ORIGINAL RESEARCH
Inclusion of disability-related content in nurse practitioner curricula Suzanne C. Smeltzer, EdD, RN, FAAN (Professor and Director)1 , Elizabeth Blunt, PhD, RN, APRN-BC (Assistant Professor and Coordinator and Adjunct Clinical Instructor)2 , Heather Marozsan, MSN, APRN-BC (Nurse Practitioner)3 , & Lisa Wetzel-Effinger, MSN, RN (Project Coordinator)4 1
Center for Nursing Research, Villanova University College of Nursing, Villanova, Pennsylvania Nurse Practitioner Program, Villanova University College of Nursing, Villanova, Pennsylvania 3 Progressive Insurance Health Services, Mayfield Village, Ohio 4 Villanova University College of Nursing, Villanova, Pennsylvania 2
Keywords Disability; health promotion; nurse practitioners; education; primary care; curriculum. Correspondence Suzanne C. Smeltzer, EdD, RN, FAAN, Center for Nursing Research, Villanova University College of Nursing, Villanova, PA 19085. Tel: 610-519-6828; Fax: 610-519-7650; E-mail: [email protected] Received: 3 June 2012; accepted: 4 March 2013 doi: 10.1002/2327-6924.12140 Funding Inglis Foundation Innovation Award HRSA Grant 1 D09HO18998-01-00
Abstract Purpose: To examine the integration of disability-content in a national sample of nurse practitioner curricula. Data sources: Responses of National Organization of Nurse Practitioner Faculties (NONPF) members to an online 34-item survey designed to assess disabilityrelated content included in nurse practitioner (NP) curricula; populations of people with disabilities addressed; models of disability; and resources used to teach about disability, facilitators and barriers to inclusion of disability, and respondents’ assessment of the adequacy of coverage of disability in their programs. A survey used previously to assess integration of disability content in undergraduate nursing programs was modified to make it relevant to NP curricula. Nursing faculty and people with disability validated the survey to ensure its completeness and sensitivity to the disability community. Participating programs represent 111 (33.6%) NP programs. Conclusions: Lack of disability-related content reported by NP faculty in the majority of programs suggests that there is considerable room for improvement in efforts to address this often vulnerable population. Because people with disabilities can be found in any setting where health care is provided, all NPs need to be prepared to care for people with disabilities across the life span. Implications for practice: Strategies need to be developed and implemented to increase the awareness of NP faculty about the health issues of people with disabilities and integration of disability-related content without disrupting existing overloaded NP curricula.
Disability affects 20%–30% of people in the United States (Centers for Disease Control and Prevention, 2009; U.S. Census Bureau, 2009). It is estimated that there are 60 million or more individuals across all age groups in the United States with one or more disabilities (Kirschner & Curry, 2009). The World Health Organization (WHO, 2011) recently reported that the number of people with a disability around the world currently exceeds 1 billion. These numbers are expected to increase with aging of the population, survival of many children with developmental disabilities and childhood illnesses well into adulthood, improved management of chronic illnesses and trauma,
Journal of the American Association of Nurse Practitioners 27 (2015) 213–221 C 2014 American Association of Nurse Practitioners
and adoption of healthy lifestyles by many. Recent and widespread military conflicts across the globe have also contributed to the rising numbers of people with disabilities. The WHO (2001) has defined “disability” as an umbrella term for impairments, limitations in activities, or restricted participation in the community. This definition moved away from the previous definition of WHO, which focused on consequence of disease, to focus on health, and factors that affect health. Based on this definition, disability is viewed as an interaction between health conditions (e.g., diseases, disorders, injuries, etc.) and
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personal and environmental factors that affect health. The WHO definition of disability is reflected in the inclusion of health promotion topics in the survey used in this study. Disability has been identified as part of the human experience and inevitable in nearly all people at some point during their lifetime (Kirschner & Curry, 2009). Although great variability exists among definitions, causes, severity, and consequences of disability, an experience shared by many is the likelihood that they have greater difficulty obtaining health care, including primary health care and screening, than people without disabilities. There is a strong and growing body of empirical evidence indicating that people with disabilities receive health care less often and of poorer quality than that provided to people without disabilities (Iezzoni, McCarthy, Davis, Harris-David, & O’Day, 2001; Iezzoni, McCarthy, Davis, & Siebens, 2000; Nosek, Howland, Rintala, Young, & Chanpong, 2001; Shabas & Weinreb, 2000). They also have unmet healthcare needs compared to those without disabilities in part because of unequal access to healthcare services. Available screening and treatment options are often not offered to or even discussed with those with disabilities (McCarthy et al., 2006; Smeltzer, 2006). The United Nations General Assembly (2006) reinforces the right of persons with disabilities to receive the highest standard of health care, without discrimination. Studies (Shakespeare, Iezzoni, & Groce, 2009; Smeltzer, Dolen, Robinson-Smith, & Zimmerman, 2005; Smeltzer, Robinson-Smith, Dolen, Duffin, & Al-Maqbali, 2010) have examined the inclusion of disability content in medical education and undergraduate nursing education and have revealed that discussion of disability and its impact on health often receives inadequate attention in medical and nursing education. Further, other health conditions that affect disabling conditions and disability are, in turn, often overlooked, ignored, and not addressed (Nosek et al., 2001; Smeltzer, Sharts-Hopko, Ott, Zimmerman, & Duffin, 2007). Because of continuing reports that people with disabilities receive inadequate health care despite the enactment of the Americans with Disabilities Act in 1991, the U.S. Surgeon General’s Office has issued several calls to action to improve the health and well-being of people with disabilities in general (U.S. Department of Health and Human Services [USDHHS], United States Public Health Service, 2005) and people with intellectual and cognitive disabilities in particular (USDHHS, 2002). Further, the Institute of Medicine (2007), the National Council on Disability Report (2009), and the WHO World Report on Disability (2011) have identified strategies to improve the health and health care of people with disabilities. Included
