustments based on what appears to be a relatively high level of

‘neuro-diverse’ (Braihne, n.d.) entrants to undergraduate training. Such a skew would be at the expense of

those affected by other disabilities and arguably contribute to a more fundamental challenge facing the

profession. With relatively little known about the nature and extent of disabilities in the professions there is

considerable scope to improve understanding and awareness at all levels with some specific goals in mind

including: improving awareness of diversity issues with a view towards the healthcare professions becoming a

professional group more representative of the people they serve; challenging the perception that nursing is not

a profession for people with disabilities; and prioritising areas of interest for further study. All of these

objectives are dependent on progress in the quality of the information we rely on going forward.

Despite the current climate there are examples of nurses with disabilities including deafness, amputation, and

chronic neurological problems necessitating the use of a mobility scooter practicing in diverse clinical areas

including high secure forensic care at Rampton Hospital, quality improvement in older adult care, and in

intermediate care in a Primary Care Trust setting (Hitchen, 2008). These and other examples should prompt

wider reflection about attitudes to disability, perhaps particularly because some healthcare professionals

become disabled over the course of, and possibly as a consequence of, their career. With this in mind the

professions' informed stance should reflect a position which promotes recovery and independence as well as

the requirements under the law. Accordingly, each student placement area should have access to a

policy/procedure for ensuring student needs are considered in relation to reasonable adjustments, and each HEI

should have policies/ procedure in place for ensuring student needs are considered in relation to reasonable

adjustments.

24

Table 1: Full text papers excluded (with reasons)

Author(s) Reason(s) for exclusion

Abraham 1988 Not about reasonable adjustments (flexible working arrangements)

Azzopardi et al. 2014 Not about clinical placements Bialocerkowski, Johnson et al. 2013 Focus on developments of inherent requirement standards for

physiotherapy trainees incorporating reasonable adjustments

Castles et al. 2014 Not about reasonable adjustments

Cawthon 2011 Not about health students (pre-university students)

Chetty 2013 Not about reasonable adjustments

Cole 1996 Not empirical research (discussion article)

Davies 2012 Not about health students (pre-university students)

Dupler, Allen et al. 2012 Not empirical research (Discussion of legal aspects)

Evans 2014 Not about reasonable adjustments

Evans 2015 Not empirical research (discussion article)

Gibson 2009 Not about reasonable adjustments for students / staff

Hadjikakou & Hartas 2008 Not about health students (higher education - any subjects) Hashim & Saodah 2014 Includes health/social care organisations but does not report

this separately

Helms, Weiler 1993 Not empirical research (Discussion in legal context)

Holley et al. 2015 Not about reasonable adjustments Ingram 1997 Main focus on "essential functions" that must be achieved by

physiotherapists in training with or without reasonable adjustments

Janus 2009 Not about reasonable adjustments

Kirk & Payne 2012 Not empirical research

Kloss 2008 Not empirical research (editorial)

Konur 2002 Not empirical research (article)

Kornblau 1995 Not empirical research (discussion article)

MacArthur et al. 2015 Not about reasonable adjustments for students / staff

Markiewicz 2012 Not empirical research (article) Neely-Barnes et al. 2014 Not empirical research (Case examples and discussion in legal

context) Olkin 2005 Not empirical research (Discussion about supporting

psychology graduates)

Paton 2003 Not empirical research (article)

Punch et al. 2007 Not about health students (higher education - any subjects)

Roberts 2010 Not empirical research (Discussion of supporting people with ASD)

Roberts et al. 2011 Not about reasonable adjustments

Sanderson-Mann 2005 Not empirical research (discussion article)

Sharby, Roush 2009 Not empirical research (discussion article)

Taylor 2004 Not about health students (pre-university students) Taube, Olkin 2011 Not empirical research (discussion of self-disclosure by

trainees)

Van Dusen 2001 Not empirical research (discussion article)

van Hoorebeek 2009 Not about health students (higher education any students)

Wilkie 2012 Not about health students (pre-university students)

Wray et al. 2013 Not about clinical placements

25

Table 2: Quantitative studies quality assessment

Study

Exp

licit a

ims

Sam

ple

siz

e

jus

tificatio

n

Researc

h

ind

ep

en

de

nt o

f ro

utin

e p

ractis

e

Well d

escrib

ed

sam

ple

Rep

resen

tativ

e

sam

ple

Exp

licit in

clu

sio

n/

exclu

sio

n c

riteria

Hig

h re

sp

on

se ra

te

(50%

+)

Qu

estio

nn

aire

d

evelo

pm

en

t

de

scrib

ed

Valid

ity a

nd

re

liab

ility ju

stifie

d

Qu

estio

n w

ord

ing

availa

ble

Dis

cu

ssio

n o

f g

en

era

lisab

ility

Sta

tem

en

t of

fun

din

g s

ou

rce

To

tal S

co

re (m

ax.

12)

