Support: adjustments

In  respect  of  reasonable  adjustments,  Dennis  (CLEL)  said  there  is  a  fine  line   between  implementing  reasonable  adjustments  versus  unfair  advantage.    In   his  experience,  practice  educators  do  have  anxieties  about  how  far  to  go  in   respect  of  accommodating  the  student’s  needs  in  relation  to  their  disability.     Application  of  reasonable  adjustments  is  a  balancing  act.    Ultimately,  if  the   practice  educator  goes  too  far  it  can  advantage  the  student  to  enable  them  to   pass  the  placement  -­  unfairly  -­  in  some  cases.    The  application  of  reasonable   adjustments  then  is  not  necessarily  straightforward  and  requires  judicious   implementation  and  skill  in  considering  the  stage  of  practice  education   reached  and  whether  the  student  is  being  given  a  fair  opportunity  to  be  able   to  meet  the  placement  learning  outcomes.    Practice  educators  have  a  critical   role  as  gatekeepers  to  their  respective  profession  so  need  to  be  confident  in   asserting  whether  their  student  is  meeting  the  required  competencies  or  not   to  pass  the  placement.      

Mary  stated:  “Success  on  placement  depends  on  how  open  the  student  is   and  the  coping  strategies  they  have.    Some  students  use  disability  as  a   crutch”.    There  are  some  interesting  notions  arising  from  Mary’s  comments,   notably  the  importance  of  the  student  being  prepared  to  have  an  open  and   honest  dialogue  with  the  practice  educator  regarding  their  disability.    The   second  point  concerns  the  type  of  strategies  the  student  might  already  have   or  be  prepared  to  try  out  in  practice  and  how  readily  the  strategies  translate   into  the  realities  of  day-­to-­day  practice  in  the  actual  working  environment.     Another  key  comment  from  Mary  is  the  assumption  that  some  students  use   their  disability  as  a  crutch.    This  raises  a  number  of  questions  as  regards  the   meaning  of  this  statement  -­for  example,  that  some  students  may  be  using   their  disability  as  an  excuse  not  to  have  to  face  up  to  the  realities  concerning   the  demands  and  expectations  of  the  placement.      

It  is  interesting  to  note  that  strategies  utilised  by  students  within  the  university   setting  do  not  always  readily  translate  to  the  practice  placement  setting  (for   example  extra  time  on  course  tests  or  use  of  specific  software  such  as  

Dragon  Dictate).    This  view  is  also  shared  by  Mary  (PE)  and  also  Dennis   (CLEL)  who  said  practice  educators  may  not  have  as  much  time  as  they   need  to  sit  down  and  explain  things  to  the  student  or  help  work  out  what  their   strategies  are,  as  they  are  likely  to  be  under  a  huge  pressure  of  work.  Not   having  time  to  understand  the  implications  of  the  student’s  disability  is  of   concern  and  potentially  hints  at  a  work-­place  culture  that  is  not  catering  for   the  needs  of  a  student  with  a  disability  as  part  of  the  workforce.    Dennis   cautioned  the  need  to  be  aware  of  the  following:  “You  need  to  consider  the   tension  between  the  student’s  strategies  in  their  personal  and  academic  life   versus  being  on  placement  for  example,  the  need  to  write  up  patient  

documentation  under  time  pressures”.    

The  reality  of  strategies  implemented  within  the  university  compared  with   those  on  placement  is  further  illustrated  by  Andrea  (VT)  who  recounted  an   experience  where  she  visited  a  student  on  placement  and  because  of  their   dyslexia  they  tended  to  misspell  words.    This  was  so  significant  that  it  had  a   negative  impact  on  their  placement  performance.    Andrea  said  she  and  the   practice  educator  worked  very  hard  to  try  and  come  up  with  appropriate   coping  strategies  but  it  was  not  easy  as  the  student  could  not  complete  their   notes  in  a  timely  manner.    This,  she  says,  really  was  a  difficult  situation  and   illustrated  that  the  reality  of  extra  time  for  course  tests  in  the  university   setting  does  not  always  readily  translate  into  the  clinical  setting  due  to  the   need  to  complete  tasks  in  a  timely  manner,  under  pressure.    What  needs  to   be  acknowledged  here  is  that  some  strategies  are  not  necessarily  

