Nurse Education in Practice xxx (2011) 1e5

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Nurse Education in Practice

journal homepage: www.elsevier.com/nepr

Supporting students with disabilities e Promoting understanding amongst

mentors in practiceq
Stephen Tee*, Michelle Cowen
Faculty of Health Sciences, University of Southampton, Southampton, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: Introduction: Good practice demands a clinical practice culture positively disposed to students with
Accepted 20 March 2011 disabilities. Equality legislation seeks to protect those with a disability from either direct or indirect
discrimination. The balance between providing reasonable adjustments for the student, whilst
Keywords: ensuring Fitness to Practice, and ultimate employability, requires a close partnership between higher
Practice Learning education and practice mentors.
Disability
Methods: This paper reports on the development and evaluation of a range of interactive resources, used
Mentors
in the preparation of mentors to help them address the specic learning needs of disabled students.
Reasonable adjustments
Results: The evaluation revealed the benet of student stories in helping mentors to understand the
support needs of disabled students and ensure reasonable adjustments are implemented in compliance
with disability legislation. The interactive resources have been helpful in promoting positive action
towards disabled students learning, empathic understanding of mental health issues and knowledge and
skills acquisition in support of dyslexic students.
Conclusion: Implementing reasonable adjustments in practice requires a close working partnership
between HEIs and mentors who appreciate support in understanding the development and application
of coping strategies to overcome disabilities. Effective preparation of mentors is essential to ensure that
opportunities for disabled students to succeed are maximised.
2011 Published by Elsevier Ltd.

Introduction The Equality Act (HMSO, 2010) denes a disability as a condition

The support of nursing students with a disability in practice
requires a high level of understanding amongst those responsible
for their development and education, principally their mentor.
Within the UK, the Nursing and Midwifery Council (NMC) require
all students to have a named mentor who supports the student,
helps them to develop their knowledge and skills and ultimately
assesses their clinical competence (NMC, 2008a). However recent
literature suggests the general level of awareness amongst mentors
in practice is inadequate with gaps in knowledge of relevant
legislation, including the former Disability Discrimination Act
(HMSO 1995, 2005) and the new Equality Act (HMSO, 2010). This is
compounded by the broad nature of many conditions which would
be recognised by law as a disability.
q This paper was presented at the NETNEP 2010 3rd International Nurse
Education Conference e Nursing Education in a Global Community: collaboration
and networking for the future, 11e14th April 2010, Sydney, Australia.
* Corresponding author.
E-mail address: s.r.tee@soton.ac.uk (S. Tee).
which has a signicant, long term, adverse effect on an individuals
ability to carry out day to day activities. This would therefore
include a wide range of long term health conditions including many
physical illnesses, mental health problems and specic learning
differences such as dyslexia, along with conditions such as a visual or
hearing impairment which have traditionally been recognised as
a disability. To automatically refuse a student with a disability
admission onto a nursing or midwifery programme would be illegal
and it is therefore imperative that mentors are aware of this and fully
understand the implications of relevant legislation for their men-
toring practice (Morris and Turnbull, 2006; Sanderson-Mann and
McCandless, 2006). Although exact denitions of disability may
vary the Americans with Disabilities Act (United States Department
of Justice, 1992) and the Australian Disability Discrimination Act
(Ofce of Legislative Drafting and Publishing, 1992) illustrate that
this is of relevance to those in nurse education around the world.
A previous study by Tee et al. (2010), demonstrated how a new
initiative, known as Student Practice Learning Advisor Service
(SPLA), introduced within a School of Health Sciences, was shown
to have had a positive effect on the learning experiences of students
with disabilities. As an outcome of this work it was clear that

1471-5953/$ e see front matter 2011 Published by Elsevier Ltd.

