Support for nursing and midwifery students with dyslexia

In the past decade, the publication of employment and equality law in Ireland and elsewhere has precipitated a significant rise in those with disabilities applying for professional careers in teaching and nursing. One such disability is dyslexia.

Definitions of dyslexia are variable and complex, but what is common to most is difficulty in one or more of the key literacy domains, including reading, writing or spelling, as well as problems in the organisation and processing of information. 

Dyslexia, also called a specific learning difficulty (SLD), is evident worldwide irrespective of culture or gender. It affects approximately 8% of the population.¹ The prevalence of dyslexia is not fully defined, although a recent study found a 12% incidence among undergraduate nursing students.²

Nurses make up a large proportion of the healthcare workforce and the numbers with dyslexia are relatively significant. Individuals with dyslexia have traditionally been viewed in certain ways or linked to specific identities, two of which are creativity and risk to patients. 

Some suggest that students with dyslexia have a high probability of being innovative and talented.^3,4 However no reliable evidence confirms this to be true⁴ and there are growing objections to such views.⁶ Some believe promoting such a view is unhelpful to those with dyslexia who have no distinguishing talents. Assuming creativity in these instances can create potentially impossible expectations on students with dyslexia in practice placements and may alienate them as a result. Unrealistic assumptions put stress on students and place them under unnecessary pressure to achieve.⁴ Preceptors should not assume, therefore, that a student with dyslexia may be more creative or talented than their fellow peers.

Because of the literacy difficulties people with dyslexia experience – including potential problems in nursing documentation, drug administration and processing of instructions – many employers consider students with dyslexia as more likely to produce errors and pose a risk to patients.⁷ However, a number of arguments are made to counter this aligning of a risky identity to students and staff nurses with dyslexia. 

The first highlights the many innovative strategies students and qualified nurses devise to overcome the challenges they experience.^2,8,9 Secondly, students with dyslexia have demonstrated heightened self-awareness that promotes patient safety in the placement setting.¹⁰ Thirdly, incidents that are highlighted around patient safety are largely based on isolated personal experiences¹¹ and are described as ‘folk theories’¹² with a lack of substantive evidence to support the linkage.^8,10

Finally, student and staff nurses are guided by a professional scope of practice that ultimately influences patient care interventions and minimises risk.

Reasonable accommodation

Under current Irish equality legislation, all educational establishments are required to provide reasonable accommodations to support students with disabilities in accessing their chosen course.¹³ Healthcare service providers are legally obliged to complete an individual needs assessment on students who disclose their dyslexia and proactively implement reasonable accommodations as a result (see Table 1). 

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Such accommodations are justified and necessary for students with dyslexia. They counteract the literacy disadvantages that students with dyslexia have, and introduce them to a level playing field that is equivalent to their peers. Significantly, it does not confer ‘special treatment’ or ‘an unfair advantage’ on students with dyslexia but instead brings them to a point where they are equal to others at their stage of the programme.  

More importantly, attempting to treat everyone the same is not akin to treating everyone fairly.⁴ Some confusion exists as to what constitutes reasonable accommodations for students with dyslexia in clinical practice. Two recent Irish publications offer clarity on this: ’Supporting nursing and midwifery students with a disability in clinical practice’ and ‘National guidelines for working with students with a disability or specific learning difficulty in clinical practice’.^14,15

Healthcare institutions should avoid focusing exclusively on their sole implementation but aim instead at introducing a much wider socio-cultural emphasis on disability awareness and diversity in the workplace. 

Achieving competency standards are the same for all students and irrespective of whether a student has dyslexia or not, all qualified nurses must be capable of ‘safe and effective practice without supervision’ on qualifying as a registered nurse.¹⁶

Assessment of competency standards must take into account the provision of reasonable accommodations, and in some instances, altering an assessment or the inclusion of an alternative mode of assessment may need to be considered.¹³

The provision of reasonable accommodations offered to students as they move from academic to practice placement settings are comparatively different and should be identified using separate and discrete criteria. For example, while considerations on grammatical and spelling may be waived by a lecturer marking an academic piece of work, no such accommodations are possible in practice placements given its criticality to standards and continuity of patient care. 

Equally, having a reader present during formal examinations is regularly granted in higher education settings. However, such accommodations are not permissible in practice placement settings in the context of reading patient documentation. 

Also, when considering appropriate accommodations, assessors should take into consideration whether patient safety has the potential to be compromised¹⁶ and remind students of their ongoing professional obligations.

Reasonable accommodations provided to students with dyslexia have the potential to indirectly assist all students completing their practice placement. Every effort should be made to create portals for all students to access patient documentation, and construct unique abbreviation lists applicable to specialist and generic placements. In essence this is described as universal instructional design, where educational settings are striving to provide an accessible education for all students including those without dyslexia.¹⁷

Disclosure of dyslexia

Students with dyslexia are not legally obliged to disclose their diagnosis. However, a positive working environment is more conducive to this taking place.¹⁴ Dyslexia may carry a stigma that may lead to student nurses not disclosing.⁸ Stigma can be linked to being perceived or considered by others as stupid, slow or not suitable on professional grounds.¹⁸

A clinical placement that is not conducive to disclosure of an unseen disability has potential competency implications for students which may ultimately impact on standards of patient care. A student, who indicates that they have dyslexia, does not constitute disclosure in a formal sense. 

