The American Community Survey (U.S. Census Bureau, 2005) estimated that of the 188 million people ages 16 to 64 working in the United States, an estimated 13.8 million (7.3%) have a disability. Although the number of nurses or nursing students with disabilities is unknown, there is ample evidence that students with visible disabilities have historically been denied admission to schools of nursing and have been discriminated against in nursing education programs solely on the basis of their disability (Maheady, 2003; Maheady & Fleming, 2005; New England ADA Center, 2008). Students with disabilities have been expected to complete tests and tasks not expected of students without disabilities, have been denied admission outright on the basis of a disability, or have been admitted and then treated differently due to a disability (Maheady, 2003; Maheady & Fleming, 2005; New England ADA Center, 2008).
The American Nurses Association (ANA) established a position statement (1998) on discrimination and racism. The document specifically mandates that nurses should not discriminate on the basis of disability in nursing education or nursing practice. The statement reads:
Discrimination and racism continue to be a part of the fabric and tradition of American society and have adversely affected minority populations, the health care system in general, and the profession of nursing. Discrimination may be based on differences due to age, ability, gender, race, ethnicity, religion, sexual orientation, or any other characteristic by which people differ. The American Nurses Association (ANA) is committed to working toward the eradication of discrimination and racism in the profession of nursing, in the education of nurses, in the practice of nursing, as well as in the organizations in which nurses work. The ANA is further committed to working toward egalitarianism and the promotion of justice in access and delivery of health care to all people.
Ongoing discrimination against individuals with visible disabilities inflicts damage on those discriminated against, contradicts the ANA mandate of inclusivity, and threatens the integrity and health of the nursing profession. Serious study of the causes and mechanisms of discrimination is urgently required.
Because attitudes predict behavior and indicate values (Debono & Snyder, 1995), research into attitudes is an appropriate first step in the investigation of the causes of ongoing discrimination against individuals with disabilities. Explicitly held attitudes (i.e., those easily stated in the presence of others) of nurse educators toward disabled individuals are well documented in the literature and are overwhelmingly positive (Brillhart, Jay, & Wyers, 1990; Christensen, 1998; Ney, 2004; Trawick, 1990). These findings conflict with the documented discrimination against individuals with disabilities who wish to attend nursing school and work as nurses. It is clear that explicitly held attitudes do not provide a sufficient basis for understanding values and behavior.
Explicitly held attitudes are subject to social desirability (Greenwald & Banaji, 1995) and thus have limited usefulness in terms of measuring what nurse educators truly value. In many academic environments, it is unlikely that an educator will publicly announce a preference for individuals without disabilities over those with visible disabilities. The measurement of implicit, or unconsciously held, attitudes represents a more accurate basis for the description of values and behaviors. It is also important to note that implicit attitudes have been found to be a related but distinct construct from explicit attitudes (Nosek et al., 2007) and have been found to be a better predictor of behavior (Debono & Snyder, 1995). The implicit attitudes held by nurse educators toward disabled individuals have not been documented in the literature and may help to explain the discrepancy between the discriminatory behavior of nurse educators toward disabled individuals and the positive explicit attitudes that nurse educators hold. To our knowledge, the current study is the first to document implicit attitudes held by nurse educators toward individuals with disabilities.
Study Purpose
The purpose of this study was to measure the implicit attitudes of nurse educators toward individuals with visible disabilities by using the Disability Attitude Implicit Association Test (DA-IAT). The research question was “What are the implicit attitudes of nursing faculty that influence the admission and subsequent treatment of students with visible disabilities?” This was a mixed-methods study; however, only the quantitative results are reported in this manuscript. Thus, interpretation of the quantitative data presented here is based solely on the quantitative findings. The open-ended questions are provided in Table 1.
