Part I Our Students Chapter 1
Nursing Education for Students
with Disabilities:
Our Students, Our Teachers
Bronwynne C. Evans We have a student entering our program who is mature,
bright, and motivated. In [act, she has a degree in another
discipHne and has taught anatomy and physiology at the college level. She will be a wonder[ul nurse and, by the way,
she uses a wheelchair [or mobihty. lthough our Associate Dean for Academic Affairs delivered this
message in perfect faith that we stood ready for the challenge,
she rocked the Intercollegiate College of Nursing with her announcement. There was universal astonishment, and many faculty expressed concems about the safety of our new student, who was
paraplegic, in the clinical setting. Still, after the initial shock, most
declared themselves ready to participate in this innovative educational endeavor.
Others expressed continuing discomfort at the imminent arrival
of the student and questioned whether or not we were vacating our
responsibihties to health care consumers in Washington. Those faculty
played an important role in this story because they insisted that we
become informed about the Ameficans with Disabihties Act (ADA,
1990), university rules about accommodating students with disabilities,
and teaching strategies that would result in the education of a safe and
capable practitioner. Their discomfort was invaluable because it also A 4 OUR STUDENTS forced us to examine the role of a nurse and question the essential
requirements of our nursing program.
This chapter tells the story of that student, a woman named Victoria
(shown with her service dog. Maverick, in Figure 1.1), who is one of
the first people in the country to enter a baccalaureate nursing program
using a wheelchair, graduate successfully, and practice as a registered
nurse (RN). This chapter is a chronicle of my experience as an instructor
accompanying this nursing student into her first clinical rotation, and
is based on program records and the joumals of the student and myself. FIGURE 1.1 Victoria and her service dog. Maverick. NURSING EDUCATION FOR STUDENTS WITH DISABILITIES 5 written day-to-day as I supervised her experience. Victoria's story attests
to the need to understand the journey of nursing students who have
disabilities and those who teach them, and the support necessary from
administrators, peers, clinical staff, clients, and the nursing profession
to ease their journey. The issues raised have profound implications
for educators to reevaluate our traditional assumptions about nursing
education and the nursing profession. SHIFTING THE PERSPECTIVE: TEACHING A STUDENT
USING A WHEELCHAIR IN THE CLINICAL SETTING
Historically, nursing faculty have been less favorably disposed toward
students with disabilities than are beginning students, graduating students, and practicing nurses (Brillhart, Jay, & Wyers, 1990). However,
in a 1998 study (Christensen, 1998), faculty attitudes were generally
more positive than students or practicing nurses, but the less the faculty
contact, the more negative their attitudes. In the case of our school,
our experience was certainly limited, but we had robust administrative
support and a strong student with whom to blaze the trail.
Victoria self-disclosed and documented her disability, and produced
evidence that she was qualified for the nursing program in all areas.
Her inability to walk was viewed by both Vi(5toria and program administrators as incidental to the nurse's role. As this chapter will demonstrate,
however, Victoria was entering a profession in which little is known
about accommodation for students with disabilities, and where students
encounter challenging attitudinal as well as physical barriers to success
(Marks, 2000).
In an effort to better understand the complexities, doubts, and
successes in Victoria's clinical education, she and I each kept a journal
of our time together. Verbatim portions of my clinical journal, along
with selections from Victoria's journal, are used to shed light on the
experience of teaching a nursing student who uses a wheelchair. The
early days of my joumal reflect a growing understanding of the issues
in this educational endeavor:
' • \ m . ^ u : •• : • - • • • . •• <r' . Victoria came to my office to tell me she had requested my clinical group.
I have doubts about whether or not her body can stand the strain, just
as I did when I heard she was entering the program. Yet every student • 6 OUR STUDENTS -, . , / ,i . has the right to succeed and the right to fail and she is no exception, i ,^
My chief worry is that she will invest so much, yet he unsuccessful.
Although some instructors continue to resist her entrance to their
clinical rotations, she knows me from a didactic class and 1 know her. •'.•>'
She is mature, articulate, hright, courageous, and sensitive to others. She ,';!
also has a strong science background along with self-discipline, high
motivation, good organizational skills, and not least of all, her service
dog. Maverick. It's hard not to pet and interact with him, but I think I'm
not supposed to because he is a working dog.
