The Institute of Medicine (IOM, 2000) published To Err Is Human: Building a Safer Health System, exposing serious safety issues in the health system; research indicates a lower estimate of at least 210,000 deaths per year and likely more than 400,000 related to medical errors and harm (James, 2013). The IOM (2001) then published Crossing the Quality Chasm: A New Health System for the 21st Century and called for total qualitative system change so that the health system is patient-centered, safe and effective, reduces and eliminates disparities, and has the capacity needed to better promote and manage population health at a time when access to care has expanded and the population of persons with chronic illnesses and mental health illnesses has expanded. Ongoing system redesign models include efforts to shift the focus of health care from reacting to acute care needs of individuals to proactively engaging the population in their own health through frameworks and models such as the Chronic Care Model and the Patient-Centered Medical Home (Agency for Healthcare Research and Quality, 2015). Other efforts include improving the focus on outcomes, the health literacy of the population, and the willingness of healthcare professionals and staff to speak up about problems (Agency for Healthcare Research and Quality, 2015). In the Future of Nursing: Leading Change, Advancing Health, the IOM (2010) calls for transforming nursing education in order to provide leadership in redesigning and expanding the health system and meeting the workforce needs of a redesigned health system.
The American Nurses Association (ANA, 2010, p. 3) defines nursing as the following: “the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.” Part of educating students capable of leadership in a redesigned health system is addressing the technical (nonacademic) standards necessary for a 21st century workforce. Nonacademic skills considered to be important in the nursing profession include communication, flexibility, critical thinking, and attention to detail (Ericksen, 2015). The Institute for the Future (a think tank that conducts research in technology, health, and organizations) issued Future Work Skills 2020; it included nonacademic skills such as cross-cultural competency, new media literacy, transdisciplinarity, design mindset, cognitive load management, and virtual collaboration (Davies, Fidler, & Gorbis, 2011).
A diverse workforce with skills for the 21st century (Davies et al., 2011 ; Ericksen, 2015) is important to provide the leadership needed to make qualitative changes in the health system (IOM, 2010). The connection between the delivery of patient-centered safe and effective care and a diverse nursing workforce is well recognized by nursing leadership, hospital associations, governmental bodies, and numerous stakeholders (American Association of Colleges of Nursing [AACN], 2014). Efforts to improve disability diversity inclusion are important in improving care (Ailey, Brown, Friese, & Dugan, 2016). Disability as diversity is discussed in higher education in general (Interwork Institute, 2009), but it is rarely discussed in nursing education (Marks & Ailey, 2014).
Competencies for rehabilitation nurse leaders include promoting the successful living of people with disabilities, advocating for their clients, and impacting health policy regarding persons with disabilities (Association of Rehabilitation Nurses, 2014). Using their knowledge about the experiences of persons with disabilities and strategies for managing problems affecting their inclusion (deFranca & Pagliuca, 2009), rehabilitation nurse leaders can play an important role in changing the perspective of disability as a diversity issue in both the field of nursing and nursing program admissions for persons with disabilities who can accomplish the nursing role as defined by the ANA. Dr. Howard Rusk is considered to be the father of Rehabilitation Medicine. During and after World War II, he led the development of rehabilitation programs that helped wounded and disabled servicemen to return to duty and/or civilian life. He felt that people do not “need physical wholeness to be the best at a particular occupation, whether it be lawyer, doctor, elevator operator, teacher, researcher, potato peeler or even President of the United States” (Rusk as cited in Harper, n.d., p. 1).
The purpose of this paper is to discuss the importance of disability diversity in nursing, review the history of existing technical standards used in many nursing programs, propose a new model of technical standards, and discuss the role that rehabilitation nurse leaders can play in eliminating barriers to persons with disabilities entering nursing.
Diversity inclusion embraces both uniqueness and belongingness; people from diverse backgrounds bring unique perspectives to the workforce and are valued members of the group. As of 2013, nurses from minority backgrounds still made up only 19% of the nursing workforce (including about 6% African American, 6% Asian, 3% Hispanic, 1% American Indian/Alaskan Native), and men made up less than 10% (AACN, 2014). People with disabilities make up about 10% of the noninstitutionalized U.S. population ages 16–64 (U.S. Census Bureau, 2014). The few existing statistics demonstrate that persons with disabilities are not well represented among healthcare professionals. For example, in California, persons with disabilities represent only 3% of the healthcare workforce (including nursing; U.S. Census Bureau, 2013). On the assessment test for nursing program admission in California, students requesting a disability accommodation represented only 1.4% of test takers and 1.3% of those who passed (Harris, 2014).