Method
Participants
A total of 781 nurse educators who teach primarily in baccalaureate nursing programs from all 50 states were invited by e-mail to participate in this study; 132 (16.9%) completed the entire study. In addition, 35 (4.5%) participants were able to complete the DA-IAT but were not enrolled in the study due to noncompletion of all study tools. The DA-IAT results from these 35 participants are presented here as further data about implicit attitudes held by nurse educators. Study information and risks were provided in the invitation to participate, and consent was implied after participants chose to continue and participate in the study.
Instruments
Implicit attitudes were measured through the use of the Implicit Association Test (Greenwald, McGhee, & Schwartz, 1998), a group of computer-based tools created by researchers from Project Implicit and supported and managed through the University of Virginia. The Project Implicit staff works with researchers to design and conduct research using the Implicit Association Test (Greenwald, Banaji, & Nosek, 1998).
The DA-IAT was the specific Implicit Association Test test used. Images and words were displayed on the computer screen, and participants were asked to categorize them into either the “able-bodied” or “disabled” category or the “good” or “bad” category as quickly as possible. In the first step, individuals were asked to categorize the images as “able-bodied” or “disabled.” The images used were children crossing the street, an individual running, an individual cross-country skiing, crutches, a guide dog, a wheelchair, and an individual walking with a cane.
In the next step, words were categorized into “good” or “bad.” The words in the DA-IAT were joy, love, pleasure, peace, wonderful, excellent, rotten, angry, terrible, bomb, nasty, and hate.
In the next step, participants were directed to identify “able-bodied” images and “good” words with the same computer key and “disabled” images and “bad” words with the same key.
In the following step, good words were associated with disabled images and bad words were associated with able-bodied images. Words and images that most people would easily categorize together were considered congruent pairings, and words and images not easily associated were considered incongruent pairings. The difference in the time required for participants to categorize the congruent and the incongruent pairings of images or words, measured in milliseconds, demonstrated the relative strength of the association between the paired concepts. If the response time for the first pairings was faster than the response time for the second pairings, the conclusion was that there was an implicit preference for the first over the second. Mean response times were calculated for congruent and incongruent pairings. The two means were subtracted from each other and divided by the standard deviation of all the response times. This mathematical technique provided a D score.
Any D score greater than 0 indicates preference for able-bodied individuals over disabled individuals (Greenwald et al., 1998). With the DA-IAT, a D score of 0.16 to 0.35 indicates slight preference, 0.36 to 0.65 indicates moderate preference, and 0.66 or greater indicates strong preference for able-bodied individuals (Greenwald, Nosek, & Banaji, 2003). Any D score lower than 0 indicates bias against disabled individuals.
Good construct validity for the DA-IAT was established by both Pruett (2004) and Pruett and Chan (2006). Pruett (2004) also demonstrated that DA-IAT scores are not subject to social desirability. Pruett (2004) conducted a multiple regression to evaluate whether the psychosocial variables, including social desirability, predict DA-IAT scores. Social desirability, measured through the Marlowe-Crowne Social Desirability Scale, failed to explain the variance in the DA-IAT scores, R2 = 0.001, F(1, 170) = 0.12 (not statistically significant). Therefore, the author concluded the scores were not subject to social desirability. White, Gordon, and Jackson (2006) established good discriminate validity—that the DA-IAT discriminates well between explicit and implicit attitudes, which is expected given that explicit and implicit attitudes are separate constructs. The reliability of the DA-IAT was documented (Pruett, 2004; Pruett & Chan, 2006) through a test–retest correlation of r = 0.78 during a 2-week period.
Procedure
Nurse educators from all 50 states were invited by e-mail to participate. After reading the introductory information and consenting to proceed, each participant completed the DA-IAT as well as a series of open-ended questions. Only the DA-IAT result is reported here, as the open-ended questions (Table 1) will be reported in the future.