••
It is clear to me that although 1 know the tenets of multicultural
education pretty well, 1 am a neophyte in the area of disabilities. I hope
I don't do too many clumsy things while I am learning. These excerpts from my journal reflect my uncertainty about what
lay ahead for us all, along with an appreciation of Victoria's intellectual
and emotional strengths grounded in our previous experiences. Although I welcomed this opportunity, 1 felt awkward in my role as
advocate in a situation that I did not yet completely understand. Learning Experientially
Faculty and staff in the learning lab were quite concerned about how
Victoria might adapt procedures to accommodate her limitations in
mobility. Looking back, the energy we expended in speculating on
possible adaptations was out of proportion to the difficulties actually
encountered in clinical agencies. However, this exercise helped us begin
to think in new ways about our nursing and our teaching skills. Faculty
who initially resisted Victoria's entrance to the nursing program ultimately gained a new perspective of who could be a nurse (Rhodes,
Davis, & Odom, 1999). .
^ ':x.:: . , . , ' , : - . . - i- .
During the first practice lab, I taught students to roll the head of the bed
up in order to save their backs during transfers and to help the client's
blood pressure equilibrate in a sitting position. Victoria noted that rolling
up the head of bed with a patient in it may cause shearing of sacral skin,
and of course she's correct. 1 think we'll see a lot more of these insights
that come from rehab and are valuable, new ways to approach our work.
At break time, Victoria realized that she had not toileted at the
proper intervals that morning and so was a few minutes late for the next
session. What physical effort it takes for her to accomplish things the
rest of us do so easily! 1 must be more mindful of giving breaks in a
y- timely way. : - ? . ' ' ; . , i : ; M P p i ; ,:•-,!.. , ; j i i * r - s ; f : j . s a w yS-,. : Nl«SING EDUCATION FOR STUDENTS WITH DISABILITIES . ;,;i
I conrinually search for ways to balance things: providing additional
\. help with such things as bed-making lo lower Victoria's fatigue so that
she can do more psychomotor tasks versus allowing her independence
and treating her like other students; giving her more teacher time to
assist with adaptation versus staying out of her way and letting her leam.
It feels like a delicate business but also like we're pioneering something
wonderful here. 7 : Although I customarily thought of myself as an expert colearner
with the students, this was different. I was more acutely aware of the
continual need to be open to what my student could teach me about
nursing and adjust my classroom management practices to promote her
safety and comfort while juggling instructional demands. Opening Doors : It was a challenge to approach clinical agencies knowing that a student
in a wheelchair, not to mention her service dog, might not be welcome
(Pool V. Riverside Health Services., D.C. Kan. 1995, cited in Simunek,
1999). Previous good relationships with agency personnel were used as
a basis for entry, and although all agencies agreed to host the student,
reactions were mixed.
;,
Maverick can do all sorts of things such as tum on lights and ring
doorbells, but Victoria uses him chiefly as a means of connecting with
others, so it's okay to pay some attention to him. She has decided, though,
to leave him in her van while she is in clinical.
Victoria and 1 talked about possible adaptations at the nursing bome,
' sucb as use of a lap tray to set up and transport medications and otber
clean tasks, anotber for dirty linen, and assignment to a team of tbree
students (1 usually assign beginning students in pairs). We also discussed
bow sbe migbt clarify ber needs for our clinical group so tbat everyone
' can relax around ber. Many of tbese students know ber from didactic
classes, so sbe is perhaps less of an oddity tban sbe would be otberwise.
1 called tbe clinical facilities. Tbe Outpatient OR supervisor immediately agreed, saying, "Tbat's wonderful!" Also, no problem witb tbe director at tbe nursing bome, altbougb one supervisor said, "Sbe bas no
business in nursing school—what can she ever do when she gets out? " We
negotiated for approximately 30 minutes, and eventually tbe supervisor
admitted tbat it migbt be interesting-and that sbe would be willing to
try it out. Wbat a relief! I knew I could force tbe issue, baving gotten
tbe director's permission, but wben staff really don't want students, everyone is miserable. Victoria will only be witb tbis nurse one day, so it was
a lot of effort for tbe payoff, but necessary.