Nolan 2015 + + + + - + - + - + + - 8

Solan & Heiberger 1995 - + + - + + + - - + - - 6

Watson 1995 - + + + - + + + - + - - 7

26

Table 3: Critical appraisal of qualitative studies

Exp

licit a

ims

Qu

alita

tive m

eth

od

ap

pro

pria

te

Desig

n a

pp

rop

riate

Recru

itmen

t

stra

teg

y

ap

pro

pria

te

Settin

g o

f da

ta

co

llectio

n

d

escrib

ed

Data

co

llectio

n

m

eth

od

s c

lear

Qu

estio

ns

/ sch

ed

ule

in

clu

de

d

Eth

ics d

iscu

ssed

Co

ns

en

t dis

cu

ssed

Descrip

tion

of

an

aly

sis

Rela

tion

sh

ip

co

ns

ide

red

Cle

ar s

tate

men

t of

fin

din

gs

Cla

rity o

f the

mes

Researc

h v

alu

ab

le

To

tal s

co

re

Ma

xim

um

14

Howlin at al

2014b

+ + + + + + + + + + + + + + 14

Morris &

Turnbull 2006

+ + + + + + + + + + - - + + 12

Reeser (1992) + + + + + + + - - - - + + + 10

Ridley 2011 + + + - - + + + + - - + + + 10

Tee & Cowen

2012

+ + - - - - - + - - - - - - 3

Tee et al. 2010 + + + - - - - + + - - - + + 7

White 2007 + + + - - + - - - - - - + + 6

27

Table 4: Critical appraisal of mixed method studies

Mixed methods Quantitative Qualitative Integration

Exp

licit a

ims

Mix

ed

meth

od

de

sig

n

ap

pro

pria

te

Mix

ed

meth

od

de

sig

n

jus

tified

Desig

n fo

r mix

ing

meth

od

s

de

scrib

ed

Ro

le c

lear

Me

tho

d d

escrib

ed

Me

tho

d a

pp

rop

riate

Rep

resen

tativ

e s

am

ple

Cle

ar in

clu

sio

n/ e

xclu

sio

n

crite

ria

Ro

le c

lear

Me

tho

d d

escrib

ed

Me

tho

d a

pp

rop

riate

Recru

itmen

t stra

teg

y

ap

pro

pria

te

Rela

tion

sh

ip w

ith th

e d

ata

co

ns

ide

red

Inte

gra

tion

of d

ata

rele

van

t

Co

ns

ide

ratio

n o

f limita

tion

s

of in

teg

ratio

n

To

tal s

co

re

Ma

xim

um

16

Cook et al. 2012) + + + - + + + - + + + + + - - - 11

28

Table 5: Critical appraisal of case studies

Exp

licit a

ims / c

learly

foc

used

qu

estio

n

Case s

tud

y

ap

pro

pria

te

Desig

n a

pp

rop

riate

Recru

itmen

t stra

teg

y

ap

pro

pria

te

Data

co

llectio

n

meth

od

s c

lear

Descrip

tion

of

an

aly

sis

Eth

ics d

iscu

ssed

Co

ns

en

t dis

cu

ssed

Tria

ng

ula

tion

Rela

tion

sh

ip

co

ns

ide

red

Resu

lts re

levan

t for

pra

ctic

e

Co

nc

lus

ion

s ju

stifie

d

by

resu

lts

Tra

ns

fera

ble

find

ing

s

Researc

h v

alu

ab

le

To

tal s

co

re

Ma

xim

um

14

Ashcroft et al.

2008 + + + n/a - - - - - - + - + + 6

Griffiths et al.

2010

+ + + - - - + + - - + + + + 9

Howlin et al

2014a + + + - - - - - - - + + - + 6

Maheady 1999 + + + - + + - + + - + + + + 11

Wright &

Eathorne 2003 - + - - - - - - - - + + - - 3

29

Table 6: Characteristics of included studies

Authors Title Country & setting

Aims / objectives Sample Disability / condition

Design / data collection

Instrument

Ashcroft, et al. 2008

Nursing Students with Disabilities: One Faculty’s Journey

Canada. University

To describe the actions of a nursing faculty working with nursing students with disabilities

N unknown. University of Manitoba Nursing Faculty

Disabilities Case study n/a

Cook, et al. 2012

Supporting students with disability and health issues: lowering the social barriers

UK. Medical school

Evaluation of two 'student support card' schemes for students with disabilities

N=37 (n=31 medical students [questionnaire] n=6 medical students [interviews])

Disability and health issues

Mixed methods / questionnaire and semi-structure interviews

Questionnaire with quantitative and qualitative items

Griffiths et al. 2010

Supporting disabled students in practice: A tripartite approach

UK. University

To describe and demonstrate a six-phase, tripartite model that provides a supportive framework for disabled student nurses in the practice environment The aims of the model are to: 1. Extend support provided for disabled students to encompass practice. 2. Design a tripartite proactive working arrangement between the university, practice partners and students. 3. Establish a working policy for practice that incorporates the identification of appropriate support for disabled students. 4. Develop a valid and reliable system to plan, implement and evaluate practice support provided for disabled students.

N=1 nursing student with Myalgic Encephalopathy

Disabilities Case study n/a

30

Table 6 continued

Authors Title Country Aims / objectives Sample Disability / condition


Instrument

Howlin et al. 2014a

Development and implementation of a clinical needs assessment to support nursing and midwifery students with a disability in clinical practice: Part 1

Ireland. University

To develop and implement a Clinical Needs Assessment designed to identify the necessary supports or reasonable accommodations for nursing and midwifery students with a disability undertaking work placements in clinical practice.

Consultation with expert advocacy groups and disability services within the university

Disabilities Literature/ policy reviews and consultation on a clinical needs assessment

n/a

Howlin et al. 2014b

Evaluation of a clinical needs assessment and exploration of the associated supports for students with a disability in clinical practice: Part 2

Ireland. University

To evaluate a clinical needs assessment for students with a disability and explore their experiences of support in clinical practice.

N=4 undergraduate students

n=3 dyslexia; n=1 mental health

Semi-structured interview

‘Tell me about your experience of support received in relation to your disability while on clinical placement?’

Maheady 1999

Jumping through hoops, walking on eggshells: The experiences of nursing students with disabilities

USA. Universities / clinical settings

To describe the experiences of nursing students with disabilities

N=71(n=10 undergraduate/ graduate/ recently graduated nursing students with disabilities, n=61 nursing faculty, staff nurses, patients and fellow students)

Disabilities Qualitative multiple case study design / Interviews, observations, document review

n/a

31

Table 6 continued Authors Title Country Aims / objectives Sample Disability /

condition Design / data collection

Instrument

Morris & Turnbull 2006

Clinical experiences of students with dyslexia

UK. University

To explore the clinical experiences of student nurses with dyslexia and its potential influence on their practice

N=18 nursing students with dyslexia

Dyslexia Semi-structured interviews

n/a

Nolan et al. 2015

Higher education students registered with disability services and practice educators: issues and concerns for professional placements

Ireland. University

To identify the issues and concerns of practice educators in both supporting students with disabilities and exploring the concerns for students with disabilities on professional courses.