Recruitment of minority and male nurses is widely agreed to be a priority for the profession (AACN, 2014), but recruitment of nurses with disabilities is not discussed as a diversity issue in these same documents (AACN); however, this may change. The Department of Labor (2013) now requires federal contractors to have a goal that 7% of their employees be persons with disabilities.
On many issues, from obesity to cigarette smoking to preventive health screening, the health of persons with disabilities is worse than that of the general population (Centers for Disease Control and Prevention, 2016). Persons with disabilities face difficulties with access to health care. In California, less than half of the facilities serving the primary care needs of persons with Medicaid were fully architecturally accessible; only 8.4% had accessible examination tables, and less than 4% had accessible weight scales (Mudrick, Breslin, Liang, & Yee, 2012).
The lack of persons with disabilities in the healthcare workforce may have consequences. Among unemployed respondents to the California Survey of People With Disabilities (Kaye, 2010), 97.3% noted as a reason for unemployment that a healthcare provider told them they could not work. The drivers of unemployment of people with disabilities are complex; however, if persons with disabilities were in the healthcare professional workforce, perspectives on employment and employment possibilities might improve (Marks & Ailey, 2014).
Florence Nightingale, often considered the mother of modern nursing, had a disability. Noted to have had episodes of depression in her teens and early 20s, she led nurses to dramatically improve death rates among soldiers during the Crimean War. Following the Crimean War, she was frequently confined to her home, nevertheless making substantial contributions to the nursing profession. Bipolar disorder and chronic brucellosis are considered as possible causes of her disabilities (Roberts, 2003). Educating the new generation of nurse leaders requires recruiting and retaining diverse highly qualified students and thoughtfully transforming nursing education; this applies to both recruiting and retaining students from underrepresented minorities and students with disabilities (Marks & Ailey, 2014).
Technical Standards: Inclusion Versus Exclusion
The competencies outlined in Essentials for Baccalaureate Education (AACN, 2008) emphasize “patient-centered care, interprofessional teams, evidence-based practice, quality improvement, patient safety, informatics, clinical reasoning/critical thinking, genetics and genomics, cultural sensitivity, professionalism, practice across the lifespan, and end-of-life care” (AACN, 2008, pp.3–4). Nurse educators need to consider both academic and technical (nonacademic) standards conducive to the education of future nurses who can carry out nursing as defined and meet competencies.
Technical standards for education are not the same and should not be confused with essential functions for particular employment settings. Current disability legislation has language that allows for the employer’s judgment of essential job functions be considered. (Americans With Disabilities Act Amendment Act, 2008). Although the two concepts are different, essential functions of particular nurse employment settings are frequently conflated with technical standards for admission to nursing education programs. Technical standards for admission, as currently conceptualized in many nursing programs, contain physical capabilities such as being able to “twist, stoop, squat” and “push/pull/support light and heavy objects” (Good Samaritan College of Nursing and Health Science, n.d.). Although such physical qualifications may or may not be important for specific nursing jobs, they are not part of nursing as defined by the ANA (2010) or emphasized competencies for registered nurses (AACN, 2008). Such technical standards are barriers to the entry of persons with disabilities capable of fulfilling the nursing role (Marks & Ailey, 2014).
To grasp how technical standards have been and continue to be barriers to persons with disabilities entering the nursing profession, it is necessary to understand the following: (1) the history of technical standards since the first civil rights legislation for persons with disabilities, (2) the existing technical standards for admission to many programs, and (3) the associated issues that are perceived barriers to persons with disabilities entering nursing programs (e.g., accomplishing clinical hours for students in settings that often are not accessible and conducive to employment of persons with disabilities, the misconception of needing “undifferentiated” graduates who could be expected to work in all clinical settings, the notion that having students with disabilities may compromise safety).