.f : • •• ws •
;
. 8 OUR STUDENTS -V • . ' • „ • { - „.i . . ••- Making these arrangements work was a weighty task because I felt
that my reputation, as well as Victoria's, was on the line and that we
had to deliver on our promises and persuasion. ^^ Taking on the Responsibility
Although we knew that we were ethically and legally required to give
Victoria the opportunity to succeed, sometimes it felt as if there was an
undercurrent of resistance. For example, I requested reduced student
numbers in my clinical because of the extra time needed to deal with
issues involved in our commitment to Victoria. Nevertheless, I was
assigned ten students although a reasonable ratio in this instance is
four students to one faculty member (Murphy & Brennan, 1998). The
responsibility was sobering, and 1 wondered how I would find the time
to meet everyone's needs.
,
My job is to make sure that she is treated fairly so that she can do her
best and approach the next rotation with evidence of her ability to meet
objectives. It's a big responsibility because I can't shake the feeling that
we are being beld up to scrutiny, a "test case" on whicb many students'
futures may depend. Victoria also feels this scrutiny and has written in
ber joumal about it. 1 also was responsible for providing requested accommodations
without substantially changing the curriculum or creating an undue
hardship for the school and its clinical facilities. If the school or the
agencies believed that these accommodations posed a hardship, then it
became my role to facilitate the identification of alternative accommodations iZuckle V. Regents of the Univ. of Cal, CA9 Cal, 1999, cited in
Simunek, 1999). Needed accommodations had to be identified, including adaptations for medication administration, during a series of preclinical visits to the agency, but in the end only minimal accommodations
were needed at the nursing home. That continued to hold true across
clinical settings (Rhodes et a l , 1999).
We visited the nursing home and poked into all the closets to see what
adaptations will be necessary. I'm surprised that she can reach most things
including glove boxes mounted on the wall. We had a long discussion
about hand washing technique while sitting and where to place dirty
linen prior to taking it to the linen hamper in the hall. NURSING EDUCATION FOR STUDENTS WITH DISABILITIES •Mi The charge nurse came into
sat on a low stool to talk about
pants in white fabric, made by a
access to self-catheterize and will
knee to attach the lap tray. 9 the tiny medication room with us and
Victoria's uniform, some balloon-like
friend who sews. The pants allow her
enable her to use a velcro strap on her
' • Victoria and I welcomed the personal attention from the charge
nurse to our adaptive efforts, and although we originally planned to use
the velcro strap, we eventually found it unnecessary. Instead we used
a plastic box that could be easily disinfected to carry items on her lap,
a task at which she was already proficient. The box remained in the
medication room, marked with Victoria's name, when she was not in
c l i n i c . •• - -• • ' , ; . • . - .: -.. ^ - ; . ••••..,,•. •'•'.v,- • » . . , • • . - ! ; ; . Exploring Roles and Responsibilities in Nursing
Students participated in well-elder experiences in the community, including one day in an outpatient surgery center, before progressing to
the nursing home for basic skill acquisition. In the Outpatient OR, a
classmate helped her change into scrubs and transfer to a hospital
wheelchair. Victoria was uncomfortable not having her own chair, which
was an extension of herself, and she seemed anxious. However, a surgeon
(sitting to use a microscope for cataract removal) was welcotning and
put her at her ease.
>. „•
Victoria worked as part of a team in the nursing home, caring for
several residents, and was held to the same standards as other students,
considering accommodations (Maheady, 1999; Rhodes et a l , 1999;
Wood, 1998). She faced the same challenges as other students along
with some unique ones. ,
.
,..
.... .. ;
At orientation, Victoria wore a gray lab coat with tails like a cowboy's
slicker over her uniform top and white pants. She was patted on the
shoulder and moved out of the way by a staff member who thought she
was a resident. We decided thai Victoria would remove the lab coat and
wear a stethoscope around her neck in order to proclaim her identity as
a student.
She feek a bit overwhelmed, like everyone else, but is joining with
other students to tackle the materials. She worries that 1 will not critique
or correct her performance because I already know her from the didactic
class or because of her disability. It is hard to move out of the role of
caregiver that seems natural with someone in a chair particularly in a
clinical setting. However, several students did not complete their written 10 OUR STUDENTS "1 preparation for clinic today, Victoria among tbem, and they all got specific,
immediate feedback, so I'm learning to treat her just as I do other students.