transferable  between  university  and  placement  settings  nor  between   placement  settings.    This  illustrates  the  inherent  complexity  involved  in   implementing  strategies  as  each  student  should  be  considered  as  unique:   what  works  for  one  may  not  work  for  another,  for  no  two  students  with  the   same  disability  will  have  the  exact  same  needs.      

Nancy  (ST)  recalled  a  point  during  her  practice  education  experience  when   her  practice  educator  gave  her  an  opaque  notebook,  which  she  said  was  to   help  her  read  and  write  notes  simultaneously.    However,  Nancy  explained  

that  this  was  helpful  only  for  jotting  down  personal  notes  to  aid  her  learning   about  the  placement.    The  opaque  notebook  did  not  resolve  the  difficulties  in   being  able  to  handwrite  entries  in  the  patient’s  notes  as  these  comprise   notes  or  folders  which  are  legal,  official  documentation.    This  touches  on  an   earlier  statement  in  the  previous  section  that  some  reasonable  adjustments   may  only  go  so  far  in  helping  the  student  to  mitigate  the  impact  of  their   disability.    Some  strategies  -­  either  an  adjustment  in  attitude  or  perhaps  a   piece  of  equipment  or  adaptation  -­  may  assist  to  some  extent  but  the  

connotations  of  the  adjustment  require  careful  thinking  through  as  it  may  not   mitigate  the  consequences  of  the  disability  completely.    

Aurelia  (ST)  said  that  for  her  acute  placement  the  practice  educator  was   helpful  in  suggesting  she  utilise  a  bullet-­point  format  for  capturing  key  points   from  patient  interviews.    This  suggests  the  importance  of  practice  educators   working  with  students  to  identify  strategies  to  compensate  for  the  disability   and  perhaps  that  on  occasion,  a  simple  strategy  has  the  potential  to  be  truly   effective  in  overcoming  the  challenge  of  processing  incoming  information  and   multi-­tasking.    Reasonable  adjustment  can  occur  on  a  number  of  differing   levels  ranging,  for  example,  from  the  provision  of  tangible  objects  such  as  an   opaque  notebook  as  described  by  Nancy  (ST)  to  more  complex,  nuanced   subtleties  such  as  attitudes  of  the  practice  educator  towards  the  student  with   a  disability.      

This  theme  has  highlighted  the  influence  of  public  perception  and   management  of  identity.    In  addition,  implementation  of  the  basic   infrastructure  in  relation  to  following  policies  and  procedures  within  the   practice  education  experience,  such  as  a  consideration  of  tools  for  learning,   is  critical  in  supporting  students  with  a  disability.    What  this  points  to  is  the   importance  of  recognising  and  acknowledging  that  each  and  every  student   with  a  disability  is  unique  and  that  a  number  of  factors  need  to  be  

implemented  to  support  their  learning.    These  factors  will  be  explored  in   more  depth  in  the  next  chapter.      