N=68 practice educators and N=63 students with disabilities (Education, Social Work, Speech and Language Therapy, Deaf Studies, Human Nutrition, Dentistry, Medicine, Nursing, Occupational Therapy, Physiotherapy, Radiation Therapy

Specific Learning Difficulties, Significant Ongoing Illness, Mental Health Difficulties

Questionnaire survey

Two purpose-designed questionnaires (student version, educator version)

32



Instrument

Reeser 1992

Students with disabilities in practicum: What is reasonable accommodation?

US. School of social work

What can and do schools and agencies do to prepare, place, and facilitate students with disabilities in practicum, and what can students do for themselves?

N=10 students and N=4 former students with disabilities from two schools of social work and N=12 field directors from accredited social work programs

Blind, hearing impaired, ambulatorily disabled, neurologically disabled

Semi-structured interviews

Purpose-designed covering type(s) of field placement desired/ attained, expectations and considerations for placement, rejections for interviews and/or for placement, agency/field instructor experience with persons with disabilities, and advice for the school, the agency, and other students

Ridley 2011

The experiences of nursing students with dyslexia

UK. University

To explore the experiences of pre-registration nursing students with dyslexia at one university

N=7 nursing students (with dyslexia)

Dyslexia Semi-structured interviews

n/a

Solan, Heiberger 1995

The learning disabled optometry student: Compliance with Section 504 of the Rehabilitation Act of 1973

US. Optometry schools

To establish compliance with Section 504 requiring that educational institutions make reasonable accommodations in the classroom, clinic, and testing procedures.

N=15 Chief Student affairs Officers from optometry schools

Disabilities Questionnaire survey

Purpose-designed questionnaire

Table 6 continued

33



Instrument

Tee & Cowen 2012

Supporting students with disabilities Promoting understanding amongst mentors in practice

UK practice settings

To evaluate resources developed to help mentors working with students with disabilities

Nursing students. N unclear.

Disabilities Evaluative questionnaire

Open ended questionnaire

Tee et al. 2010

Being reasonable: Supporting disabled nursing students in practice

UK university and practice settings

To analyse recurring adjustments made in practice settings and the support strategies put in place to enable disabled students to achieve the levels of proficiency required on pre-registration nursing programmes

Referral data of N=27 pre-registration nursing students (2.3% of school population) meeting DDA criteria of disabled person

Disabilities Evaluative case study design using: Progression data Individual interviews Reflective accounts

n/a

Watson 1995

Nursing students with disabilities: A survey of baccalaureate nursing programs

US universities

To determine the responses and reactions of nursing program respondents to applicants and students with disabilities.

N=247 nursing programmes

Disabilities Questionnaire survey

Nursing Students With Disability/Special Needs Questionnaire was developed by the investigator to elicit factual information from baccalaureate nursing programs.

Table 6 continued

34



Instrument

White 2007

Supporting nursing students with dyslexia in clinical practice

UK. University

To determine whether pre-registration nursing students with dyslexia experience specific problems in developing clinical competence, identify what strategies they use and how they may be supported in clinical practice

Stage 1: n= 8 admissions lecturers, n=3 learning needs support officers, n=7 nursing students with dyslexia n= 9 clinical mentors Stage 2: n=4 nursing students with dyslexia, n=9 clinical mentors

Dyslexia Stage 1: Semi-structured interviews; postal questionnaires Stage 2: Longitudinal study / interviews

n/a

Wright & Eathorne 2003

Supporting students with disabilities

UK. University

To consider how healthcare applicants with disability can be supported in the clinical environment

Two workshops. N unclear. Designation of attendees unclear.

Disabilities Two workshops n/a

Table 6 continued

35

Table 7: Study results and implications for practice

Authors Results Implications for practice

Ashcroft et al. 2008

Students meet individually with clinical course leaders at the start of the course to discuss the course objectives, placements, and learning activities to allow them to identify accommodations, strategies, and resources that may help students to complete the course.

Meeting with students prior to clinical placements may allow reasonable adjustments to be put in place before the placement.

Cook et al. 2012 Provision of an individualised student support card, detailing the disability and necessary adjustments gave credibility to requests for reasonable adjustments, particularly in clinical settings and OSCEs.

A formal but discrete method of detailing and communicating disabilities and reasonable adjustments may be useful in supporting students on clinical placement.

Griffiths et al. 2010

‘… adjustment(s) should support a student to provide safe and effective practice’ Phases of the model: 1. Disclosure: identifying and assessing need(s) 2. Establishing support systems and processes in practice 3. Mid-placement review; determine alternative strategies 4. Development of detailed plans and models of support; establish critical information base 5. End of placement review; evaluation 6. Revise support strategy Relies on engagement of the practice team, practice partners and the disability service, all working student-centrically.

Following a systematic model, that is flexible and which can be tailored to individual needs, means that students with disabilities can be prepared for clinical practice placements.

36

Table 7: continued


Howlin et al 2014a Literature suggests that disclosure by students of a disability is viewed as a high risk strategy that could affect progression, training, and employment. Legislation requires reasonable accommodations in clinical practice. A clinical needs assessment was devised based on literature and consultation to support disclosure and reasonable accommodations. Acknowledges replacement of statutory requirements for 'good health' or 'fitness' with professional competence and conduct standards to achieve protection of the public and inclusion of people with a disability.