doi:10.1016/j.nepr.2011.03.020

Please cite this article in press as: Tee, S., Cowen, M., Supporting students with disabilities e Promoting understanding amongst mentors in
practice, Nurse Education in Practice (2011), doi:10.1016/j.nepr.2011.03.020
2 S. Tee, M. Cowen / Nurse Education in Practice xxx (2011) 1e5
mentors who support learning in practice required additional
preparation in terms of understanding the needs of disabled
students and the use of reasonable adjustments.
Building on the work of Tee et al. (2010), this paper seeks to
implement strategies and guidance developed by the Disability
Rights Commission (2007) (now the Commission for Equality and
Human Rights) in relation to inclusivity and employability. This was
achieved through a series of interactive learning resources exploring
specic learning needs of students with a range of disabilities. The
series includes material covering physical disabilities, mental health
problems and learning differences such as dyslexia, and are designed
to encompass the entire student journey, covering both campus
based and practice based learning. Once developed the resources
were made available locally to assist in the preparation of mentors,
supervisors and academic staff. A key part of the development
process was to ensure that the resource fully met the needs of those
for whom it was intended and so ongoing evaluation was conducted
at each stage of the project.
Background literature
An extensive literature search was conducted, using BNI, CINAHL
and MEDLINE databases in order to determine current practice with
regard to disabled students in nurse education. As discussed by Tee
et al. (2010), there is a growing body of work addressing the practice
learning support and adjustments for students with dyslexia
(Illingworth, 2005; Sanderson-Mann and McCandless, 2006; Morris
and Turnbull, 2006, 2007; Dale and Aiken, 2007; Cowen, 2010a,b)
but relatively little addressing the wider disabled community
(Abbott, 2005; Oxtoby, 2005).
Similarly there is a paucity of literature exploring mentors
understanding of the issues, with the available literature focussing
much more on the student perspective. Several authors have
expressed concerns over safety issues, questioning the advisability
of allowing students with dyslexia onto nursing programmes
(Dufn, 2001 and Watkinson, 2002). Both of these focussed on
potential risks, highlighting areas that the individual might struggle
with and are largely based on isolated personal experiences. Related
work around tness to practice has discussed recent policy devel-
opments and considered health issues in general but has not been
specic to disability issues (Tee and Jowett, 2008). Currently the
Nursing and Midwifery Council expect the individual practitioner to
act within the boundaries of their professional competence as
described in the Code of Conduct (NMC, 2008b) and to declare that
they are of good health and good character when they renew their
registration (NMC, 2008c).
Whilst the work by Dufn (2001) and Watkinson (2002) high-
light some important considerations they do little to advance posi-
tive approaches but arguably reinforce stereotypical negative
attitudes. Morris and Turnbull (2006), pick up on this highlighting
how positive aspects of dyslexia are rarely raised or even acknowl-
edged. According to the Disability Rights Commission (2007),
following the case of Beverly Allitt and the subsequent publication of
the Clothier Report (HMSO, 1994), there has been a signicant
increase in the incidence of myth and prejudice surrounding those
with mental health problems who are seeking to enter health
professional careers.
Historically, the cautionary attitudes held by many when asked
to consider admitting a student with a disability reect those held
by society as a whole. The Disability Rights Commission (2005)
drew attention to the level of social exclusion and disadvantage
experienced by many people with disabilities and highlighted that
often this is not as a direct result of their impairment, but stems
from attitudinal and environmental barriers created by society. This
led to a move towards the social model of inclusion, where society
Please cite this article in press as: Tee, S., Cowen, M., Supporting students with disabilities e Promoting understanding amongst mentors in
practice, Nurse Education in Practice (2011), doi:10.1016/j.nepr.2011.03.020
is urged to adopt a more proactive approach that fosters growth
and enables individuals to reach their potential (Riddick, 2001).
To realise this social model there is a need for awareness raising
both in society in general and specically those working in health-
care settings. This has led to many key publications over the last
decade including those by Quality Assurance Agency for Higher
Education (1999), Department of Health (2000,2002), Department
for Education and Skills (2002), Royal College of Nursing (2004),
Health Professions Council (2006), Kane and Gooding (2009), and
Cowen (2010a), which all seek to educate and inform Higher
Education providers and their clinical partners of their responsibil-
ities towards individuals with a disability who wish to enter a health
care profession. They also provide advice regarding legal responsi-
bilities, help clarify what might constitute a reasonable level of
adjustment and overall aim to challenge negative attitudes and
inuence good practice.
Whilst going part of the way towards educating staff involved in
student support, persuading staff to access such material remains an
issue. Both Morgan (2001) and Klein (2001) suggest that staff may
avoid staff development sessions they feel cater for the needs of
a minority group, and consequently only attract those already sensi-
tive to the issues thereby preaching to the converted. In an attempt to
ensure that all of those involved in mentoring student nurses receive
appropriate professional development the Nursing and Midwifery
Council in their Standards to Support Learning and Assessment in
Practice called for all mentors to have disability awareness training
(NMC, 2008a). In clinical practice, where the opportunity to release
staff to attend formal development sessions is increasingly difcult,
innovative methods to meet this need were urgently required.
The project
In line with the social model of disability this project aimed to
develop enhanced awareness and a positive approach to disability
amongst academic staff and mentors, to promote:
 Early recognition of symptoms and condent, positive responses
to undiagnosed disabilities such as dyslexia, depression, bi-polar
disorders etc.
 Early, informed referral to university resources to maximise the
likelihood of future success
 Positive, timely and planned responses to recognised disabilities
to enhance the student experience in academic and placement
learning environments.
 Development of a culture in which disabled students can
expect an empathic understanding which might make it less
challenging for them to condently declare that they have
a disability without fear of discrimination and in the knowl-
edge that appropriate adjustments will be made for them.
 A supportive, tolerant culture wherein diversity triggers
opportunities for creative problem solving for all, including
students without disability who will encounter disabled people
both in study and in life.
The primary method by which these aims were to be achieved
was through the development and evaluation of a series of elec-
tronic, interactive resources that would be exible enough to allow
staff to access either as individuals or within a small group learning
environment.
Method
The method employed for this project aimed to utilise the
philosophy behind action research which integrates a problem
solving approach within a participatory context (Kemmis and
 S. Tee, M. Cowen / Nurse Education in Practice xxx (2011) 1e5 3

