While institutions of higher education may have increased access and accommodation for students with disabilities, institutions primarily providing nurse training in South Africa do not mirror the same practice.
Notwithstanding the integration of disability policies enacted in South Africa in 2010, a majority of people with disabilities are still excluded from the activities of society equally applicable to nursing education. This article describes the current access and recruitment practices for student nurses with disabilities (SNWDs) in nursing education institutions in KwaZulu-Natal to provide baseline data, which is largely absent in nursing institutions.
A concurrent mixed-method design using a multiple embedded case study approach was employed. This article presented phase 1 of the study, a quantitative survey of all private nursing education institutions (
The findings revealed that the majority of private NEIs lack policy guidelines for recruiting SNWDs; however, other means of guidance is sought, for example, using the technical assistance. While NEIs were willing to recruit SNWDs, access to clinical sites, lectures, support systems and reasonable accommodation was challenging.
Private NEIs are providing an inclusive education to all students including those with disabilities; however, they still have a long way to go in meeting the needs of SNWDs with regards to support and accommodation.
Higher education institutions have been encouraged to ensure access for and participation of people with disabilities; however, policies in the institutions of higher learning that train nurses still show gaps in meeting the needs of learners with disabilities. Previous education policies and practices have been focused along racial and political lines (Foundation of Tertiary Institutions of the Northern Metropolis [FOTIM]
Integration of disability in South Africa’s policies was enacted in 2010, with the aim of ensuring equal rights to all people in South Africa, including people with disabilities. There are various policies and frameworks in South Africa related to disability, which prevent discrimination, including: the constitution of South Africa (Republic of South Africa
Current policies reinforce an equitable education for all, including people with disabilities. The World Report on Disability (World Health Organization
Such discrimination overtly discourages students with disabilities from entering the nursing profession. Structures within the nursing profession itself, such as the absence of disability policy guidelines and in particular the clinical component of the undergraduate nurse training programmes, make it difficult for SNWDs to become registered or enrolled nurses. The clinical component is designed as a ‘one size fits all’ model for able-bodied students and is therefore looked at as being essential (Ryan
An appraisal of available literature reveals limited studies on access and recruitment practices, or how well assessment and teaching practices cater for the needs of SNWDs in Higher Education Institutions (HEIs) and NEIs in South Africa (Matshedisho
This article reports on the results of a survey of all private NEIs and one public university in South Africa regarding their current access and recruitment practices. The study draws from Christensen and Rizvi’s (
The framework guiding the study was adapted from the Integrated Primary Health Care model by Sibiya and Gwele (
The number of NSWDs entering the nursing programme in South Africa is increasing, even though the exact number of these students is unknown (Neal-Boylan & Miller
This article’s purpose was to describe the current access and recruitment practices for SNWDs in NEIs in KZN.
What are the current access and recruitment practices for SNWDs in NEIs in KZN?
A descriptive, qualitative design using a concurrent mixed methods case study approach was employed. A quantitative design was employed to explore the current access and recruitment practices of SNWDs in NEIs. This article presents phase one of a much larger PhD study, a quantitative survey of all private NEIs (
This phase of the study took place in all private NEIs in KZN and one South African university. The private NEIs were purposively selected as they are more independent, and function as a stand-alone NEI, where decisions and procedures with regard to SNWDs can be made by the NEI itself without any outside influence.
The list of NEIs from the South African Nursing Council (SANC) website was used as a sample frame (Polit & Beck
SNWDs were purposively selected (Polit & Beck
Two types of data collection instruments were utilised in this study, namely survey questionnaires for all NEIs, strengthened by a semi-structured interview guide for SNWDs. The self-report, semi-structured survey questionnaire was adapted from a study by Wray, Gibson and Aspland (
The semi-structured interview guide elicited information on the experiences of SNWDs with an emphasis on the access and recruitment practices at NEIs. The guide was flexible enough to allow the SNWDs to express themselves, and they were given an opportunity to raise concerns relevant to the study, even if it was not mentioned in the interview guide.
Individual face-to-face interviews were held with ten SNWDs at a date, venue and time convenient to them. All interviews were tape-recorded with their prior consent, and after explaining the ethical aspects including no monetary payment for participation.