A Clinical Needs Assessment (CNA) is proposed based on domains of competence and containing background information; questionnaire to assist a detailed history of the individuals' disability; presence/absence of any aggravating factors and a list of reasonable adjustments outlining the responsibilities of the University, clinical site and student. Process of CNA: 1. Students with an academic/examination needs assessment and registered with disability services invited to meet a member of Disability Learning Team to discuss and agree reasonable adjustments for forthcoming clinical placements. Requested to bring any supporting information, letters, reports etc. 2. Role of DLT and purpose of CNA explained; focus on individual student needs and identification of strategies used successfully in other settings. Reasonableness defined as practical effective measures that do not cause excessive cost or disruption to the placement or employer. 3. Examples of supports: assistive technology pens, speaking medical dictionaries, adjusted shift patterns, additional support in form of a mentor. These may require revision to ensure they remain suitable throughout the program. 4. Disclosure of information about the individual’s disability in the CNA is discussed with the student. Success of adjustments is dependent on disclosure to make relevant persons aware. Student has a legal right to non-disclosure except for issues of patient safety which contravene the right. Consent/non-consent provided in writing by the student. 5. Student invited to liaise with Clinical Contact Person to discuss their reasonable accommodations.

37

Table 7: continued


Howlin et al 2014b All students disclosed disability on placement to an extent. Clinical needs assessment was used to highlight accommodations to clinical staff on placement. Issues raised included: communication (e.g., issues from clinical needs assessment not passed on to clinical staff), negative staff attitudes and need to improve provision of accommodations. Reasonable accommodations identified as the responsibility of the undergraduate team, the clinical area, or the student. For dyslexia, reasonable accommodations included: extra time for writing notes; additional checking of notes with preceptor; use of note book to record difficult words/medications; time to write down telephone information; additional support for organisation and management of patient care; demonstrate nursing skills rather than explaining verbally to the student; provide written information on skill in advance; template for nursing handovers;; provide list of common abbreviations; additional check of calculation for medicines/fluids; provide pre-placement visit; extra time to read patient notes [clinical area]; use a highlighter pen in patient notes; use a medical dictionary; use a calculator; use SMART pen and electronic paper for handovers [student]; provide learning disability awareness; additional practice time for clinical skills (undergraduate team). For mental health, continue with own self-care and medication use (student). No accommodation identified for clinical practice area.

Clinical needs assessment 'bridges the gap' between HEIs and clinical placements. Disclosure is challenging and requires education for clinical staff and students, and preceptors to support student in practice by implementation of accommodations. Communication needed to ensure student has a positive experience of support. Regulatory bodies need to provide better guidance for all.

Maheady 1999 Technological accommodations: Special stethoscopes, hearing aids, adapted telephones, beepers that vibrate, audiotape recorders Accommodations made in clinical settings: Participant in wheelchair was given parking spot, gates always open on arrival, ‘clicker’ for the doors

There are technological accommodations that may help students on clinical placement. However, the age of this study means that the technologies described may be outdated. Environmental considerations may be of benefit.

Morris & Turnbull

Helpful strategies on placement: Pre-prepared drug calculation tool Capital letters on drug charts and other patient documents

People with dyslexia and dyscalculia may need RAs to practice safely, particularly in relation to medication administration, so they need to be able to disclose in a supportive environment

38

Table 7 continued


Reeser 1992 Three themes: Field education expectations: students with disabilities are expected to meet the same educational standards and requirements. Students' expectations raise issues where making adjustments is discretionary. Perceived fine line between making adjustments and lowering educational standards. Adjustments may therefore be linked to viewing people with handicaps as less able and unqualified for their position. But advantages are that making adjustments may raise confidence in success, and facilitates a more representative workforce. Special considerations for students with different handicaps: willing field instructors required; support for people with learning disabilities in terms of secretarial/admin help; for hearing impaired students the degree of telephone work, quiet office; for blind or ambulatorily disabled students: physical accessibility, public transport availability. Generally accepted that for this group home visits were precluded and work that required fast transition from e.g. floor to floor. More demanding adjustments involved a student who was required to work in a pre-1950 constructed building without air conditioning and an agreement from staff that they would not use hairspray or cologne." Some people may not make competent social workers because of their handicaps". General considerations for students with disabilities:

Ridley 2011

Helpful strategies on placement included: Pre-prepared drug calculation tool Capital letters on drug charts and other patient documents

People with dyslexia and dyscalculia may need reasonable adjustments to practice safely, particularly in relation to medication administration. Therefore they need to be able to disclose issues in a supportive environment

Important to have a patient, approachable, flexible mentor on placement who understands dyslexia

Mentors with a knowledge of dyslexia, who students feel are approachable, can provide support for students on placement.

Tee & Cowen 2012

Using interactive learning for mentors may enhance their skills thereby improving the learning experience of students with disabilities.

Table 7 continued

39


Tee et al. 2010 Strategies employed to address adjustments: Student with dyslexia: Implement adaptations (e.g. coloured overlay) and monitor effectiveness Provide student with ways of structuring common tasks such as assessment e.g. using ABCDE and devising cue cards as an aid. Provide detailed learning contracts which structure learning into small manageable parts, and encourage repetition and sequencing, building from basic to complex. Student with dyspraxia: Supervised practice and organised repetition of identified skills Strict timeframe for progression from participation to initiation and management of care; Use of notebook and handover sheet to plan care; Student and mentor agreeing shift rota every week and clarifying expectations re time and place of next shift at the end of each shift; ‘Prioritisation and planning’ skills rehearsal away from practice area with SPLA.

There are some common support strategies across conditions that are useful for students with a range of disabilities, but there also need for individual packages to be in place.

Student with hearing impairment: Facilitate Occupational Health(OH) and Disability Services (DS)referral and involvement with student; Liaise with DS to ensure implementation of recommended adjustments and effectiveness of equipment subsequently supplied; Advise mentor on practical issues such as allowing the student to sit/stand facing the person speaking in hand over/wards rounds; Consider the level of background noise when explaining and teaching procedures to the student; Ensure student is allocated patients whose care they are responsible for to encourage them to identify care needs independently and develop their initiative. Student with 'mental impairment': Facilitate OH and DS referral and involvement with student; Encourage student to use Counselling and Mentorship services; Initiate programme adjustment and extension of practice experience to allow time off when required; – negotiate shift pattern with placement in order to: – avoid long shifts; – allow later starts; – minimise night shift requirements; Initiate a learning contract detailing weekly targets for achievement; Use learning contract to enable development of levels of activity and independence.