McTaggart, 1982; Reason and Bradbury, 2007). Although the project Excerpts were grouped into representative topics to ensure a logical
was not set up as a research study the need to identify the problem ow. The nal stories were then delivered by the actors and
(mentors lack of understanding of disability issues) and review the subsequently presented to groups of mentors to gauge reaction and
current literature, before using this to develop a series of exible, receive feedback.
interactive resources was viewed as best practice. The plan was to
develop resources, in collaboration with participating disabled
Results
students, and then to use these resources to help prepare mentors
for their role. Having implemented the plan we would collect and
Once prepared the student experiences were used to create the
interpret evaluation data and use this to rene the materials. The
teaching materials. These were presented in two formats; the DVD
nal stage of the process was to disseminate our ndings through
and a booklet with guidance notes. The booklet provided an outline
publication and conferences. To support this project funding was
of the resource and how it might be used in a paper format. This
obtained from a grant awarded by a University Learning and
allows individuals to quickly review the breadth of content and
Teaching Enhancement Unit.
length of each session without needing access to a computer. The
booklet also contained additional structured exercises suitable for
Ethics
use with small groups, with facilitator notes where appropriate.
These indicate possible areas for discussion/consideration and
Although it was not classed as research, due to the sensitive
provide links to further information such as useful websites.
nature of the topic and vulnerability of the participating disabled
The DVD contains a series of interactive teaching sessions pre-
students, the project was conducted in line with the Universitys
sented on PowerPoint. Each session is designed as stand-alone
ethical procedures. A written participant information sheet was
although it is anticipated that individuals will choose to watch all of
devised to ensure that participants understood the purpose of the
the presentations over a period of time. Topics covered include
project and exactly how their contributions would be used in the
background sessions on the Equality Act and its implications and
nal teaching materials and their dissemination. Signed consent
sessions related to specic areas such dyslexia, mental health prob-
forms were obtained and total anonymity was ensured at all times.
lems and physical disabilities. Video clips recount student stories that
reinforce the messages contained within the teaching material.
Recruitment process
The PowerPoint presentations were created using Adobe
Presenter. This allows the creator to record a narrative to accom-
A key component of the teaching resource was the inclusion of
pany each slide. These are particularly valuable as many of the
a series of video clips through which the student voice could be
sessions are highly specialised and the opportunity to listen to an
heard. The rst phase of the project was therefore to recruit
explanation of the concepts by someone familiar with the content
students (past and present) who felt able to share their personal
is a real enhancement.
experiences of their disability during training. It was through real
The following illustrative examples convey some powerful
life examples of how particular learning needs were responded to
messages. One student with a slight mobility problem (limp) talked
that we could identify general principles and lessons learnt.
about her mentors reaction towards her on her rst placement:
The method of recruitment was through an advert placed on the
students electronic learning platform (Blackboard) supplemented I was born with my disability and it did not occur to me that it
with invitations to students already known to disability support would affect anyone else, that anyone would have a problem with
services. The support service acted as a liaison to avoid pressure it..she (the mentor) said that she was surprised that someone
being placed on the student to participate. As the purpose was to with a disability such as mine got a place and it really hit me that it
provide a selection of real life experiences to include in the was visible.
teaching materials there was no specic requirement in terms of
The same student later talked about a different mentor she met
the number of students who were needed. Using a convenience
during her second year:
sampling approach, all of the students who offered to participate
were given the opportunity to do so. She said that she had a great deal of admiration for me, I dont
want peoples admiration. I want them to think I am doing a good
Hearing the student voice job.
The power of this type of content is twofold in that it provides
Those who volunteered to participate were offered a variety of
tips on how to help students with disabilities to succeed, but also
formats through which to record their experiences, although they
reminds us of the human being living with the disability and the
all selected face-to-face interview which was audio-taped.
emotional impact of insensitive and prejudicial comments.
In order to maintain strict anonymity students were advised
The student stories reect a range of disabilities including those
that their experiences would be used to create a script to be
listed in Table 1.
delivered by an actor when the video clips were created. Alterna-
tive methods were explored, including having the students back to
the camera, lming their silhouette or pixilating the image. Mentor feedback
However it was felt that there was still a risk that the student could
be identied. To ensure authenticity semi-professional actors were The ongoing evaluation has involved presenting aspects of the
employed, who had the skill and ability to recreate the story in package, as they were created, to several groups of mentors and
a manner that conveyed the emotion of the experience.