Formal disclosure of an unseen disability like dyslexia occurs once the necessary documentation and confirmation of diagnosis is received by the appropriate disability services in the higher education institution where the student is registered. If a student informs you that they have dyslexia, you need to manage the matter sensitively and inform them that you will be passing on the information to the designated personnel so that the disclosure can be formalised and appropriate supports put in place.¹⁵

For many students with dyslexia, attending to patient documentation can emerge as a particular challenge. However with appropriate early interventions and strategies tailored to students’ individual needs, difficulties, such as familiarisation with specialist terminology and length of time to complete documentation, can be effectively managed. 

If there is an emphasis in first year on completing patient care documentation that continues throughout the four years of their programme, the necessary strategies to alleviate the difficulties they face can be honed and perfected. If this is ignored, some such students may have a fragile competency attainment, culminating in inadequate patient care documentation as a result.

Not everyone who wants to be a nurse will ultimately become one.¹⁹ Nurse preceptors who partake in decisions about a students’ future must focus exclusively on their capacity to achieve competency, and not become shackled with unrelated concerns that centre more generally on their dyslexia label. 

Increasingly, in the nursing profession and elsewhere, advocates of inclusion and widening participation policy are promoting the notion of diversity through encouraging tolerance.^20,21 However, tolerance, in this context is problematic and positions students with dyslexia as having an unqualified acceptance, advocating a pejorative notion of ‘putting up with them’ notion in nursing. 

By contrast, valuing difference and the important contribution and valuable life experience that individuals with a disability might bring to the nursing profession, should be welcomed. Students with dyslexia in nurse education can help challenge enduring assumptions about how disability is constructed and help stimulate a more flexible, responsive and universal experience for all students immersed in the journey of becoming a registered nurse.

References

1. European Dyslexia Association. 2013. Retrieved from: http://www.eda-info.eu/en/dyslexia-incidence-and-emotional-effects.html
2. Wray J, Aspland J, Taghzouit J, Pace K, Harrison P. Screening for specific learning difficulties (SpLD): The impact upon the progression of pre-registration nursing students. Nurse Ed Today, 2011; 32(1): 96-100
3. Cowen M. Dyslexia, dyspraxia and dyscalculia: A guide for nurses and practitioners. London, England 2010: Royal College of Nursing
4. Hutchinson JO, Atkinson K. Into physiotherapy: Welcoming and supporting disabled students, 2010. Retrieved from: http://www.csp.org.uk/publications/physiotherapy-welcoming-supporting-disabled-students   
5. Lawrence D. Understanding dyslexia: A guide for teachers and parents. Berkshire, England, 2009: The McGraw Hill Companies
6. Dimitriadi Y. Resistance from within: Children with dyslexia gazing at their disability. In: Satterthwaite J,  Martin W,  Roberts L  (Eds.), Discourse resistance and identity formation. Stoke on Trent, England: Trentham Books, 2006: 145-167
7. Child J, Langford E. Exploring the learning experiences of nursing students with dyslexia. Nursing Standard, 2011; 25(40): 39-46
8. Dale C, Aiken F. A Review of the literature into dyslexia in nursing practice: Final report. London, England: Royal College of Nursing 2007
9. White J. Supporting nursing students with dyslexia in clinical practice. Nursing Standard, 2007; 21(19): 35-43
10. Morris D, Turnbull, P. Clinical experiences of students with dyslexia. J Adv Nursing, 2006; 54(2): 238-247
11. Tee S, Cowen M. Supporting students with disabilities: Promoting understanding amongst mentors in practice. Nurse Ed Practice,  2011; 12: 6-10
12. Millward L. Understanding Occupational and Organisational Psychology. London, England, 2005: Sage Publications Ltd
13. Association for Higher Education, Access and Disability. Good practice guidelines for the providers of supports and services for students with disabilities in Higher Education. Dublin, Ireland: Association for Higher Education, Access and Disability (AHEAD), 2008
14. Halligan P, Howlin F. Supporting nursing and midwifery students with a disability in clinical practice: A resource guide for clinical and academic staff. Dublin, Ireland: University College Dublin, 2011
15. Association for Higher Education Access and Disability. National guidelines for working with nursing and midwifery students with a disability or specific learning difficulty in clinical practice. Dublin, Ireland: AHEAD. 2011
16. Nursing and Midwifery Council (NMC)(2011).  Advice and supporting information for implementing NMC standards for pre-registration nursing education. Available at: http://standards.nmcuk.org/PreRegNursing/nonstatutory/Documents/Advice%20and%20supporting%20information%20for%20SPNE%2020110325.PDF
17. Ginsberg S, Schulte K. Instructional accommodations: Impact of conventional vs. social constructivist view of disability. J Scholarship of Teaching and Learning, 2008; 8(2): 84-91  
18. Evans, W. “I am not a dyslexic person.  I’m a person with dyslexia”.  An examination of dyslexic identities and related discourses within nurse education in Ireland. Unpublished Doctoral Thesis. Sheffield, England: University of Sheffield, 2013
19. Heelan A.  Forward in:  The real risk is doing nothing. Dublin, Ireland: AHEAD, 2011
20. Roberts H. Listening to disabled students on teaching, learning and reasonable adjustments. In M. Fuller, J. Georgeson M, Healey A, Hurst K, Kelly S, Riddell et al (Eds). Improving disabled students’ learning: Experiences and outcomes. London, England: Routledge, 2009: 38-59
21. Crowley N. Empty promises: Bringing the equality authority to heel. Dublin, Ireland: A & A Farmer Ltd, 2010