The quantitative data collected were captured and subsequently analysed using the Statistical Package for Social Sciences (SPSS version 24). Descriptive statistics, such as frequencies and percentages, were used to summarise the data (Polit & Beck
Content analysis was used to analyse qualitative data obtained through the individual interviews with SNWDs (Hsieh & Shannon
Ethical approval was obtained from University of KwaZulu-Natal (UKZN) Ethics Committee (reference number: HSS/1367/015D). Individual consent was obtained from each participant to participate in the study, and to have their voices recorded. Participants were reassured that their names would be kept confidential, and their right to self-determination, privacy, anonymity, confidentiality, fair treatment and protection from harm and discomfort were respected (Burns & Grove
The presentation of the findings was guided by the research questions and conceptual framework. Findings are presented according to socio-demographic information, current access and recruitment practices of nurse training programmes.
The majority of the principals of the NEIs were female 95.5% (
This study findings revealed that the majority of the principals of private NEI (76.2%;
Only 14.3% of students (
‘All my lecturers didn’t notice I didn’t have a finger, even the principal, all of them they didn’t notice.’ (Participant 4, Martha, female, 24 years old)
A majority (85.7%,
Access to nurse training programmes is similar amongst the different NEIs, which requires all students to complete an application form, and attach their curriculum vitae. In some NEIs, selection is based on the results of a test students are obliged to take. This suggests that there is no discrimination between able-bodied and SNWDs and that all students are therefore treated equally.
One student noted:
‘Well, my experience on admission to the nursing college, […] I can’t really comment much about that. I didn’t have any problems, ’cause we follow a procedure like everyone else: you go and write a test, which consist[s] of [an] English essay and the Mathematics, and the Physical Science. So, we wrote that exam and then based on who got the highest mark[s], that’s how we got accepted’. (Participant 7, John, male, 37 years old)
In addition, the application form includes a section to be completed eliciting information about the students’ disability. This was not accurately completed, as SNWDs deliberately chose not to disclose their disability because of the fear of stigma and discrimination. For example, one hearing impaired student recounted:
‘I do feel that if I do put on the form that I have a disability, it may affect my chances of getting in, or lessen my chances I should say. Um, and because it doesn’t affect my work, I don’t find it necessary. Really, I’ll just tell them verbally that I have a hearing problem when I get there’. (Participant 2, Katy, female, 24 years old)
On the occasion where a decision needs to be made regarding a student’s fitness to train as a nurse, the NEI consults different key stakeholders.
Key stakeholders involved in decision-making regarding the students’ fitness to undertake nurse training.
Key stakeholders | Yes | % | No | % | |
---|---|---|---|---|---|
Nursing service manager | 2 | 12.5 | 14 | 87.5 | 16 |
Principal of the college | 14 | 82.4 | 3 | 1.6 | 17 |
College council/senate/campus board | 2 | 12.5 | 14 | 87.5 | 16 |
Doctor/medical advisor | 10 | 52.6 | 9 | 47.4 | 19 |
Human resource practitioner | 2 | 12.5 | 14 | 87.5 | 16 |
The applicant | 3 | 18.3 | 13 | 81.3 | 16 |
Occupational health nurse | 4 | 30.8 | 9 | 42.9 | 13 |
Social worker | 1 | 8.3 | 11 | 91.7 | 12 |
Psychologists | 4 | 33.3 | 8 | 66.7 | 12 |
Access to clinical sites.
Type of reasonable accommodation | Yes | % | No | % | |
---|---|---|---|---|---|
Providing modified equipment | 2 | 13.3 | 13 | 86.7 | 15 |
Modify workstation, for example OSCE | 2 | 14.3 | 12 | 85.7 | 14 |
Make existing facilities accessible to SNWDs | 5 | 35.7 | 9 | 64.3 | 14 |
Modify test times | 3 | 21.4 | 11 | 78.6 | 14 |
Allow for special leave on duty | 3 | 21.4 | 11 | 78.6 | 14 |
Provide additional support | 8 | 57.1 | 6 | 42.9 | 14 |
Provide training or retraining | 4 | 28.6 | 10 | 71.4 | 14 |
Provide counselling | 1 | 7.7 | 12 | 92.3 | 13 |
OSCE, objective structured clinical examination; SNWDs, student nurses with disabilities.