Table 1
Data collection and analysis Disability stories.

Following each student interview, a transcript was produced Physical e mobility problems, narcolepsy, sight impairment, limb deformity
Mental Health e anxiety, depression
from which excerpts were selected. These were chosen because Learning e dyslexia, dyspraxia
they conveyed a strong message and illustrated key learning points.

Please cite this article in press as: Tee, S., Cowen, M., Supporting students with disabilities e Promoting understanding amongst mentors in
practice, Nurse Education in Practice (2011), doi:10.1016/j.nepr.2011.03.020
4 S. Tee, M. Cowen / Nurse Education in Practice xxx (2011) 1e5
obtaining feedback on their experiences and how the resource has
developed their understanding. A semi-structured open ended
questionnaire was developed based on question types used by the
Faculty to evaluate teaching and learning.
Overall mentors indicated they felt they understood the needs
of disabled students and were therefore more able to take positive
action towards their learning. They indicated that the stories made
them realise the challenges disabled students face and how their
reactions can enable or inhibit student learning.
Interestingly the stories raised questions about whether partic-
ular students would cope. For example one mentor who watched the
story about a student who struggled to differentiate right from left
but who had since learnt an effective coping strategy, stated:
When I saw the clip about the student who couldnt tell their left
from their right I was really worried, would they be able to cope? I
think that it could be a big problem.
Such reactions provide perfect learning opportunities for small
group discussion to explore their attitudes, beliefs and strategies
that may be helpful to such students.
Another mentor had a similar reaction when shown a story of
a student born with several ngers missing:
What about the student with no ngers? How will she manage?
Interestingly this student had two missing ngers and several
others shorter in length than normal. This is carefully explained
prior to the clip being shown but despite this the mentor inter-
preted the clip as the student having no ngers at all.
This highlighted the benet of skilful facilitation in order to
unpick the mentors concerns and ensure those viewing the
package hear what is really being said. It also usefully illustrated
how preconceptions may inuence attitudes in practice prior to the
arrival of a student on placement, when it may be known the
student has a disability. For this mentor there was an important
lesson around not jumping to conclusions.
Other evaluation feedback indicated that the teaching resources
had helped the mentors to understand how reasonable adjustments
can be implemented in practice without compromising standards of
professional practice. The types of adjustment and support with
which mentors have become more familiar are illustrated in Table 2.
Greater empathy towards those with mental health problems
through a better understanding of how support can be provided to
students more effectively was also illustrated through the examples
of reasonable adjustments. Mental health problems raise particular
concerns and anxieties amongst mentors but they had begun to
think through strategies such as negotiating shift patterns when
a student is struggling at a particular point in time, or supporting
self-disclosure of a mental health problem and guiding the student
to appropriate help. This may involve additional mentor support or
negotiated time-out.
A common area of need has been knowledge and skills acquisi-
tion in support of dyslexic students. Although most mentors had
a basic understanding of some of the areas which might be affected
they tended to focus on reading, writing and spelling issues. These
are not always a signicant problem in adults with dyslexia, because
Table 2
Reasonable adjustments.
B Ways of helping students to structure information eg use of cue cards
B Use of coloured overlays
B Use of tailored notebooks
B Providing additional skills rehearsal
B Organising seating arrangements in key meetings
B Negotiating shift patterns
B Supporting disclosure
Please cite this article in press as: Tee, S., Cowen, M., Supporting students with disabilities e Promoting understanding amongst mentors in
practice, Nurse Education in Practice (2011), doi:10.1016/j.nepr.2011.03.020
they have developed successful strategies to overcome these dif-
culties. Mentors were much less aware of problems associated with
organisation, working memory and automaticity which are more
likely to cause difculties in a clinical setting and the package raised