Results
The 132 study participants demonstrated a mean D score of 0.76 (SD = 0.46), confirming the descriptive findings in Table 2 that participants demonstrated a preference for able-bodied individuals. The D scores ranged from −0.63 to 1.64 of a possible range of −2.0 to 2.0. The mean D score of 0.76 is within the range described by Project Implicit as corresponding to strong preference for able-bodied individuals. As noted, 35 participants completed the DA-IAT but not the other study tools (open-ended questions). Of note, analysis of data from these 35 participants is similar to that of the sample that completed all study tools. A post hoc analysis of these 35 DA-IAT results revealed a mean D score of 0.71 (SD = 0.52), which also corresponds to a strong preference for able-bodied individuals. The difference between the two groups was not statistically significant, t(166) = 1.28, p = 0.24. The total sample of 167 nurse educators in this study can be described as having strong implicit preference for able-bodied individuals. Internal consistency reliability of the DA-IAT was established by a Cronbach’s alpha of 0.798 for this study.
Table 2 describes individual ratings of the participants enrolled in the study based on the D score from the DA-IAT. More than half the participants (65.1%) received a rating of strong preference for able-bodied individuals. Only six participants demonstrated preference for disabled individuals. Strong preference for disabled individuals is not included in Table 2 because none of the participants received that rating.
Nosek et al. (2007) documented results from the DA-IAT from 38,544 participants who took the DA-IAT through the Project Implicit Web site between 2003 and 2006. The mean D score for these participants was 0.45 (SD = 0.43), which Project Implicit describes as a moderate preference for able-bodied individuals. In addition, the more than 3,000 individuals who completed the DA-IAT and reported they had a disability also showed an implicit preference for able-bodied individuals.
Discussion
The mean D score of 0.76 for the participants enrolled in the study and the mean D score of 0.71 for participants not enrolled in the study reveals a strong preference for able-bodied individuals. As previously described, the Project Implicit Web site has documented a mean D score of 0.45 (SD = 0.43) from more than 38,000 individuals who completed the DA-IAT between 2003 and 2006 (Nosek et al., 2007). This remarkable difference suggests that there is something unique about nurse educators that affects their values and behavior.
The significant difference in D scores may be related to a long-held belief in the importance of the ability to complete hands-on tasks in the practice of nursing. This focus on physical ability may have reflected the reality of nursing practice in previous professional nursing environments. However, it has become evident that many physical tasks, such as the insertion of a catheter, can be completed by other health care workers and that many nursing jobs do not involve direct patient care or are not in a hospital environment. According to the U.S. Department of Health and Human Services’ 2004 National Sample Survey of Registered Nurses, only 62.5% of the 30,233 nurses surveyed worked in a hospital or long-term care setting. The remaining participants worked in nursing education (2.6%), community or public health (10.7%), school nursing (3.2%), occupational health (0.9%), ambulatory care (11.5%), insurance (1.8%), federal or state policy or planning (0.4%), or other settings (6.4%) (U.S. Department of Health and Human Services, 2004).
The persistence of nurse educators’ focus on hands-on skills important for direct patient care in hospitals, although one third of nurses work in other settings, may be traced to the fact that current nurse educators trained as nurses in an educational system in which hands-on, direct patient care receives disproportionate emphasis.
In addition, the current textbooks used to train nurses emphasize a certain look or appearance of a nurse. For example, nursing skills textbooks rarely provide pictures denoting nurses using assistive devices. This is not dissimilar to how persons of color were not included in textbooks with any consistency until just the past decade. Nurse educators who hesitate to accept students with disabilities may benefit from reflection on the ANA’s Standards of Professional Performance (ANA, 2004), which focus on cognitive ability rather than hands-on skills. For example, assessment, diagnosis, outcome identification, and planning are four of the Standards of Professional Performance (ANA, 2004). Recognition of strong nurse educator preference for individuals without disabilities will be challenging, but the discussion may lead to constructive modifications to nursing education, as well as to better preparation of all nurses.