A common thread that emerged amongst SNWDs was communication barriers, especially in hearing impaired SNWDs when lecturers spoke in a very soft tone, as indicated in the following:
‘…especially at college, when writing the notes while the teacher is busy educating us. Sometimes I can’t hear. She can’t write the notes, she so difficult’. (Participant 8, Isobel, female, 41 years old)
Another student noted:
‘They understood, and they allowed me to sit in the front. They spoke louder and usually they would give me eye contact while lecturing, and that helped a lot. There were some strict ones that don’t want to hear anything you have to say. Hey, they just want to lecture and leave, so I didn’t want to bother them with my situation’. (Participant 2, Katy, female, 24 years old)
The above quote suggests that while some educators are willing to assist and accommodate SNWDs, other educators are not so accommodating.
Nursing education institutions perceive students with chronic conditions, such as epilepsy, to have a disability and reported that these students needed more time to grasp the teaching material as compared to other able-bodied students. The NEIs further reported that students on chronic medication, such as anti-epileptics, experienced side effects for example altered thought processes, decreasing a student’s concentration span.
A percentage of 52.4% (
More than half of the NEIs surveyed did not provide support in the form of modified equipment (86.7%,
Accessing the clinical area for SNWDs was challenging because of a lack of funds for transport, as SNWDs already had to pay fees for training at NEIs. Sometimes the only source of income for SNWDs is a state grant.
A majority of NEIs are accessible to SNWDs, but with some limitations, such as a lack of escalators, as quoted below:
‘I would just love the schools to accommodate people with disabilities; I would say maybe lifts, because at first, I didn’t know how to walk up and down the stairs. In the first week, I used crutches, but as I’m saying […] it was difficult, it was difficult for me. But at the same time, I was […] the tutors were waiting for me at the top, I need to go up … I need to have my bag, … Because she’ll [educator] be […] waiting for me at the top’. (Participant 3, Rachael, female, 23 years old)
In NEIs where escalators were present, access to certain lectures not on the ground floor was denied, for example lectures held in the skills laboratory. Even though lecturers were willing to change the venue to accommodate SNWDs, they were unable to move the skills laboratory because of availability of specialised equipment, resulting in SNWDs missing those lectures, as well as clinical time in the skills laboratory. This is a revealing and critical finding, as it demonstrates the disjointed nature of disability support in programmes that go outside of the regular classroom lecture setting. This finding is key and is in violation of the equity of access practices.
A small minority of private NEIs (23.8%,
The majority of the principals were female, as seen in studies by Christensen (
The common thread that emerged from all participants was that gaining access to the nurse programmes was not difficult. The different NEIs have a common procedure used to recruit all students, including SNWDs, which includes completing an application form and attaching a curriculum vitae. The study’s findings suggest that the majority of NEIs lacked internal policy guidelines for recruiting and integrating SNWDs; however, alternate sources were used as a point of reference. While the majority of the principals of the NEIs are directly involved in recruiting SNWDs, when decisions need to be made regarding a student’s fitness to undertake the nursing programme, different key stakeholders from the multidisciplinary team are consulted.
The findings of the survey indicate that a large majority of students were either not disabled or did not disclose their disability. It is interesting to note that while one NEI indicated ‘not applicable’ on the survey questionnaire, during the individual interview with the SNWDs, this participant revealed having completed the enrolled nurse programme with the NEI, suggesting a disjuncture between the findings. This study further suggests that SNWDs were afraid to disclose their disability, for fear of discrimination, and hence being excluded from the course, which concurs with the findings of a study by Ryan (
It is important to note that even though the NEIs requested a declaration of health and/or disability at periodic intervals during the students, training, none of the NEIs requested a physical examination during the recruitment process. The majority of the students had hidden disabilities, which made it easier for the SNWDs to hide their disabilities, until they were accepted into the nurse training programme, and only disclosed their disability once they secured a place in the programme. In some instances, the lecturers only became aware of the disability when meeting the students, usually in class or during clinical accompaniment, which resonates with findings from Aaberg (
This study’s findings concur with previous findings of Mosia and Phasha (
The NEIs indicated a lack of funds to purchase specialised equipment or to recruit additional staff members, which confirmed the findings of a study by Emong and Eron (
On a more positive note, SNWDs depend heavily on other colleagues for assistance, such as note taking (Mosia & Phasha
The findings of this study evidence adequate access to the physical environment of NEIs, such as well-designed buildings with ramps and escalators; however, the escalator was often not in good working order. This prevented SNWDs from accessing lectures such as those in the skills laboratory located above the ground floor. Even though lecturers were willing to relocate the venue for normal classroom lectures, specialised rooms such as the skills laboratory could not be moved, because of specialised equipment and resources.