awareness of these issues. Resources such as Cowen (2010b) that
explain areas of potential difculty in detail and suggest a range of
strategies are therefore highlighted in the teaching pack.
Discussion
This project has been concerned with promoting positive atti-
tudes towards students with disabilities to enable them to make
a valued contribution to the nursing profession. The specic goal
was to achieve greater inclusivity, by raising awareness of the
challenges that students with disabilities face and by sharing real
life experiences promote positive attitudes, enhance the skills of
mentors and thereby improve the student learning experience.
Students with disabilities, according to the DRC (2007), still face
many signicant structural, cultural and attitudinal obstacles that
arguably arise through myth and ignorance rather than prejudice.
This project whilst not claiming to address all challenges, seeks, in
a small way, to overcome some obvious difculties and to make the
journey that bit easier for students already struggling with obstacles
imposed by their respective disabilities. A particular issue for nursing
is the reliance on practice for 50% of the student learning experience.
Unlike the academic learning environment, the practice learning
environment is less susceptible to the measures that exist for
implementing special arrangements for students. The greater
uncertainty and unpredictability in practice create unique challenges
for inducting, supporting, teaching and assessing nursing students
which will only be addressed where knowledge and understanding of
the support requirements of disabled students is well understood.
There is a growing body of evidence advocating the use of
experiences and stories of those who use public services as learning
resources (Lathlean et al., 2006; Tee et al., 2007; Simons et al., 2007,
2010). It was very apparent that the students stories created for this
project have a powerful authenticity. The variety of stories reecting
key categories of disability, provide a broad perspective and enables
mentors to develop insights and empathy into the students expe-
rience. Mentors reported nding the resources of great interest and
revealed aspects that had not previously been considered, which can
only benet students in the future.
It is evident that the interactive package has the potential to be
used more widely with other disciplinary groups both within the
university and across practice partners to promote an inclusive
approach to teaching and learning. However despite such initia-
tives and the national drive for greater equality and inclusivity it is
clear more needs to be done to improve the lot of people with
disability and ensure they can participate fully and equally in
professions such as nursing. We hope that through such initiatives,
understanding will spread and the structural, cultural and attitu-
dinal barriers will continue to be eroded.
Limitations
Although the project demonstrated potential benets from
using the resource, the following limitations are acknowledged.
1. Tight timescales and budgetary constraints meant that we had
a relatively short window of opportunity to recruit students,
create the resource and gather evaluation data thereby limiting
its scope.
2. To avoid overburdening students during their studies we kept
the interviews quite short, this may have reduced the depth of
information obtained.
 S. Tee, M. Cowen / Nurse Education in Practice xxx (2011) 1e5
3. The sample is small and transferability is therefore limited.
4. Certain disabilities may not be represented if volunteers did not
come forward who were affected by these conditions.
Conclusion
Organisations such as higher education institutions are required
by law to proactively prepare for the needs of students with
disability to ensure they have equal access to the full range of
teaching and learning opportunities. These issues become more
complex in professional healthcare programmes involving signi-
cant proportions of learning within a practice environment located
within another organisation. This project highlights the importance
of working closely and exibly with mentors in order to address
their learning needs and to prepare the learning environment to
receive students with a range of disabilities.
If students are to fully experience a culture that promotes the
well-being of disabled people in a positive and informed way then
Universities will need to demonstrate condence in their approach
and a positive creative attitude towards disability, as ultimately this
will not only be advantageous to disabled students but to all
students embarking on a programme of learning.
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