She did well with therapeutic relationships today, changed a bed,
and gave perineal care, calling me to belp ber assess a reddened area.
Sbe makes adaptations logically and practically and seeks help wben
needed. We were not sure wbat to do witb a plastic bag filled witb dirty
linen—we discussed putting it on top of a lidded wastecan. Sbe has
figured out tbat sbe must wash ber bands, tben put on gloves, wbeel ber
cbair to tbe bedside, and cbange gloves. Sbe leans on the split siderail
' " (up) with the bed in low position to steady berself and to reacb patients,
and sbe gets up and down tbe hallway quicker tban 1 can. Sbe bas
been an excellent resource for otber students wbo are transferring older
residents, in fact, better than me.
Victoria had not charted successfully on an exam but after working
tbrougb examples in clinical conference, sbe turned in good nursing
diagnoses and charting the next day. ln many respects (most, I guess), she
is like every otber student—same kinds of dif'ficulties, fears, and strengths. - Every day brought unexpected challenges but that is the nature of
clinical teaching. 1 began to gain confidence as 1 learned how to interact
effectively with Victoria and realized that our situation was not as strange
or unmanageable as I had anticipated.
Adjusting Expectations - ' ;> I learned to go into elevators ahead of Victoria, letting her tnanage the
door. However, I always felt as if 1 should sit or squat down (as I did
with the nursing home residents) when I talked to her, although she
said she was used to people standing. I learned to say, "students with
disabilities" rather than "disabled students" to define her first as a person
and only then as someone who happened to have a disability. I also
learned that I was not the only one who occasionally felt clumsy when
working with Victoria.
In clinic, a new nurse said to ber, "Are you finding out what the residents
feel Uke sitting in wbeelcbairs?" Victoria said, "Well, no, tbis is my
cbair." The nurse burst into tears, apologizing profusely, kissed tbe top
,_•-,-• of Victoria's bead, and fled precipitously. Later, I cbecked with tbe nurse,
and she was still embarrassed but okay. I also cbecked witb Victoria; she
was amazingly unruffled. For both the staff and me, learning to interact in a sensitive but
natural and appropriate manner occurred with practice, as it does in
most unfamiliar situations. NURSING EDUCATION FOR STUDENTS WITH DISABILITIES Preparing to Move On ' ' 11 ' Toward the end of the rotation, I learned that assigning Victoria to a
physically demanding resident was not necessary for her learning, and
that there was no ohligation for her to try to do things exactly as the
nondisabled students did. I was called on to live up to my reminders
to students that, "It is not the tasks that make you a nurse, it is your
nursing knowledge."
Victoria worries about her next patient; she doesn't want someone with
a lot of heavy physical care because her team members wind up doing
it. But she does l)ring something extra to the equation. For example,
today she worked with a disabled patient who wants to go home and
had quite an impact because of her own experiential knowledge.
She must balance herself by leaning on something in order to do
tasks. Where 1 can twist or squat to put myself into an optimal position,
she cannot. She was very shaky while administering her first insulin
injection but fine with number two. 1 believe this is partly due to limited
ability to position herself and partly due to the stark fear that usually
accompanies a student's first "real" injection.
The medication nurse sought me out to tell me, "She'll be just fine,
there are lots of places she can work when she gets out of school!" It
was an unsohcited remark out of the blue. She hasn't said much about
the situation before, but she has apparently watched Victoria and made
up her mind. It's especially interesting because this nurse is not usually
a student advocate.
Victoria has the same questions and difficulties as every other student in clinic—beginner "stuff that we all had to learn no matter how
smart, mature, or experienced. We also have the same issues as with
any experience in diversity; we must work to make accommodation for
differences, but it seems there are many more commonalities than
- differences.