The lecture method is the most common teaching strategy used, which requires face-to-face contact. This was a challenge, as the lecturer sometimes walked around the class, which made it difficult for hearing impaired students to lip read. Hearing impaired students, in addition, use facial expressions and facial cues when interpreting messages, and this proved difficult when educators spoke and wrote on the board at the same time, which coincides with the findings of Emong and Eron (
Reasonable accommodation provided to SNWDs includes modifying equipment, workstations, test times, providing additional support, training or retraining and counselling. Modified test times varied at different NEIs, between 15 and 30 min extra per test and/or examination, because of the absence of policy guidelines to guide NEIs when recruiting SNWDs. Emong and Eron (
The financial implications of recruiting SNWDs are a challenge for NEIs, which do not have adequate funds to purchase any new and specialised equipment/resources, such as employing a sign language interpreter for hearing impaired students. Hearing impaired students also experienced challenges when lecturers spoke in a soft tone or when lecturers walked around the class while lecturing. Hearing impaired students expressed concern that they needed to see the lecturer to be able to lip read. They added that facial expression also played a role during communication. The researcher proposed these aspects be included in the guidelines for nurse educators to have a source of reference to guide their practice. The only source of income for students with mobility impairment is a minimal state grant, which makes it difficult for them to travel to the clinical site daily using public transport to ensure their clinical hours are met. Mobility impaired students also experienced difficulty accessing lecture venues. Barriers to the lecturers for vision impaired students were the lack of notes and/or PowerPoint presentations from some lecturers.
The rational explanation for the lack of support and provision of reasonable accommodations is the lack of disclosure by students themselves. The lack of guidelines further compounds these challenges as nurse educators lack a reference document to ensure support and reasonable accommodation is provided to all students in a fair and consistent manner preventing any form of discrimination. Hence, the researcher proposes including a standardised procedure for recruitment and selection of all learners including SNWDs, which should encourage voluntary disclosure within an enabling and supportive environment by a multidisciplinary disability committee.
In addition, students themselves reported the course as being stressful, and sought assistance and counselling from lecturers. The author concludes that determining the physical skills essential for the nursing profession and identifying skills that are able to apply accommodation without harming the integrity of professional competence may help reduce barriers.
These study findings indicate that SNWDs still choose to hide their disability because of disclosure. The number of students identified in this study is limited to those students who disclosed their disability, and hence the study cannot represent the total population of SNWDs in private NEIs. In addition, this study was conducted in private NEIs and one public university only, and for that reason, it should be interpreted with caution and not be generalised to all NEIs in South Africa.
Recruitment practices, teaching and learning practices, and the nursing curricula can all influence the recruitment of SNWDs in NEIs (FOTIM
While every effort was made to include SNWDs in NEI programmes, accommodating SNWDs was situational rather than systemic, and in the absence of clear policy guidelines, some lecturers were more than supportive, while others were not. SNWDs preferred to hide their disabilities until they secured a space in the programme, and only disclosed their disability when reasonable accommodation was required, while some students went through the entire programme without informing the NEI about their disability. It is significant to note that countries like the United States of America have federal laws such as the Americans with Disabilities Act 1990, amended in 2008, and Section 504 of the Rehabilitation Act of 1973 that protect people in higher education from any form of discrimination and require higher education accommodation as a civil right (Americans Disability Act
The researcher makes the following recommendations: further collaborative planning of the NEI principals and disability support staff is needed to develop the mutually agreed upon support system to use. Barriers in nurse training environments need to be identified and the ‘essential functions’ of nursing programmes need to be decided on by key stakeholders involved in nursing education. Continuing professional development of educators on the integration of SNWDs and inclusive teaching practices in the classroom, as well as reasonable accommodation in the practice-based setting (Lombardi, Murray & Dallas
The authors thank the National Research Foundation for financially supporting this study and SANTRUST for the many workshops and support they continue to provide.
The authors declare they have no financial or personal relationships that may inappropriately influenced them in writing this article.
S.M. was responsible for study design, data collection and analysis, and manuscript writing. M.G. was responsible for guidance during the whole research process and review of the manuscript.