A final possible factor for this striking difference in D scores between nurse educators and the general population is the focus that nurses have on health and wholeness. Nurse educators may tend to categorize individuals as healthy or sick and able-bodied or disabled. This may lead to further (perhaps unconsciously held) positive or negative categorizations of individuals. Therefore, it is not surprising that because disability is perceived as illness or brokenness, nurse educators gravitate toward individuals perceived as healthy and whole, especially given that nurses work in a profession in which individuals with visible disabilities are underrepresented.
Regardless of the reason for the difference in D scores between the general population and nurse educators, this study reveals a significant amount of bias held by nurse educators against individuals with disabilities and is the first study to document these implicitly held attitudes. Nurse educators must be aware of their attitudes to effect cultural change and to ensure that individuals with disabilities have the opportunity to gain admission to nursing programs, to be treated with respect and dignity, to graduate with degrees in nursing, and to practice as professional nurses.
Implications
Nurse educator implicit preference for individuals without disabilities may be a factor in the underrepresentation of disabled students in nursing programs. Implicit attitudes toward individuals with disabilities may be explicitly expressed in the form of essential functions–based or core performance–based models of nursing. For example, the Southern Council on Collegiate Education for Nursing (SCCEN, 1993) has developed a list of core performance–based standards for nursing that includes critical thinking and interpersonal communication, mobility, motor skills, hearing, and visual and tactile skills. According to the SCCEN, nurses must be able, for example, to hear monitor alarms, to maneuver in tight spaces, and to perform palpation. These are listed as requirements for all nurses, although 39% of nurses do not work in settings that include alarms, tight-space maneuvering, or palpation. In addition, essential functions refer to “fundamental job duties” (U.S. Equal Employment Opportunity Commission & U.S. Department of Justice, 1992), and such lists may have no appropriate place in educational settings.
Nurse educator DA-IAT results may be useful in promoting a discussion of the possibilities in nursing for individuals with disabilities. Lists of essential functions often exclude potential nurses. However, lists of essential abilities for specific jobs may provide the basis for a more reliable assessment of possibilities for success in nursing education and in nursing work in general. For example, the ability to push a bed to an operating department in an emergency is important for a labor and delivery nurse, and direct patient care in labor and delivery may not be suitable work for nurses with certain disabilities. However, this does not imply (as essential function-based admissions and employment policies appear to presume) that nurses with disabilities may not work in other areas of nursing, such as telephone triage, childbirth education, or patient care in the clinic setting.
Nurse educators who have an implicit preference for individuals without disabilities may have great difficulty when asked to provide accommodations for disabled students. However, while working to provide accommodations, nursing faculty have repeatedly found that there may be more than one way to complete tasks. Published case studies describe accommodations for students with hearing loss and for a student using a wheelchair. Accommodations for students with hearing loss included turning intravenous poles and monitors toward students and providing amplified stethoscopes, hearing aids, telephones, and American Sign Language interpreters (Ashcroft et al., 2008; Maheady, 1999; Rhodes, Davis, & Odom, 1999). One student using a wheelchair visited the clinical site with the instructor to identify his or her needs, used a lap tray to carry clean items, learned to catheterize female patients on their sides, and moved out of the chair and onto the floor to complete chest compressions for CPR (Evans, 2005).
Students with disabilities may not have the same clinical experience as students without disabilities, but it is crucial that each experience meets course objectives. Concerns about patient safety or insufficient training may obscure the fact that in many areas of clinical education, no student, visibly disabled or not, is responsible for total patient care. In labor and delivery, for example, students are never responsible for the total care of laboring women. Competence in this specialty area requires months of supervised orientation and experience. In the clinical setting, these students are able to gain knowledge and meet course objectives in the same way as other students—through reading, observation, and completion of certain tasks. Nurse educators accept that students may learn patient care without having total responsibility for that care. In the name of patient safety and essential functions, students with visible disabilities may be asked to meet standards that are not asked of students without visible disabilities.