Table 7 continued

40


Tee et al 2010 continued Common support strategies for all students: Encourage student to visit placement prior to commencement to learn about the placement and be able to identify potential problems; Support students in disclosing issues affecting their practice learning; Ask mentors to schedule regular, honest and constructive feedback sessions; Encourage mentor and student to regularly assess learning needs, set objectives and use a learning contract; Advocate regular progress meetings with SPLA, student and mentor to facilitate feedback and revise learning objectives/ learning contract; Facilitate effective liaison between Ensure student is allocated patients whose care they are responsible for to encourage them to identify care needs independently and develop their initiative.

White 2007

Some clinical placements are more appropriate for students with dyslexia, some of the characteristics of such placements are: small, close knit teams; open, friendly, relaxed atmosphere; small numbers of patients with infrequent patient turnover; clear protocols or structured routines; minimal report writing or sufficient time to write reports. Planning with mentors to achieve learning outcomes was seen as helpful, as long as the mentor considered the student’s needs rather than setting tasks that were too daunting or challenging.

Students with dyslexia need to experience a range of clinical settings, but some may be more suitable than others. Mentors who are supportive of students with dyslexia will make the clinical setting a beneficial learning environment.

Wright & Eathorne 2003 There are a range of support mechanisms available for students on clinical placements including: encouraging students to disclose their disability in a non-discriminatory environment, listening to students (they are the experts on their learning needs) , provide clear instructions and expectations, and discuss how these can be met , ask the student to repeat or write down instructions or expectations where necessary , encourage the student to keep a book for notes , offer the opportunity for testing new skills before using with patients, make time to discuss new learning and ongoing practice , be flexible and innovative

Reasonable adjustments can be made for students in various ways.

41

Table 8: Example framework analysis of study results (coloured blocks refer to specific conditions, unshaded blocks to disability in general)

Pre-course Pre-Placement Placement Post-placement

Clinical practice environment and policy

Development of detailed policies/plans and models of support.

Provision of common technical fixes/solutions in clinical practice area (e.g., special stethoscopes, hearing aids, adapted telephones, beepers that vibrate, audiotape recorders*). Access issues in surrounding areas (e.g., ‘clicker’ for doors), parking (e.g., for students with mobility problems).

Monitor effectiveness of technical solutions.

Review

Dyslexia/Dyscalculia

Issues related to medication administration are particularly important. Helpful strategies on placement included: Pre-prepared drug calculation tool; Capital letters on drug charts and other patient documents; Coloured overlay for drug charts.

Provide student with ways of structuring common tasks such as assessment e.g. using ABCDE (Airways, Breathing, Circulation, Disability, and Exposure) approach and devising cue cards as an aid. Provide detailed learning contracts which structure learning into small manageable parts, and encourage repetition and sequencing, building from basic to complex.

Tutor/ HEI Students to meet individually with course leaders prior to the course to discuss objectives, placements, and learning activities to allow them to identify accommodations, strategies, and resources that may help them to complete the course.

Provision of an individualised student support card, detailing the disability and necessary adjustments lends credibility to requests for reasonable adjustments, particularly in clinical settings and Observed Structured Clinical Examinations. A formal but discrete method of detailing and communicating disabilities and reasonable adjustments may be useful in supporting students on clinical placement.

Listen to students as experts about their own learning needs.

Encourage student to visit placement prior to commencement to learn about the placement and to identify potential problems.

Facilitate Occupational Health (OH) and Disability Services referral and involvement with student.

Liaise with Disability Services to ensure implementation of recommended adjustments and effectiveness of equipment subsequently supplied.

Support students in disclosing issues affecting their practice learning. Ask mentors to schedule regular, honest and constructive feedback sessions. Encourage mentor and student to regularly assess learning needs, set objectives and use a learning contract.

Ask mentors to schedule regular, honest and constructive feedback sessions;

Encourage mentor and student to regularly assess learning needs, set objectives and use a learning contract.

Advocate regular progress meetings with SPLA, student and mentor to facilitate feedback and revise learning objectives/ learning contract.

Advocate regular progress meetings with student, mentor, and practice education facilitator (or equivalent) to facilitate feedback and revise learning objectives/ learning contract.

Review

42


Tutor/ HEI continued

Hearing impairment

Advise mentor on practical issues such as allowing the student to sit/stand facing the person speaking in hand over/wards rounds

Student Meet individually with clinical course leaders at the start of the course to discuss the course objectives, placements, and learning activities to identify accommodations, strategies, and resources that may help students to complete the course.

Communicate disability-related learning needs if able to do so. Contribute to e.g., an individualised student support card, detailing the individual’s disability and necessary adjustments

Visit placement prior to commencement to learn about the placement and be able to identify potential problems

Engage in Occupational Health and Disability Services referral and involvement

Dyspraxia

Use of notebook and handover sheet to plan care.

Supervised practice and organised repetition of identified skills.

End of placement review; evaluation and revise support strategy

Mentor Mentor training

Using interactive learning for mentors may enhance their skills thereby improving the learning experience of students with disabilities. Reasonable adjustments mentors became more familiar with include:

Ways of helping students to structure info. e.g., cue cards

Coloured overlays

Tailored notebooks

Additional skills rehearsal

Organising seating arrangements in meetings

Negotiating shift patterns

Supporting disclosure

Meeting with students prior to clinical placements may allow reasonable adjustments to be put in place before the placement

Support disclosure of disability/need

Listening to students as experts on their learning needs

Ensure student is allocated patients whose care they are responsible for to encourage them to identify care needs independently and develop their initiative

Provide clear instructions and expectations, and discuss how these can be met , ask the student to repeat or write down instructions or expectations where necessary; encourage the student to keep a book for notes; offer the opportunity for testing new skills before using with patients; make time to discuss new learning and ongoing practice; be flexible and innovative

Mid-placement review; determine alternative strategies. End of placement review; evaluation and revise support strategy. Support disclosure of disability/need. Listening to students as experts on their learning needs

End of placement review; evaluation and revise support strategy

43


Mentor continued

Dyslexia/ Dyscalculia Important to have a patient, approachable, flexible, and supportive mentor on placement who understands dyslexia Mentors who are supportive of students with dyslexia will make the clinical setting a beneficial learning environment. Planning with mentors to achieve learning outcomes was seen as helpful, as long as the mentor considered the student’s needs rather than setting tasks that were too daunting or challenging.