History of Technical Standards
The conflation of technical standards with essential functions is rooted in the history of civil rights legislation for people with disabilities and ensuing legal court cases. Section 504 of the Rehabilitation Act (1973) was the first major civil rights legislation for persons with disabilities. Section 504 is a short paragraph at the end of the Rehabilitation Act; it states that “no otherwise qualified handi-capped individual in the United States shall solely on the basis of his handicap, be excluded from the participation, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance.” The language is similar to the Civil Rights Act of 1964 that prevented discrimination on the basis of race, color, religion, sex, or national origin under federally funded programs.
Section 504 (Rehabilitation Act of 1973) ushered in an era of civil rights for persons with disabilities; however, specific regulations and guidelines on implementing Section 504 were not immediately developed, leading to both court cases and protests by the disability community (Rothstein, 2010). The 1976 Cherry v. Matthews case was the first major court case related to interpretation of disability rights legislation. In this case, the U.S. District Court for the District of Columbia held that Congress intended regulations for the implementation of Section 504 and regulations had to be issued. This ruling plus protests by the disability community, the most significant being a 28-day sit-in at the federal office building in San Francisco, led to the issuance of specific regulations in 1978 with regard to education (Cone, 1997). The regulations stated that a “[q]ualified handicapped person” is, “[w]ith respect to postsecondary and vocational education services,” someone “who meets the academic and technical standards requisite to admission or participation in the [school’s] education program or activity” and that physical qualifications could be part of the standards (Nondiscrimination on the basis of handicap, 1978, p. 3). This was the first official discussion of technical standards related to persons with disabilities as students.
Following the Cherry v. Matthews (1976) case, the 1979 Southeastern Community College v. Davis case was the first to provide guidance on how to implement technical standards in education, especially in health professional education (the Davis case; as cited in Rothstein, 2010). The Davis case rulings held that educational programs are not required to make substantial changes in their requirements to make accommodations and they also could establish physical requirements for clinical programs. The Davis case involved the nursing program at Southeastern Community College. A prospective student with a hearing impairment, who was already a Licensed Practical Nurse, was denied admission to the nursing program at the college. The admission was denied on the basis that the student could not accomplish the clinical requirements of the program and would not be employable in some settings. In particular, it was held that the prospective student would not be employable in operating rooms. The Supreme Court ruled in favor of Southeastern College and found that educational programs could establish physical requirements for clinical programs (as cited in Rothstein, 2010). This ruling continues to have impact today, more than 40 years later, on how health professional education programs establish technical standards for admission.
Discussion of technical standards in health professional education developed after the Cherry v. Matthews and Southeastern Community College v. Davis cases. The Association of American Medical Colleges (1979) outlined five key areas for technical standards: (1) intellectual–conceptual abilities, (2) behavior and social attributes, (3) communication, (4) observation, and (5) motor capabilities (the five standards became requirements for acceptance into medical school after the passage of the Americans With Disabilities Act in 1990). Early concerns were expressed about the usefulness of these technical standards and how they were used as a barrier to students with disabilities. For example, the Association of Academic Physiatrists (1993) published a White Paper regarding denial of admission of students with disabilities to medical schools. The White Paper noted that graduates of medical schools should not be expected to acquire all technical skills and that performance of all procedures independently is not necessary; rather, students should be able to learn and direct the methodology involved and to use the results. Despite expressed concerns, the five areas or categories are commonly addressed in current technical standards for nursing students, medical students, occupational therapy students, social work students, and others in the health professions (College of Health Sciences and Professions, Ohio University, n.d. ; School of Pharmacy, Notre Dame of Maryland University, n.d.).
Technical Standards in Nursing Education
In 1990, the U.S. Congress passed the Americans With Disabilities Act (ADA, 1990). Similar to Section 504, the ADA required colleges and schools to provide reasonable accommodations to students with disabilities. To address the requirements of the ADA in the nursing profession, the Nursing Practice and Educational Committee of the National Council of State Boards of Nursing (NCSBN) published the Guidelines for Using Results of Functional Abilities Studies and Other Resources (Nursing Practice & Educational Committee, 1997). This document included A Validation Study: Functional Abilities Essential for Nursing Practice (Yocom, 1996). Sixteen functional ability categories and associated attributes were addressed in the Yocom (1996) validation study. The attributes included being able to lift 25 pounds, reach below the waist, see objects at 20 feet away, hear faint body sounds, and move in small spaces (Yocom, 1996; see Table 1). The essential functions described in the study became widely used as technical standards for admission to nursing education programs.
