Faculty of Nursing, University of Sydney NSW 2006

rdixon@nursing.usyd edu.au

Faculty of Nursing, University of Sydney

The aim of this study was to assess the impact of a 30 hour community-based clinical placement on the willingness of nursing students to work with clients who have developmental disabilities.

It has been observed that this area is avoided by nursing health professionals because of their negative attitudes towards people with developmental disabilities. To overcome this perception and to allow students contact with people with disabilities in an environment where they are not sick, dependent or helpless, students completed a 30-hour community-based clinical placement. In addition, a year-long course of study was given which emphasised an empowerment model.

Three hundred and seventy nine students participated. All students were enrolled in the second year of a Bachelor of Nursing program. After the completion of the clinical placement two cohorts of undergraduate nursing students were asked to complete an extensive evaluation of the experience. This yielded both quantitative and qualitative results.

The quantitative results indicated that the majority of the students were able to apply theory to practice. Many student nurses who had previously indicated that they would not want to work in this area had changed their attitudes. The actual setting in which the students worked was not a significant variable in the increased willingness to work in the area. There were no differences found on any variable between males and females and this contradicts previous findings that males are less willing to work in this area.

Qualitative results indicated that the clinical placement had a positive effect on attitudes. The students identified areas where improvement could be made.

The World Health Organisation definition of developmental disability is the one used in the course at the University of Sydney. A developmental disability is a delay in the development of the child which is attributable to a mental or physical impairment or a combination of impairments. It is manifested before the age of 18 and results in substantial limitations in one or more of the areas of major life activity.

Undergraduate nursing students hold negative attitudes towards people with disabilities because of fear, ignorance and cultural and societal influences. According to Shaw (1995) some nurses have been influenced by the medical model which closely associates disability with illness. George (1992) and Goodall (1992) also describe how people with disabilities have been treated as "patients" by the medical system. The depersonalisation which occurs when a person's disability is discussed, rather than the individual's needs or wishes is particularly harmful (George, 1992; Shaw, 1995). Lee and Rodda (1994) state that "the disability becomes the distinctive characteristic masking other traits and potentials of the people with disabilities" (p.231). Attitudes of nurses can positively and negatively impact on their approach to and care for a client (Brillhart, Jay & Wyers, 1990). In order to provide appropriate care for people with disabilities nursing students must overcome their misperceptions about disability and develop understanding and accepting attitudes towards diversity.

The research literature in this area seems to have two foci. Studies have described the attitudes of nurses and other professionals towards people with disabilities or they have examined different strategies which have been employed to overcome the continuation of negative attitudes.

Nurses' attitudes towards people with disabilities.

Goodall (1992) described the hostile attitudes of some registered nurses towards people with disabilities in acute care settings. Biley (1994) cites recent research which points to nurses' negative attitudes and a general lack of awareness of needs of patients with a physical disability. Nurses often ignored the patients' knowledge about their disability and condition Goodall, 1992).

In previous research it has been demonstrated that nursing students hold beliefs about people with disabilities which need to be challenged (Oermann & Lindgren, 1995, Brillhart et al, 1990). Nursing students in one study believed that elderly people were easier to get along with than people who have a disability or a "mental handicap" (Murray & Chambers, 1991). Furthermore, the students described people who were "mentally handicapped" as "cross" (Murray & Chambers, 1991, p.365).

Brillhart et al (1990) found that nursing students' attitudes deteriorated over their course of study. Registered nurses were more positive than either beginning student nurses or graduating nurses. Teachers in a faculty of nursing had the poorest attitudes. Attitudes of graduating nurses were not significantly different from their teachers' attitudes. The authors concluded that the negative attitudes of the nursing faculty staff had an impact on the development of negative attitudes in their students throughout the course of their education.

Most studies have concentrated on contact, knowledge or a combination of contact plus knowledge in various combinations or proportions to improve attitudes.