Review

Dyspraxia Structured timeframe for progression from participation to initiation and management of care.

Student and mentor agreeing shift rota every week and clarifying expectations re time and place of next shift at the end of each shift.

Hearing impairment Consider the level of background noise when explaining and teaching procedures to the student;

Ensure student is allocated patients whose care they are responsible for to encourage them to identify care needs independently and develop their initiative.

Mental impairment Encourage student to use Counselling and Mentorship services;

Initiate programme adjustment and extension of practice experience to allow time off when required.

Negotiate shift pattern in order to: avoid long shifts; allow later starts; minimise night shift requirements.

*N.B. from 1996 paper. Currently available technical fixes may be more advanced.

Dyslexia/Dyscalculia Dyspraxia Hearing impairment Mental impairment

44

6. REFERENCES (* Denotes paper included in the integrated review)

ABRAHAM, K.G. 1988. Flexible Staffing Arrangements and Employers' Short-Term Adjustment Strategies. Cambridge, United States, Cambridge: National Bureau of Economic Research, Inc.

*ASHCROFT, T., CHERNOMAS, W.M., DAVIS, P.L. and SWIDERSKI, L.M. 2008. Nursing students with disabilities: One faculty's journey. International Journal of Nursing Education Scholarship, 5(1), 1-15.

AZZOPARDI, T., JOHNSON, A., PHILLIPS, K., DICKSON, C., HENGSTBERGER-SIMS, C., GOLDSMITH, M. and ALLAN, T. 2014. Simulation as a learning strategy: supporting undergraduate nursing students with disabilities. Journal of Clinical Nursing, 23(3), 402-409.

BIALOCERKOWSKI, A., JOHNSON, A., ALLAN, T., and PHILLIPS, K., 2013. Development of physiotherapy inherent requirement statements - An Australian experience. BMC Medical Education, 13(1).

BRAINHE n.d. http://brainhe.com/index.html [Accessed 18th March 2016]

CASTLES, A., BAILEY, C., GATES, B. and SOOBEN, R. 2014. Experiences of the implementation of a learning disability nursing liaison service within an acute hospital setting: a service evaluation. British Journal of Learning Disabilities, 42(4), 272-281.

CAWTHON, S. 2011. Test item linguistic complexity and assessments for deaf students. American Annals of the Deaf, 156(3), 255-269.

CHETTY, L. 2013. The role of physiotherapy in occupational health rehabilitation: A review of the literature. Indian Journal of Physiotherapy and Occupational Therapy, 7(4), 118-122.

COLE, B.S. and CAIN, M.W., 1996. Social work students with disabilities: A proactive approach to accommodation. Journal of Social Work Education, 32(3), 339-349.

*COOK, V., GRIFFIN, A., HAYDEN, S., HINSON, J. and RAVEN, P. 2012. Supporting students with disability and health issues: lowering the social barriers. Medical Education, 46(6), 564-574.

CRITICAL APPRAISAL SKILLS PROGRAMME 2013. 10 questions to help you make sense of a review. Available http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf [Accessed 19th June 2016].

DAVIES, M. 2012. Accessibility to NAPLAN assessments for students with disabilities: A 'fair go'. The Australasian Journal of Special Education, 36(1), pp. 62-78.

DEPARTMENT FOR WORK AND PENSIONS AND OFFICE FOR DISABILIY ISSUES, 2014. Official statistics: Disability facts and figures. Available: https://www.gov.uk/government/publications/disability-facts-and-figures/disability-facts-and-figures (Accessed 19th June 2016).

DISABILITY RIGHTS COMISSION. 2007. Report of a DRC formal investigation Maintaining Standards: Promoting Equality Professional regulation within nursing, teaching and social work and disabled people’s access to these professions. London: Disability Rights Commission 2007. Available from: http://www.equalityhumanrights.com/sites/default/files/documents/Education/maintaining_standards_summary_report.pdf [Accessed 5 February 2016].

45

DUPLER, A.E., ALLEN, C., MAHEADY, D.C., FLEMING, S.E., and ALLEN, M., 2012. Levelling the playing field for nursing students with disabilities: Implications of the Amendments to the Americans with Disabilities Act. Journal of Nursing Education, 51(3), 140-144.

EQUALITY AND HUMAN RIGHTS COMMISSION 2010. Equality Act guidance and information. Available: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/85010/disability-definition.pdfAccessed 19th June 2016].

EVANS, W. 2015. Disclosing a dyslexic identity. British Journal of Nursing, 24(7), 383.

EVANS, W., 2014. "If they can't tell the difference between duphalac and digoxin you've got patient safety issues". Nurse Lecturers' constructions of students' dyslexic identities in nurse education. Nurse Education Today, 34(6), e41-46.

GIBSON, T. 2009. People with learning disabilities in mental health settings. Mental Health Practice, 12(7), pp. 30-33.

GREENHALGH, T., 2006. How to read a paper: The basics of evidence based medicine. Blackwell, Malden, MA.

*GRIFFITHS, L., WORTH, P., SCULLARD, Z. and GILBERT, D. 2010. Supporting disabled students in practice: a tripartite approach. Nurse Education in Practice, 10(3), 132-137.

HADJIKAKOU, K. and HARTAS, D. 2008. Higher education provision for students with disabilities in Cyprus. Higher Education, 55(1), 103-119.

