Student nurses who attend preregistration nursing programmes in the UK are assessed on their academic work and their performance in clinical placement. Some of these require reasonable adjustments to support their learning. Storr et al (2011) suggested examples of conditions requiring reasonable adjustments include dyslexia and dyscalculia (intellectual disabilities), mental health issues and long-term health conditions. According to the Equality Act 2010, part 2, section 6 (1b), such an ‘impairment has a substantial and long-term adverse effect on P's ability to carry out normal day-to-day activities'.
National guidance sets out the reasonable adjustments available for academic work, which include access to disability tutors and computer software aids, and allowing extra time for assessments (Equality Challenge Unit, 2010). However, the information available for reasonable adjustments associated with clinical placement is limited.
The Nursing and Midwifery Council (NMC) provides guidance on this in preregistration nursing programmes, which includes defining who is responsible for supporting student nurses while they are on clinical placement. This is primarily the nurse mentor (supervisor) and the link lecturer (a nurse lecturer from the university who visits clinical placement areas regularly), who ensure that student nurses have the most effective learning experience (NMC, 2008). However, only limited guidance is provided by the NMC regarding reasonable adjustments for student nurses on clinical placement. More detailed and helpful guidance has been produced by the Royal College of Nursing (2010; 2017), which suggests that student nurses are given access to coloured paper or screens as aids to reading medical paperwork, are allowed extra time to read patient notes and can use other technology in the clinical placement setting. Although useful, this guidance is brief and does not address how the suggested reasonable adjustments can be facilitated.
The literature on this topic is also limited. For example, there is evidence on lecturers' views of supporting student nurses requiring reasonable adjustments in university but little on the link lecturer perspective of supporting these students in the clinical setting (King, 2018). The viewpoints of student nurses are also limited in the literature, which focuses mainly on experiences of disclosing their need for reasonable adjustments to nurse mentors and the lack of time nurse mentors have for supporting them with reasonable adjustments (Morris and Turnbull, 2007; Child and Langford, 2011; Ridley, 2011). In addition, not all types of reasonable adjustment have been reported upon and whether they were successful or indeed available in clinical placement.
This study intended to offer further research into aspects that have not previously been reported upon in depth including support for student nurses with mental health issues or who have long-term conditions. The study also aimed to identify specific problems and enabling factors associated with making reasonable adjustments in clinical placement that had not already been identified in the existing literature.
Research aim
The main research aim was to explore student nurses' and their link lecturers' experiences of reasonable adjustments in clinical placement. This not only involved descriptions of events and experiences provided by the study participants but also aimed to put these experiences into context.
Research questions
Method
To make this study as successful as possible, detailed accounts of the reality of facilitating reasonable adjustments in clinical placement had to be accessed. Therefore, a qualitative approach was adopted, with a view to obtaining rich data for analysis. Specifically because of the exploratory nature of the study, a descriptive phenomenological perspective was taken. This methodological approach has been used successfully in nursing-related research including studies investigating issues associated with supporting student nurses in clinical placement. Dowling (2004) agrees that descriptive phenomenology lends itself well to expressing the knowledge that exists within nursing practice.
Semistructured interviews were chosen as the research data collection tool to document the experiences of both student nurses who require reasonable adjustments and link lecturers. This type of interview was applicable to the research paradigm selected for the study and is frequently used in qualitative research (King and Horrocks, 2010). This semistructured style of interviewing aimed to maintain the required exploratory approach. The interview schedule consisted of similar questions for both groups (student nurses and link lecturers), thereby enabling the creation of comparable answers for subsequent data analysis. The interview schedule reflected the chosen research questions associated with the research aim.
Study participants were sourced using purposive sampling with a view to recruiting student nurses and link lecturers who had lived experience of reasonable adjustments in both universities and clinical placements. All preregistration student nurses and link lecturers were contacted via an email that set out the inclusion criteria and specified the study required participants with experience of reasonable adjustments in clinical placement areas. The specificity of the emails worked effectively. Seven student nurses and three link lecturers were interviewed from three fields of nursing (Tables 1 and 2).
| Participant ID | Current year of pre-registration course | Nursing field | Type of learning difficulty: physical/intellectual/mental health condition | Number of clinical placement experiences |
|---|---|---|---|---|
| Student A | 3 | Child | Physical disability | 7 |
| Student B | 2 | Child | Physical disability | 5 |
| Student C | 3 | Mental health | Intellectual disability | 7 |
| Student D | 3 | Mental health | Intellectual disability and mental health condition | 7 |
| Student E | 2 | Adult | Intellectual and physical disability | 3 |
| Student F | 3 | Adult | Intellectual and physical disability | 6 |
| Student G | 2 | Adult | Intellectual disability | 5 |
| Participant | Nursing field | Number of years as a link lecturer | Examples of student supported |
|---|---|---|---|
| Lecturer A | Child | 13 | Asperger's syndrome, hearing impaired, dyslexia and dyspraxia, complex learning disability diagnosis, digit reduction |
| Lecturer B | Mental health | 12 | Experience of supporting student nurses with many types of disability, both intellectual and physical, including mental health issues |
| Lecturer C | Adult | 5 | Dyslexia, dyspraxia, diabetes, epilepsy, mental health issues |
The interviews were audiorecorded and interview data transcribed. All transcriptions were read several times and coded, which included the use of a deductive coding frame, then thematically analysed. Throughout the research, methods included data analysis and advice from Brinkmann and Kvale (2015) and Smith (1995: 9–26) on how to correctly use interviews for data collection and to optimise rigour was followed closely.