4.3.4  CONCLUSION    

This  chapter  has  explored  the  challenges  that  students  with  a  disability  face   during  their  practice  education  experience  and  in  doing  so,  opens  up  new   avenues  of  enquiry.    What  is  important  to  note  is  that  given  the  prevalence  of   student  participants  with  a  diagnosis  of  dyslexia,  this  has  had  some  influence   in  the  development  of  the  themes  in  particular,  work  context  and  practices.     However,  these  themes  also  include  contributions  from  staff  –  practice   educators,  visiting  tutors  and  clinical  learning  environment  leads  –  who  drew   on  their  experiences  of  working  with  students  with  a  range  of  disabilities  –   musculo-­skeletal  conditions,  dyslexia,  dyspraxia,  hearing  difficulties,  physical   immobilities,  and  those  suffering  from  chronic  pain  and  brain  injuries.    That   such  a  variety  of  disabilities  have  a  number  of  commonalities  under  the   theme  of  work  context  and  practices  is  interesting  and  poses  a  dilemma.     While  disability  is  experienced  personally  (is  a  subjective  experience)  and   there  is  a  real  danger  of  erasing  differences  and  thus  homgenising  disabled   experiences,  the  data  from  students  and  staff  show  that  there  are  also  strong   commonalities  amongst  differently  abled  bodies  in  work  contexts  and  even   more  so  the  attitudes  towards  disabilities  that  they  seem  to  experience.    The   thrust  of  the  thesis  and  its  contributions  are  therefore  not  reliant  on  any  one   type  of  disability  in  its  entirety.    There  still  remains  the  issue  that  while  raising   awareness  of  disability,  reducing  stigma,  and  addressing  public  perceptions   remain  overall,  macro  goals  that  will  speak  to  anyone  with  a  disability,   specific  measures  (micro  goals)  that  alleviate  the  student  experiences  

related  to  particular  disabilities  must  also  be  sought.    Some  suggestions  that   move  in  this  direction  are  offered  in  the  concluding  sections  of  this  thesis.    

The  place  of  critical  disability  studies  in  particular,  the  ICF,  capability  

approach  and  the  critical  realist  approach  are  useful  frameworks  for  critically   analysing  and  explaining  the  data  findings.    As  I  conclude  this  chapter,  for   me  what  is  key  is  the  importance  of  considering  the  contextual  milieu  in   which  the  student  with  a  disability  on  placement  finds  themselves  in.    This   assertion  resonates  with  a  statement  from  Shakespeare  (2014:75)  who  says:    

The  difference  between  my  approach  and  what  social  creationists   would  describe  as  the  medical  model  is  that  I  do  not  explain  disability   as  impairment,  and  I  do  not  see  impairment  as  determining.    My   approach  is  non-­reductionist,  because  I  accept  that  limitations  are   experienced  as  an  inter-­play  of  impairment  with  particular  contexts   and  environments.    

Shakespeare  places  an  emphasis  on  the  impact  of  impairment  and  how  this   depends  on  particular  contexts  and  environments.    A  conceptual  stance   towards  the  notion  of  students  with  a  disability  on  practice  placement  will  be   explored  in  depth  in  the  next  chapter.

CHAPTER  5:  DISCUSSION  

The  purpose  of  this  chapter  is  to  synthesise  key  elements  from  the  literature   review  and  empirical  findings  leading  to  some  key  suggestions  for  practice   education  in  the  context  of  students  who  have  a  disability.    There  are  four   parts  to  this  chapter:  

Part  I  -­  a  collection  of  composite  narratives,  the  main  purpose  of  which  is  to   enable  a  reflection  on  the  practice  education  experience  from  the  

perspectives  of  student,  practice  educator,  visiting  tutor  and  clinical  learning   environment  lead.  

Part  II  -­  explores  the  impact  of  disability  conceptualisation  and  construction   with  reference  to  four  key  concepts  -­  stigma  and  disclosure;;  work  culture  and   practices;;  inclusivity  and  relationships.    These  concepts  are  then  synthesised   using  the  critical  realist  necessarily  laminated  layer  approach.      

Part  III  -­  explores  the  contribution  of  two  key  theoretical  frameworks  -­  the  ICF   and  the  capability  approach  -­  in  framing  conceptualisations  and  constructions   of  disability.  

Part  IV  -­  gives  some  tentative  suggestions  for  the  enhancement  of  practice   education  informed  by  my  findings  with  reference  to  key  arguments  from  the   field  of  critical  disability  studies,  a  critical  realist  approach,  the  ICF  and   capability  approach.