Carolyn Yocom at the 2003 Students With Disabilities: Nursing Education and Practice symposium held at Rush University College of Nursing noted that The Validation Study was an employment study to “specify the nondo-main specific functional abilities” (p. 120) of nurses and was a representative list of skills and abilities nurses may need to possess, not have to possess (Pischke-Winn, Andreoli, & Halstead, 2003). Although the NCSBN no longer disseminates the Functional Abilities Essential for Nursing Practice, a search on the Internet will reveal numerous colleges and programs of nursing using technical standards for admission that are similar to the essential functions outlined in the Yocom (1996) study (Good Samaritan College of Nursing and Health Science, n.d. ; Pima Community College Associate Degree Nursing Pro-gram, n.d.). Using the essential functions outlined in the Yocom study as technical standards for admission to nursing programs presents barriers for persons with disabilities to enter nursing (Marks & Ailey, 2014).
Accomplishing Clinical Practice Objectives
Nursing educators expressed particular concern about how to accomplish the clinical practice objectives of nursing programs for students with disabilities. Clinical practice sites vary on accessibility and the percentage of persons with disabilities in the healthcare workforce is low, making it potentially challenging to place students for clinical practice. One needs to consider that Title III of the ADA requires accessibility of public accommodations for all employees and patrons of buildings. If a hospital or other clinical site is not accessible for students with disabilities (and their own clinical staff), it is likely not accessible for nonclinical staff, patients, and visitors and may not meet the requirements for accessibility of the ADA. Reasonable accommodations for accomplishing clinical experiences can be and are made. For example, a student who is a quadruple amputee graduated from the Occupational Therapy Program at Rush University Medical Center (2011) and is employed as an occupational therapist (Van Zuidam, 2015). The video Open the Door, Get ’Em a Locker: Educating Nursing Students With Disabilities (Evans & Marks, 2009) follows the experience of a nursing student who is a paraplegic. She required very few accommodations while she was a nursing student. A medical student who is blind and whose career goal was to become a psychiatrist received accommodations of having detailed audio descriptions of surgeries during the surgical rotation. In addition, the medical student worked with patients before and after their surgery to understand the pre- and postsurgery impact (Sarah Triano, personal communication, May 27, 2014).
Undifferentiated graduate is a concept that has had more discussion in medical education than nursing education. Reichgott (1998) noted that resistance from medical schools to admitting students with disabilities was based on the idea that all graduates should be able to enter any field of medical practice. Potential students who might be unable to do this could thus be excluded. Although the concept has not received much discussion in nursing education, it exists. Part of the rationale for denying admission to the student in the Davis case was that she might not be able to work in an operating room. In the story Get ’Em a Locker, such issues were of concern during the educational experience of the student (Evans & Marks, 2009). Reichgott (1998) noted that medical schools should be assisting students to achieve the most appropriate medical career rather than expecting them to be able to have any medical career. Considering the need for nurses in many settings (IOM, 2010), nursing educators should be able to do this as well.
Safety of Students With Disabilities
The concern for public safety is paramount for regulators, educators, administrators, and all nurses—with and without disabilities. The 1997 NCSBN Guidelines raised the “initial and/or continued competence of persons with disabilities to practice nursing” as “individuals do not always have insight into the implications of one’s disability.” According to Neal-Boylan (2013) “…there are no documented incidents of a patient injury caused by a nurse with a physical disability” (p. 11). The IOM (2001) reports that medical errors are most often attributable to faulty systems, processes, and conditions rather than the characteristics of individual clinicians or recklessness or the actions of a particular group. In the context of a complex healthcare environment and the need for nursing leadership, the issue of clinical experiences should be rethought in terms of what nurses with various disabilities may bring to the profession and on what insights nurses with disabilities may bring to improve safety.
Recent court cases involve the issue of persons with disabilities entering nursing, and two recent cases in particular involve persons with hearing impairments. Terra Community College settled a suit brought in federal court and agreed to pay a former student $75,000 for dismissing her from its nursing program. The student had been a practicing Licensed Practical Nurse for 14 years and had a high grade point average. She was dismissed on the basis of claims that she would not be able to hear verbal instructions and equipment sounds (Dwyer, 2015). In a Maryland District Court case, a summary judgment was issued in favor of a recently graduated nurse who was denied employment at Johns Hopkins Hospital related to an accommodation request for sign language interpreters. At the time of the judgment, the nurse was employed at another hospital (Cohn, 2016).