Early research gave varying degrees of support for the 'contact hypothesis' (Amir, 1969 cited in Murray & Chambers, 1991; Callaghan et al., 1997). The contact hypothesis proposes that more positive attitudes towards minority groups are promoted through person to person contact. Murray and Chambers (1991) studied the effect of contact only on nursing students' attitudes to elderly people, people with disabilities (presumed physical as this was not clearly stated) and the "mentally handicapped". They found differing results, both positive and negative, which reflected the type of setting and the severity and type of disability. Students expressed more positive attitudes after their clinical placement towards people with physical disabilities who were living in the community, but more negative attitudes towards people with intellectual disability in institutional settings. No mention was made by the authors as to whether the students had any form of knowledge input before they undertook these clinical placements.

The nature of the contact may be important. Marini (1994) reviewed the literature on enhancing societal attitudes towards people with spinal cord injury. The author stated that for contact to produce positive attitude change, other factors such as personality, social skills and presentation of the person with a disability must be taken into consideration. For attitude changes to be effective, the person with a disability had to be perceived as having as positive an image as a person with a disability.

Contact with people with disabilities can also produce negative attitude changes. In a study of 38 dental hygiene students who were involved in visiting a residential centre for people with disabilities approximately half of the students had more negative attitudes following the contact experience (Braff and Nealon, 1982). The authors suggested that some students found the experiences to be emotionally confronting. Nearly all of the clients of the centre had severe or profound intellectual disabilities. This research was conducted in a segregated setting and there was very little control over the clinical experience. There was no way of ensuring whether students had a positive or negative experience.

The researchers, Lindgren and Oermann (1993) and Oermann and Lindgren (1995) have conducted studies concerned with attitude change of nursing students through the presentation of information in educational workshops. The workshop consisted of information about the care of people with physical disabilities, role playing activities and a presentation by a person with a disability. The authors suggested that the intensive workshop allowed the students "to clarify their values and develop positive attitudes towards people with disabilities" (p.9). According to Oermann and Lindgren (1995) the students were presented with both information and contact with a guest speaker with a disability. However, because workshops were held on only one day, it would not seem a significant enough contact component to be considered as an information plus contact intervention. Oermann and Lindgren (1995) conclude that the one-day workshop produced long-lasting attitude changes. At first glance this result seems spurious. It would be difficult to attribute the attitude changes solely to the workshop program because the researchers were unable to control contact and clinical experiences during the longitudinal phase of the study.

Educational programs also have the potential to produce negative attitude changes. This might happen if disability is made central to the presentation or the personality of the presenter is unappealing to students. Marini (1994) states that educational programs are more effective when people with disabilities are shown to be actively participating in community life and are not portrayed as helpless or as victims.

The limited research findings to date indicate that information plus contact is the best approach to altering negative attitudes (Oermann, 1995). There is little literature that examines the impact of information and contact educational programs on nursing students. Other studies, which have used different professional populations, have yielded some interesting results. In a frequently cited study of three groups of physical education students, Berrol (1984) found that contact plus information yielded the most positive attitude change. The other groups in this study received contact only or knowledge only. An interesting finding was that the information condition had a greater impact than the contact condition alone. However, more than 50 % of each group had significant work experience with people with disabilities. Lee-Chan (1992) (cited by Lee and Rodda, 1994) found that information initiated attitude change and that contact maintained the new attitudes of occupational therapy students.

It has been suggested that further research is necessary to determine the factors inherent in clinical experiences which effect more significant attitude changes (Oermann & Lindgren, 1995). The type of setting in which contact occurs has not been well documented in the literature but it would appear to be an important variable. Murray and Chambers (1991) measured the attitudes of first year nursing students before and after clinical placements where the students came into contact with people with disabilities who were actively participating in their communities. The study found that the nursing students' attitudes towards disabled people were more positive after the placement compared with before. It was also found that nursing students held negative attitudes towards people with a "mental handicap" who were in an institutional setting. The students reported feeling afraid of interacting with many of the boisterous residents of the institution and those with severe mental disabilities who were totally dependent on nursing care. Braff and Nealon (1992) found that dental students had more negative attitudes after they had completed a clinical placement in a residential service with people with severe to profound levels of intellectual disability. However, if people with disabilities are seen to be actively involved in the community and are not seen to be victims then these do have a positive effect in education programs (Marini, 1994).