Ethical considerations associated with the study were reviewed and addressed. These included consent, data storage, insider researcher issues and support for participants if they found the topic upsetting. Full ethical approval was gained before the study began. To date, no ethical issues have arisen. Guidelines from the British Educational Research Association (2018) were adhered to, as were ethical procedures relating to nursing research provided by the professional bodies (NMC, 2018).
Findings
The three main themes identified were: defining reasonable adjustments for clinical placement, supporting students, and being professional.
Defining reasonable adjustments for clinical placement
Encouragingly, all study participants could give examples of reasonable adjustments associated with clinical placement settings. Comprehension of how to access these specific learning needs was also evident. Reasonable adjustments used in clinical placement emanated predominantly from those previously used in the university:
‘I have asked them if it is OK for me to start them [patient notes] a bit earlier … they said “just do it how you feel comfortable” … As long as all the details are down there and everything is on there, they don't mind.’
However, making some reasonable adjustments for clinical placement could be difficult and was not always successful:
‘It was suggested having a tape recorder, take it in, but then the trust said “you can't do that, because it violates confidentiality” … As soon as I came out of each appointment, sitting down in the car for five minutes and writing down notes, but quite often I would miss things that had been said.’
Student nurses described developing their own reasonable adjustments and then instigating these in clinical placements:
‘I've actually said to them, “look, if you see me sitting down, it is not because I'm lazy, it is because I'm probably feeling dizzy and I just need to sit down.” And they're like, “Yes”.’
‘We've made some very temporary informal reasonable adjustments around mental health … they just have a week or so that they can collect themselves, or we've looked into moving people to different areas … which had a really good outcome.’
Although some success stories were reported, there appeared to be a lack of general awareness of reasonable adjustments available for clinical placement:
‘I don't think the students understand what reasonable adjustments are … To make matters worse, I don't think we, as lecturers, understand it.’
Supporting students
Both student nurses and link lecturers talked extensively about support with identifying and facilitating reasonable adjustments in clinical placement. All study participants could describe support available from the university and nursing colleagues:
‘Some of the link lecturers are very good at going and explaining to the areas about me and my limitations.’
‘Oh, yes, my mentor there was the manager. I told her and she was really supportive’
‘We did go and supported her to have a mentor and I kept positive with the student … And I'm really glad I did because she's proven to be a very good clinician and she doesn't have any support in practice now.’
Although good practices were evident, areas in this complex process still required improvement:
‘Then I go out to placement and a lady was coming to see me from, I think she was in the disability service at the university, and she was coming to see me once a fortnight. In complete honesty, it wasn't beneficial to me at all.’
‘We stopped doing things like the initial lecture to the students saying “[if you have] disabilities, get yourself registered [with the university]. That's a major mistake in my opinion … so yes, more [university preparation].’
Although some clarity existed, confusion remained regarding the roles of stakeholders involved with making reasonable adjustments:
‘I also believe that we as academics need a lot more education about [reasonable adjustments] because I've only learnt this through experience. I wish I'd learnt it 13 years, 14 years ago.’
‘Because [the nurses] are scared that I am going to catch something and it would fall back on them. Regardless of whether I say, “It is not your fault. I know my risks and my limitations and if the university are aware…” Some places are a bit worried something is going to come of it and it is going to affect them.’
Being professional
Student nurses and link lecturers reported issues relating to professional nursing practice regarding the facilitation of reasonable adjustments in clinical placement.
Link lecturers spoke about a ‘dual role tension’ (being a registered nurse versus being a nurse academic):
‘I very much identify more as a nurse than an academic … That can be quite hard and I think that I sometimes have to really realign myself to make sure that when I'm dealing with someone like this that actually I'm not on the side, if you like, with the mentor … I'm with the student and supporting them that way, but it's hard.’
Student nurses recognised the importance of adhering to their reasonable adjustments in developing their own professional nursing practice. They acknowledged the importance of professionalism when using reasonable adjustments and the importance of not compromising patient safety:
‘But then I also would be confident enough to say, “Look, would you take over that part, and do the medication, while I take over what you're doing?” But again, that is me not putting people at risk.’
Discussion
The limited national guidance was evident from the findings as all study participants described a lack of clarity and knowledge of the stakeholders' roles and the processes involved with facilitating reasonable adjustments during clinical placement. Although good practice existed, this was not widespread and tended to be because of previous experience and individual practices.
Student nurses reported that, although university and nursing staff did have some knowledge of reasonable adjustments, making reasonable adjustments was more likely to be successful if the student nurse led the process of defining their required support. Students' responses demonstrated how they had developed being proactive in being able to describe this support and in general received positive responses.
Reassuringly, professionalism was a strong theme, emerging from all study participants. The need to practise safely and maintain patient safety was the priority of all responses. Link lecturers could experience conflict with professionalism and student nurses described how accessing reasonable adjustments was part of being professional.
Whatever the experiences or opinions of the study participants, patient safety was at the heart of their need to facilitate reasonable adjustments effectively for clinical placement. These responses are not surprising as this mirrors the philosophy of nursing care.
Limitations
Although this study elicited interesting and relevant findings, it has limitations, which must be acknowledged. The small scale of the study limits the generalisability of the conclusions in addition to not including the viewpoints of all relevant stakeholders. Additionally, not all types of reasonable adjustments were investigated. The study participants were associated with only one university and their associated clinical placement areas in a small geographical area of England.
Conclusion
The process of facilitating reasonable adjustments for student nurses in clinical placement continues to be complex and dependent on many factors. These may relate to student nurse engagement or effective support from the university and nursing staff, which may maximise or prevent the effective achievement of this essential support.
Further research and more comprehensive national guidance, covering all types of reasonable adjustments and how these can be facilitated in clinical placement, are needed to ensure the future success of this process.