Nursing Role and Competencies
In light of the ANA (2010) definition of nursing, the Essentials for Baccalaureate Education (AACN, 2008, p. 3–4) includes nine essentials: “liberal education for baccalaureate generalist nursing practice, basic organizational and systems leadership for quality care and patient safety, scholarship for evidence-based practice, information management and application of patient care technology, healthcare policy, finance and regulatory environments, interprofessional communication and collaboration for improving patient health outcomes, clinical prevention and population health, professionalism and professional values, and baccalaureate generalist nursing practice.” Concepts emphasized in the essentials include “patient-centered care, interprofessional teams, evidence-based practice, quality improvement, patient safety, informatics, clinical reasoning/critical thinking, genetics and genomics, cultural sensitivity, professionalism, practice across the lifespan, and end-of-life care” (AACN, 2008, p. 3).
Technical Standards for the 21st Century
The Davis case and the initial regulations promulgated for Section 504 are now over 40 years old. Civil rights legislation, advances in technologies, and a generation of persons with disabilities who have grown up under the ADA provide an opportunity to rethink technical standards (Rothstein, 2007). Technical standards should not be written to exclude a class of people by specifying how the task will be accomplished (e.g., “must be able to hear a heart murmur through a stethoscope” vs. “must be able to gather vitals using variety of means”; Smith, 2009). Technical standards also should not be used as a mechanism to deny the admission of persons with disabilities into nursing programs; instead, technical standards should be a way to conceptualize the recruitment of diverse highly qualified nurses.
Reichgott (1998, p. 79) suggested rethinking the categories of technical standards and suggested instead the following five: (1) acquiring fundamental knowledge, (2) developing communication skills, (3) interpreting data, (4) integrating knowledge to establish clinical judgment, and (5) developing appropriate professional attitudes and behaviors. These categories for technical standards address the “what” rather than “how” and are conducive to advancing nursing practice in the 21st century and incorporating thinking on skills necessary for the future work-force (Davies et al., 2011 ; Ericksen, 2015). Table 2 provides examples of technical standards in the five areas proposed by Reichgott and compatibility with the baccalaureate essentials and related attributes proposed by the AACN (2008). Foci of model technical standards for the 21st century should aim to enhance the admission of students who are capable of carrying out nursing as defined and who will become professionals who provide care in all types of settings with the competencies proposed by the AACN.
It should be noted that programs do not have to change their core requirements and do not have to provide accommodations unreasonable for the program; however, the technical standards proposed by Reichgott (1998) are compatible with the definition of nursing and the competencies outlined by the AACN (2008).
Rehabilitation Nurses as Agents of Change
Rehabilitation nurse leaders have a philosophy to assist systems in developing environments that promote people reaching their maximum levels. The Association of Rehabilitation Nurses (2014) Competency Model for Professional Rehabilitation Nursing includes the domains of “nurse-led evidence-based interventions to promote function and health management in persons with disability and/or chronic illness, promotion of health and successful living in persons with disability or chronic illness, leadership, and interprofessional care” (pp. 5, 10, 14, 19).
Rehabilitation nurse leaders are in a unique position to assist persons with disabilities to consider nursing as a profession, to assist nursing programs in developing systems that support persons with disabilities as students, and to assist in rethinking about how a diverse nursing workforce that includes disability as diversity can be a force in needed qualitative change in the health system. In addition, rehabilitation nurse leaders can assist in rethinking technical standards so that they are conducive to a new generation of nurses who will be able to lead and practice in a qualitatively different health system.
Key Practice Points
- A diverse highly qualified nursing workforce is needed for leading a 21st century health system.
- Disability is part of diversity.
- Current technical (nonacademic) standards for entry into many nursing programs are a barrier to capable people with disabilities entering nursing, hampering diversity.
- Rehabilitation nurse leaders, with their philosophy of and competencies for assisting people to reach their maximum level and assisting systems in developing environments that promote people reaching their maximum levels, can help to break down the barriers to persons with disabilities entering the nursing profession.
The authors acknowledge the California Committee on Employment of People With Disabilities, which funded the White Paper on Inclusion of Students With Disabilities in Nursing Educational Programs. The authors declare no other conflicts of interest.
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