Gender has also been considered in previous research to be an important variable. Michael, Hayes, Gordon and Wallis (1984) found that female medical students held more positive attitudes towards people with disabilities than male medical students. However, more up to date research has found fewer gender differences. Oermann (1995) found no difference between males and females or age for student nurses but she did find differences related to personal experience with a person with a disability.

There are few studies which have attempted to assess the attitudes of nurses and students to people with disabilities and the impact of a course of knowledge and contact clinical placements with nursing students. These few make generalisations difficult to draw concerning attitudes to developmental disability. Most of the literature does not even specify the type of disability or the severity. The majority of the studies reviewed seemed to concentrate on people with physical disabilities. It was not possible to assess if these participants would qualify for inclusion in our definition of developmental disabilities as it was not known whether the disability was congenital or acquired.

Traditional nursing curricula often do not contain issues concerning the care of people developmental disabilities (for example, empowerment of people with disabilities, advocacy, the promotion of independence, simulations, lectures on all aspects of disability). They tend to emphasise the medical characteristics of individual disabilities and related pathologies. Lee and Rodda (1994) showed that negative attitudes are derived from beliefs and these beliefs are derived from information. A lack of information about people with disabilities may lead to able-bodied people feeling uncomfortable. However, Marini (1994) found that courses which concentrate on syndromes, difficulties, and emphasise medical conditions enhance negative attitudes. Therefore, it is necessary for knowledge to be structured so that a positive image of people with disabilities is presented. The course at the University of Sydney endeavours to do this.

Increased exposure to people with disabilities may decrease the discomfort felt by many people without disabilities (cited in Lee & Rodda, 1994 - Westwood, Vargo & Vargo, 1981). The contact hypothesis seems to have some validity but those studies that have reported it have found that contact with severe and profound people with developmental disabilities has led to the formation of negative attitudes. Contact must also be in settings that reinforce the positive image of people with developmental disabilities, such as the community away from institutions and acute care settings.

Information plus increased contact appears to be the most effective strategy for achieving positive attitude modification and combined strategies are more powerful than contact or information alone (Lee & Rodda, 1994). Lee and Rodda feel that information provides new knowledge to the belief system and this leads to the change of attitude, and then the contact serves to reinforce the validity of the acquired information. This is an intriguing notion for

future research.

Although there has been research examining nurses' attitudes towards people with developmental disabilities, to date there has been little investigation of how attitudes impact on nursing students' attitudes towards working with people with disabilities.

This, then, is the theoretical and research context from which the present study derives. Its practical impetus lies in the requirements which students must fulfil as part of their Bachelor of Nursing degree at the University of Sydney. In this program students undertake thirty hours clinical placement in the developmental disability field. This practical experience accompanies a unit of study on disability and a series of nursing laboratory sessions concerned with imparting some of the skills necessary for working with people who have a disability in acute care and community settings.

Traditionally, developmental disability clinical placement had consisted of students working in groups of eight or nine in institutional settings. This was found, increasingly, to be unsatisfactory for four main reasons:

1. Changes in philosophy in the field have resulted in deinstitutionalisation and increased community inclusion. A clinical experience which emphasised segregated settings was out of step with best practice in the field.

2. The limited number of placements available which were able to take groups made organisation of the clinical for more than 300 students problematic.

3. The decreased amount of funding available to pay for supervisors made it difficult to continue the previous approach of having one supervisor spend the clinical with a group of students (the usual practice in medical-surgical placements).

4. The students generally expressed negative attitudes to undertaking the disability placement often expressing a reluctance to be involved.

When explored in some detail, the students' negative feelings seemed to stem from:

1. A lack of experience and contact with people who have a disability.

2. The disability field not being perceived as "real nursing" which the students largely seemed to define as working in acute care settings. It would seem that this view was reinforced by the developmental disability clinical placement being of shorter duration than medical-surgical placements.

3. The reports of previous students' experiences in institutional settings where, for many students, the clinical placement had been confronting and, in some instances, frightening.

Change was needed. It was therefore decided to make much greater use of community settings. This decision meant that students would no longer be able to go to their clinical placement as part of a group as most of the settings would be too small to take more than one or perhaps two students at a time. This also then meant that the method of supervision would need to

change.