Although patient safety is critical and a paramount focus of our practice as clinicians, the reality of practice is that errors are also made by nurses who do not have disabilities. What is key to the safe practice of nursing includes, but is not limited to, physical tasks. Nurse educators will do well to be guided by the ANA’s Standards of Nursing Practice (ANA, 2004), in which cognitive ability, rather than hands-on tasks, is clearly regarded as primary. The ability to think critically about a patient situation, to recognize that a medication is or is not appropriate, or to evaluate the home situation of a patient in terms of safety and potential hazards is more important for many nursing jobs than is the ability to complete a hands-on task. Nurse educators need to shift their focus toward the development of critical thinking ability and interpersonal communication skills. This shift in focus will lead to less discrimination against nursing school applicants with visible disabilities, which in turn promises to lead toward a stronger nursing practice.
The current study presents nurse educators with a startling fact: when nurse educators were evaluated against more than 38,000 individuals who have participated in the DA-IAT, their mean D score was found to be consistent with a strong preference for able-bodied individuals, and this preference exceeded that found in the general population. This discovery makes an open and honest discussion of inclusivity essential in the nursing community. By definition, all individuals are unaware of implicitly held attitudes. It is possible that this common ground of unawareness might lead to a safe environment for open and honest discussion. The greater inclusion that might result promises to benefit the nursing profession because individuals with visible disabilities, along with all other nursing students and nurses, will be considered in terms of their unique gifts and skills.
Future Research
This study highlights one significant piece of the nursing education environment: nurse educators hold significant bias against individuals with disabilities. This study is an initial attempt to shine light on an area of critical importance to nursing education—the current environment in nursing education for some students with visible disabilities. The next steps in this arena of research will be to examine the other issues pertinent to the education of students with disabilities. One area for future research is nurse educators’ attitudes regarding essential abilities or technical standards in nursing, along with critical study of those abilities widely thought of as essential. Which cognitive, affective, and psychomotor abilities are critical to be eligible to be a nurse? Because only 61.5% of registered nurses in the 2004 Registered Nurse Survey (U.S. Department of Health and Human Services, 2004) worked in a hospital or long-term care setting, the others may not be required to complete hands-on skills to complete their job duties. Is a continuing insistence on physical abilities and hands-on tasks for entrance into the profession justifiable or salutary? Patient safety, which is always paramount to nurse educators, regardless of the physical abilities of students, will need to be addressed. In addition, the clinical affiliation requirements and reasonable accommodations must be addressed to provide a complete picture of the clinical education environment. Honest discussion and critical examination of lists of essential functions, patient safety, clinical affiliation requirements, and reasonable accommodations will lead to greater inclusivity and integrity in nursing education and the profession of nursing.
References
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Study Open-Ended Questions Following Completion of the Disability Attitude Implicit Association Test
What are your thoughts about the results you obtained by taking the Disability Attitude Implicit Association Test? What did you learn about yourself in taking the test and reviewing the results? Does your program have any formal or published criteria for guiding how faculty are to consider the admission of students with visible disabilities? Yes__No__ If yes, please describe these criteria. Some faculty use their own unwritten values and beliefs to influence their evaluation of an applicant’s qualifications for nursing school. What unwritten factors are you aware of that may have influenced the decision to admit or not admit an applicant with a visible disability to your program? Is there anything else that you think is important for me to know to better understand the factors that influence your program’s decision to admit or not admit a visibly disabled applicant?
|
D Score Ratings for Study Sample (N = 132)
| D Score Rating |
No. of Participants |
% of Total Sample |
| Strong preference for able-bodied (⩾0.66) |
86 |
65.1 |
| Moderate preference for able-bodied (0.36 to 0.65) |
28 |
21.2 |
| Slight preference for able-bodied (0.16 to 0.35) |
9 |
6.8 |
| No preference (−0.15 to 0.15) |
3 |
2.2 |
| Slight preference for disabled (−0.16 to −0.35) |
2 |
1.5 |
| Moderate preference for disabled (−0.36 to −0.65) |
4 |
3 |