,. Although it was necessary to focus on differences between Victoria
and other students, my journal entries repeatedly reflect discovery of
commonalities that overshadow differences and provide a basis for fostering understanding among all involved in the educational experience. LEARNING TO SHIFT PERSPECTIVES
Nurse educators have a responsibility to students with disabilities to
understand ADA guidelines to help them procure the best possible
education. Moreover, it is important for peers of these students, adminis- 12 OUR STUDENTS ' - ' • •' . ' • - • . ' trators, and staff, including clinical agency staff, to observe faculty model
appropriate behaviors in the classroom and clinical settings. Teaching
students with disabilities is a learning opportunity for faculty, setting
the stage for confirmation and extension of our already considerable
skills. Finally, nursing faculty have a legal and moral responsibility to
protect their schools and colleges from legal liability connected with
violations of civil rights. This section briefly describes the learning
opportunities that Victoria's enrollment presented in the areas of civil
rights, safety, and accommodations under the ADA. Additionally, we
describe our use of the social model of disability as a vehicle for reexamining our policies for students with disabilities. Civil Rights
During preparation for the clinical rotation with Victoria, 1 learned that
providing nursing education for students with disabilities is a matter of
civil rights, just as it is for students from other minority groups. Victoria
was to be given equality, not special treatment (ADA, 1990; Rhodes et
al., 1999). In my effort to follow legal guidelines, 1 learned more about
the ADA'S focus on functional limitations, rather than on medical diagnoses, and how it views disability as a social issue, not a medical one. For
example, the ADA and Section 504 of the Rehabilitation Act of 1973
define "disability" as having an actual physical (such as Victoria's) or
mental impairment that substantially limits one or more major life activities (functions), but it also takes into account the social element of being
regarded as having an impairment.
The College of Nursing relied heavily on inservice education from
specialists in education of students with disabilities as we sought to
balance our legal and ethical imperatives to students and health consumers (Murphy & Brennan, 1998; Sowers & Porter, 2002). Although some
faculty objected to Victoria's admission, we learned that denying her
access to public education could be seen by the courts as a restriction
on liberty; after her admission, she could claim a denial of property
interests if she were not allowed to participate (Siminoe, 1998; Simunek, 1999).
Safety
Although the ADA mandates that essential functions, fundamental taskbased criteria for employment, must be viewed separately from essential NURSING EDUCATION FOR STtrtJENTS WITH DISABILITIES 13 academic requirements (Fritsma, Fiorella, & Murphy, 1996), we had
difficuhy distinguishing these in terms of nursing. However, we could
not legally discourage Victoria from applying to our program because
of doubt as to her ability to perform work-related job functions, nor
could we question her about the presence, type, or severity of a disability
(Fritsma et al, 1996). Moreover, we were legally required to admit
Victoria as a qualified student without regard to job placement potential
(Rhodes et al., 1999, p. 49).
The struggle to understand the essential functions for employment
and their separation from essential academic requirements required
reflection on who we were and what we did as nurses (Persaud &
Leedom, 2002). For instance, is current certification in CPR a fundamental requirement for maintaining licensure as an RN? If so, 1 suspect
many faculty should surrender their licenses, although we do know the
underlying principles. Still, some faculty members who believe that
students with disabilities pose a safety threat (Murphy & Brennan, 1998;
Wood, 1998) would doubt if Victoria could be "safe" because she could
not administer CPR, catheterize a female patient without compromising
the sterile field, reach the wall-mounted suction in a cardiac care unit,
or hang an IV bag. In actuality, Victoria learned to catheterize females
in a side-lying position and successfully used an Ambu-bag for CPR,
moving out of her chair onto the floor to do chest compressions. We
assigned her to units other than CCU where she could learn the same
concepts and taught her to ask for help in hanging IVs, as some nurses
of short stature are obliged to do.
Further, we all knew nurses whose practices had been severely
curtailed by injury or illness yet who continued to function safely and
competently, maintaining their licensure, as do nurses in numerous
positions that simply do not require traditional psychomotor skills such
as CPR. Given that graduate nurses can practice safely and competently
using only their intellectual skills, what about students? We agreed that
every student should learn a certain set of concepts and that it is acceptable when students have different chnical experiences during which to
practice those concepts. We long ago retired the idea that every student
must catheterize a male patient or insert a nasogastric tube. Applying
this stance to Victoria's education allqwed us to focus on fundamental
concepts and appropriate nursing decisions instead of the performance
of physical tasks, many of which can be done by ancillary personnel,
and get to the kernel of nursing practice (Rhodes et...

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