The clinical experience was therefore designed to have the students contract to work with a person who a person who had a developmental disability, a family which had a child with a disability or a small group of people who had developmental disabilities. These hours might be spent in the person's home, a preschool or school, a training centre or a holiday camp. The one exception was that the time could not be spent in an acute care setting. Direct supervision was replaced by having the student matched with a mentor who might be a person with a disability, a parent or a professional. This person's role was to act as the student's guide as they learned about the impact of disability on individuals, their families and society. The experience was overseen, at university level, by two members of the disability teaching team who were available on pager seven days per week during the clinical period.

Assessment of the students' placement had five components. These were the completion of:

1. 30 hours' work in the setting. Students listed the date and length of each meeting in their log book and have it signed by their mentor.

2. a clinical log and clinical report which encouraged the students to reflect on their experience and which directed their learning into key areas,

3. a specific goal which students set in collaboration with their mentors,

4. a series of questions which asked students to evaluate their clinical experience, and,

5. a short evaluation form sent to the mentor and returned directly to the university which considered the students' performance.

The overriding change in the clinical was one of philosophy. The aim of the clinical experience was to enable the students to see people with disabilities living, learning and playing in the community. The medical model was replaced by the empowerment model. There was also an explicit recognition that the majority of students would not spend their nursing careers working in the disability field but that they would invariably work with people with disabilities in acute care settings. It was hoped that this change in focus would be bring about a change in attitude to people with disabilities and students' willingness to work with them.

The aim of this study, then, was to assess the effectiveness of this approach in enhancing students' attitudes to and willingness to work with people who have disabilities. Specifically:

1. After completing the clinical placement would students now consider working in the disability field?

2. Do students feel that they were able to apply theory to practice during their placement?

3. What do students see as the best features of the clinical placement and its organisation?

4. What do students see as the worst features of the clinical placement and its organisation?

The participants comprised a random sample of two cohorts of second-year undergraduate students enrolled in the Bachelor of Nursing degree at the University of Sydney. The sample of 391 included 324 females and 67 males.

It was not possible to control for the students' previous experience and knowledge of people with developmental disabilities. However, students who had documented evidence of their having worked in the field recently were exempt from the clinical placement. It could therefore be assumed that the students involved in the study had limited contact and/ or vocational experience with people with a developmental disability.

As detailed above, students were required to complete an extensive journal and evaluation of their 30 hours' clinical experience. The data for this study derived primarily from the section of the log dealing with the students' evaluation of their clinical placement and included a mixture of forced choice (Yes/No) and open-ended questions. (The questions are set out in the Appendix.)

Initial analyses of the data revealed no differences between the two cohorts. As a consequence, the samples for the two years were pooled for analysis. Similarly, no differences were found due to gender. The students' gender was therefore not included as a variable in the analyses reported below. The type of setting the students were placed in also made no difference to any of the results.

1. After completing the clinical placement would students now consider working in the disability field?

58% of the students responded yes, 42% no ( ² = 9.8179, df = 1, p <.001). It is worth noting that a large proportion of those who answered no qualified their response by saying that this decision was not related to their views of disability per se but to their having clear career aspirations in other areas of nursing. Given that the reason for changing the approach to the clinical experience derived largely from the students' reluctance to work in the field and their professed lack of interest in it, this was a very positive finding.

Furthermore, of those who responded yes, 61% saw their willingness to work now in the disability field as being a consequence of their clinical experience ( ² = 10.5688, df = 1, p<.001). The positive effect of the placement is therefore apparent. Students both enjoyed their experience of working with people with disabilities and saw it as affecting their attitudes to working in the area.

The overwhelming majority of students (87%) reported that they had found that they were able to apply the theory and skills they had learned in the disability course to the practical situation ( ² = 207.2467, df = 1, p<.001). While this is in itself a pleasing result suggesting that the students' learning in the course and workshops had been of an order which enabled them to apply and generalise skills in a variety of situations, the students comments on this question deserve noting. Although they mostly gave examples of application related to the disability course many also pointed to their having been able to apply skills learned in other areas of the program such as medical-surgical nursing. This was seen as important given the students' previous concerns that work in the developmental disability did not constitute "real" nursing.