HASHIM, J. and SAODAH, W. 2014. Predictors to employees with disabilities' organisational behaviour and involvement in employment. Equality, Diversity and Inclusion: An International Journal, 33(2), 193-209.

HELMS, L.B. and WEILER, K., 1993. Disability discrimination in nursing education: An evaluation of legislation and litigation. Journal of Professional Nursing, 9(6), 358-366.

HITCHIN, L. 2008. Nursing with a disability Nursing Times [online] Available from: http://www.nursingtimes.net/nursing-with-a-disability/1432744.fullarticle [Accessed 5 February 2016].

HOLLEY, J., GILLARD, S. and GIBSON, S. 2015. Peer worker roles and risk in mental health services: A qualitative comparative case study. Community Mental Health Journal, 51(4), 477-490.

*HOWLIN, F., HALLIGAN, P., and O'TOOLE, S., 2014a. Development and implementation of a clinical needs assessment to support nursing and midwifery students with a disability in clinical practice: Part 1. Nurse Education in Practice, 14(5), 557-564.

*HOWLIN, F., HALLIGAN, P., and O'TOOLE, S., 2014b. Evaluation of a clinical needs assessment and exploration of the associated supports for students with a disability in clinical practice: Part 2. Nurse Education in Practice, 14(5), 565-572.

INGRAM, D., 1997. Opinions of physical therapy education program directors on essential functions. Physical Therapy, 77(1), 37-45.

JANUS, A.L. 2009. Disability and the transition to adulthood. Social Forces, 88(1), 99-120.

46

KIRK, K. and PAYNE, B. 2012. Dyscalculia: awareness and student support. Nursing Times, 108(37), 16-18.

KLOSS, D. 2008. Maintaining standards: promoting equality. Occupational Medicine, 58(4), 231-233.

KONUR, O. 2002. Access to nursing education by disabled students: rights and duties of nursing programs. Nurse Education Today, 22(5), 364-374.

KORNBLAU, B.L., 1995. Fieldwork education and students with disabilities: enter the Americans With Disabilities Act. The American Journal of Occupational Therapy: Official Publication of the American Occupational Therapy Association 49(2), 139-145.

MACARTHUR, J., BROWN, M., MCKECHANIE, A., MACK, S., HAYES, M. and FLETCHER, J. 2015. Making reasonable and achievable adjustments: the contributions of learning disability liaison nurses in 'Getting it right' for people with learning disabilities receiving general hospitals care. Journal of Advanced Nursing, 71(7), 1552-1563.

*MAHEADY, D., 1999. Jumping through hoops, walking on eggshells: The experiences of nursing students with disabilities. Journal of Nursing Education, 38, 162-170.

MARKIEWICZ, D., 2012. Is it safe for pregnant workers? Industrial Safety and Hygiene News, 46(6), 24-25.

MOHER, D., LIBERATI, A., TETZLAFF, J. and ALTMAN, D.G., 2009. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLOS Medicine, 6(7), e1000097. Doi: 10.1371/journal.pmed.1000097

*MORRIS, D. and TURNBULL, P. 2006. Clinical experiences of students with dyslexia. Journal of Advanced Nursing, 54(2), 238-247.

NATIONAL INSTITUTE FOR HEALTHCARE AND EXCELLENCE, 2012. Methods for the development of NICE public health guidance (third edition): Appendix H Quality appraisal checklist – qualitative studies. Available at: https://www.nice.org.uk/article/pmg4/chapter/appendix-h-quality-appraisal-checklist-qualitative-studies [Accessed 29th June 2016].

NEELY-BARNES, S.L., McCABE, H.A., and BARNES, C.P., 2014. Seven rules to live by: Accommodations in social work education and the field. Journal of Social Work in Disability and Rehabilitation, 13(4), 279-296.

NHS EDUCATION SCOTLAND. 2008. Quality standards for practice placements Revised 2008. 2008. Edinburgh: NHS Education for Scotland. Available from: http://www.legislation.gov.uk/ukpga/1995/50/contents [Accessed 5 February 2016].

NHS SCOTLAND. 2014. Setting the Direction for Nursing and Midwifery Education in Scotland. The strategic aims from the Chief Nursing Officer's Education Review. 2014. Edinburgh: NHS Scotland. Available from: http://www.legislation.gov.uk/ukpga/1995/50/contents [Accessed 5 February 2016].

*NOLAN, C., GLEESON, C., TREANOR, D. and MADIGAN, 2015. Higher education students registered with disability services and practice educators: Issues and concerns for professional placements. International Journal of Inclusive Education, 19 (5), 487-502, DOI: 10.1080/13603116.2014.943306

NURSING AND MIDWIFERY COUNCIL. 2013. The Nursing and Midwifery Council Equality and Diversity Annual Report April 2012-March 2013. London: Authors. Available from:

47

https://www.nmc.org.uk/globalassets/sitedocuments/eandd/eandd-annual-report-2012-2013.pdf [Accessed 5 February 2016].

NURSING AND MIDWIFERY COUNCIL. 2014. NMC Equality and Diversity Annual Report 1st April 2013 to 31 March 2014. 2015. London: Authors. Available from: https://www.nmc.org.uk/globalassets/sitedocuments/annual_reports_and_accounts/the-equality-and-diversity-annual-report---english-january-2015.pdf [Accessed 5 February 2016].

NURSING AND MIDWIFERY COUNCIL. 2015. NMC Equality and Diversity Annual Report 2014-2015. 2015. London: Authors. Available from: https://www.nmc.org.uk/globalassets/sitedocuments/annual_reports_and_accounts/equality-and-diversity-report-2014-2015.pdf [Accessed 5 February 2016].

O'CATHAIN, A., MURPHY, E., and NICHOLL, J., 2008. The quality of mixed methods studies in health services research. Journal of Health Services Research and Policy, 13(2), 92-98.

OLKIN, R., 2010. The three Rs of supervising graduate psychology students with disabilities: Reading, writing, and reasonable accommodations. Women and Therapy, 33(1-2), 73-84.