3. What do students see as the best features of the clinical placement and its organisation?

The data obtained was qualitative. All responses were categorised and were seen as falling into four areas: the clients, professional skills, personal considerations and the organisation of the clinical placement.

Where the students saw the clients themselves as the best feature of the clinical they referred to the delight in teaching new skills to someone else and seeing progress, the opportunity to have direct contact with someone with a disability and building relationships. The emphasis seemed to be on seeing past the disability to the person with whom they were working. Indeed, a number of the students articulated their experience in that way.

The second category of response largely referred to the development of professionals skills. Here students pointed to the opportunity to integrate skills learned in other areas, to coming to see not only the professional but also the client's and family's perspective, and to working as part of a team and working with a mentor. This category of response can be seen as reinforcing the conclusion that the students were seeing the developmental disability placement as a venue for skill and professional development; something that had not been the case before the new approach.

The view was also expressed that students had also benefited personally form the experience. Students referred here to "using my mind differently" and realising that children with disabilities are not sick. A less pleasing response was that which saw the best feature as being "helping the less fortunate"; this is a view which is helpful to neither the nurse nor the client.

Finally, students also saw the organisation of the clinical placement itself as its own best feature. Here they emphasised the fact that they could choose the location and timing of the experience, that they were autonomous and that they had staff support.

4. What do students see as the worst features of the clinical placement and its organisation?

The students also listed what they saw as the worst features of the clinical. These responses, were found fall within the same four categories.

The issues of most concern with respect to the clients themselves were behaviour problems and what they described as their frustration in working with them. As previously stated, for many this was their first contact with someone with a disability. These comments may well be a reflection of this as well as a function of the behaviour of the clients themselves.

Some students also expressed concerns related to the development of their skills. These generally involved the lack of time spent with their mentor, staff being critical of their performance and the mentor not having the level of knowledge they expected. The latter, in particular, may have been due to the mentor not necessarily coming from the same professional background as themselves. Indeed, the mentor, could have been a parent or a person with a disability. Students' views are thus likely to have been affected by their expectations both for the role the mentor would play and the nature of the work to be undertaken.

Personal concerns included expressions of the students' fears and feelings while working with people with a disability, their feeling that they were given too much responsibility and not knowing enough before the clinical commenced.

Negative features related to the organisation of the clinical included the view that expectations had been poorly communicated, that there was not enough supervision, that they would prefer a blocked time (students could undertake the clinical at any time convenient to them and their mentor within the academic year) and there being no debriefing. The latter is an issue of some concern and one that warrants consideration.

It is also interesting to note that what some students saw as the best features of the clinical placement were what others saw as its worst. Freedom and choice for some was viewed as unclear expectations and confusion by others.

To summarise, the clinical was viewed positively by the majority of students and had a positive effect on the students' stated willingness to consider working in the field. There is a recognition however that some aspects of the organisation and implementation of the clinical experience need modification.

The data derived from the study point to a number of areas in which change could be effected. These are that the:

The message to be taken overall, however, is that the approach is worth pursuing.

Future research could involve consideration of student characteristics which affect the positive and successful completion of clinical programs and the use of normed instruments to measure student attitudes and attitude change. This is an area that warrants further study; designing and implementing clinical programs which not only allow the students to practise their skills but which go some way to enhancing their attitudes towards the particular field are to be promoted.

The assistance of Cathy Reddacliff in the preparation of this paper is gratefully acknowledged.

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1. What have you gained from this clinical experience? (Open ended)

2. Were you able to apply theory to practice? (Yes/No ..included room for comments)

3. To what extent have your attitudes towards those with disabilities changed either professionally or personally? (Open ended)

4. After completing this clinical would you consider nursing in areas that exclusively work with people with disabilities? (Yes/No ...Why/why not?)

5. Is your answer to question 4 different to what you would have said before completing this clinical? (Yes/No)

6. Was the clinical log a benefit to you? (Yes/No... Why/why not?)

7. Was the assessment load realistic and appropriate? (Yes/No.... Comments)

8. Which features of this clinical or its organisation were its best features? (Open ended)

9. Which features of this clinical or its organisation were its worst features? (Open ended)