PATON, N. 2003. Access all areas? Occupational Health, 55(6), 14-16.

PLUYE, P., ROBERT, E., CARGO, M., BARTLETT G., O’CATHAIN, A., GRIFFITHS, F., BOARDMAN, F., GAGNON, M.P., and ROUSSEAU, M.C., 2011. Proposal: A mixed methods appraisal tool for systematic mixed studies reviews. Available at: http://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/fetch/84371689/MMAT%202011%20criteria%20and%20tutorial%202011-06-29updated2014.08.21.pdf [Accessed 19th June 2016).

PUNCH, R., HYDE, M. and POWER, D., 2007. Career and Workplace Experiences of Australian University Graduates Who Are Deaf or Hard of Hearing. Journal of Deaf Studies and Deaf Education, 12(4), pp. 504-17.

REESER, L.C. Students with disabilities in practicum: What is reasonable accommodation? Journal of Social Work Education. 28 (1), 98-109.

RIDDELL, S., EDWARD, S., WEEDON, E. and AHLGREN, L., 2010. Disability, Skills and Employment: A review of recent statistics and literature on policy and initiatives. 59. London: Equality and Human Rights Commission. Available from: http://www.equalityhumanrights.com/sites/default/files/documents/research/disability_skills_and_employment.pdf [Accessed 5 February 2016].

*RIDLEY, C. 2011. The experiences of nursing students with dyslexia. Nursing Standard, 25(24), 35-42.

RITCHIE, J. and LEWIS, J., 2003. Qualitative research practice: a guide for social science students and researchers. London: Sage

RIVA, J.J., MALIK, K.M.P., BURNIE, S.J., ENDICOTT, A.R., and BUSSE, J.W., 2012. What is your research question? An introduction to the PICOT format for clinicians. The Journal of the Canadian Chiropractice Association, 56(3), 167-171.

48

ROBERTS, K.D., 2010. Topic areas to consider when planning transition from high school to postsecondary education for students with autism spectrum disorders. Focus on Autism and Other Developmental Disabilities, 25(3), 158-162.

ROBERTS, R., BEADLE-BROWN, J. and YOUELL, D. 2011. Promoting social inclusion for children and adults on the autism spectrum - reflections on policy and practice. Tizard Learning Disability Review, 16(4), 45-52.

SANDERSON-MANN, J. and MCCANDLESS, F. 2005. Guidelines to the United Kingdom Disability Discrimination Act (DDA) 1995 and the Special Educational Needs and Disability Act (SENDA) 2001 with regard to nurse education and dyslexia. Nurse Education Today, 25(7), 542-549.

SHARBY, N. and ROUSH, S.E., 2009. Analytical decision-making model for addressing the needs of allied health students with disabilities. Journal of Allied Health, 38(1), 54-62.

SKILL. 2010. Consultation response: Draft standards for preregistration nursing. Skill Policy Team April 2010. Available from: http://www.legislation.gov.uk/ukpga/1995/50/contents [Accessed 5 February 2016].

*SOLAN, H.A. and HEIBERGER, M.H., 1995. The learning disabled optometry student: Compliance with section 504 of the rehabilitation act of 1973. Optometry and Vision Science, 72(5), 346-351.

STORR, H., WRAY, J. and DRAPER, P., 2011. Supporting disabled student nurses from registration to qualification: a review of the United Kingdom literature. Nurse Education Today, 31(8), 29-33.

TAUBE, D.O. and OLKIN, R., 2011. When is differential treatment discriminatory? Legal, ethical, and professional considerations for psychology trainees with disabilities. Rehabilitation Psychology, 56(4), 329-339.

TAYLOR, M. 2004. Widening participation into higher education for disabled students. Education and Training, 46(1), pp. 40-48.

*TEE, S. and COWEN, M. 2012. Supporting students with disabilities--promoting understanding amongst mentors in practice. Nurse Education in Practice, 12(1), 6-10.

*TEE, S.R., OWENS, K., PLOWRIGHT, S., RAMNATH, P., ROURKE, S., JAMES, C. and BAYLISS, J. 2010. Being reasonable: supporting disabled nursing students in practice. Nurse Education in Practice, 10(4), 216-221.

TONG, A., SAINSBURY, P., CRAIG, J., 2007. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. International Journal for Quality in Health Care, 19(6), 349-357.

VAN DUSEN, V., 2001. Students with disabilities: Implications for pharmaceutical education. American Journal of Pharmaceutical Education, 65(2), 144-149.

VAN HOOREBEEK, M. 2009. Analysing the parameters of the duty of reasonable adjustment to facilitate access to e-learning resources. Multicultural Education and Technology Journal, 3(3), 227-241.

*WATSON, P.G., 1995. Nursing students with disabilities: A survey of baccalaureate nursing programs. Journal of Professional Nursing, 11(3), 147-153.

49

*WHITE, J. 2007. Supporting nursing students with dyslexia in clinical practice. Nursing Standard, 21(19), 35-42.

WILKIE, K.J., 2012. 'Absence Makes the Heart Grow Fonder': Students With Chronic Illness Seeking Academic Continuity Through Interaction With Their Teachers at School. The Australasian Journal of Special Education, 36(1), 1-20.

WRAY, J., ASPLAND, J., TAGHZOUIT, J. and PACE, K., 2013. Making the nursing curriculum more inclusive for students with specific learning difficulties (SpLD): Embedding specialist study skills into a core module. Nurse Education Today, 33(6), 602.

*WRIGHT, D.J. and EATHORNE, V., 2003. Supporting students with disabilities. Nursing Standard, 18(11), 37-42.

Laws and Statutes

Disability Discrimination Act 1995. Available from: http://www.legislation.gov.uk/ukpga/1995/50/contents [Accessed 5 February 2016].

Equality Act 2010. Available from: http://www.legislation.gov.uk/ukpga/2010/15/contents [Accessed 5

February 2016].

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