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in these calls to action and strategies was the recommendation to pay greater attention to the health care of people with disabilities in health professions’ education and training in order to improve knowledge, attitudes, and skills of healthcare professionals. Although a number of authors and researchers have examined and discussed strategies to include disabilityrelated content in undergraduate nursing programs (Cervantez Thompson, Emrich, & Moore, 2003; Goddard & Jordan, 1998; Webb, Tittle, & VanCott, 2000), no studies have addressed inclusion of disability-related content in nurse practitioner (NP) curricula. Thus, it is not known if and how content about care of people with disabilities is addressed in NP programs in the United States. It is also unknown how well NP students are prepared to care for patients with disabilities they encounter in clinical practice upon completion of their programs. Because it is anticipated that the Patient Protection and Affordable Care Act (2010) and recent Institute of Medicine report (2010) will increase the focus on the importance of NPs in the delivery of primary care of patients across settings, there is a need to ensure that NPs entering clinical practice in primary care settings are prepared to provide quality care to people with disabilities. Previous research (Smeltzer et al., 2005) indicates that nursing students completing undergraduate nursing programs receive inadequate content and little exposure to people with disabilities during the course of their study; thus, the majority of nurses enter NP programs with little previous exposure or knowledge about care of people with disabilities. Thus, there is a need to address disability issues in NP programs. This study is part of a broader project that has as its primary goal the preparation of NP students to care for people with disabilities by improving the skills and knowledge of NP students in caring for this population. The specific goal of this study was to fill a significant gap in the knowledge base about how NP programs address this issue.
Methods Design This study builds on a previous study conducted by the first author that examined inclusion of disability-related content in undergraduate nursing curricula (Smeltzer et al., 2005). The study of integration of disabilityrelated content in undergraduate nursing programs revealed that lack of time, overloaded curricula, and lack of faculty interest or expertise in the area of disability were major barriers to its inclusion. More than half of the respondents from 234 schools of nursing
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indicated that their programs were not effective in teaching about disability. The least frequent areas of curriculum in which disability was addressed included heath assessment, health promotion, and women’s health (Smeltzer et al., 2005). In the present study, a descriptive quantitative design was used to conduct an online survey of NP program directors or chairpersons listed in the membership database of the National Organization of Nurse Practitioner Faculties (NONPF). Following approval of the study by the researchers’ institutional review board, an e-mail was sent by NONPF to all NP program directors (n = 330) in the NONPF database with an invitation to participate in the study. A link was provided in the e-mail invitation and took the respondents to a consent form that asked them to indicate if they understood the study and agreed or did not agree to participate in the study. The consent form indicated that their involvement would be approximately 15 min in length, the estimated time required to complete the online survey. The initial e-mail was followed by a reminder e-mail in 3 weeks later to encourage those who did not complete the survey to do so. Two months later a second round of e-mail invitations was sent to individual NP members of NONPF.
Sample To be eligible, participants had to be included on the NONPF Program Director or membership e-mail list and be willing to participate in the study. The purpose of the study was described in detail in the consent form. Although the number of schools of nursing with NP programs on the NONPF database was 330, the first invitation and reminder yielded only 50 responses. This plus the e-mail sent to individual NP members of NONPF yielded a total of 160 responses. To eliminate duplicate responses from NP programs, responses from duplicate zip codes were randomly deleted unless one represented the program director and a second from the same zip code represented a faculty member teaching in the NP program; in such cases, the program directors’ responses were retained and the faculty members’ responses were deleted to avoid more than one response from a school of nursing. Of the remaining 152 respondents who had indicated agreement to participate, 38 respondents were deleted because they completed no questions or responded to no more than two questions on the survey and exited from the online site less than 3 min after beginning the survey. It is not known if these respondents elected not to complete the survey because their programs did not address disability or for other reasons. The final number of completed surveys analyzed was 111, which represented a response rate of 33.6%.
No information that could be used to identify respondents was collected; all responses were anonymous. One respondent answered no questions but asked for results of the study.
Instrument The 34-item questionnaire was based on the survey used in the previous study to assess the integration of disability content in undergraduate nursing curricula (Smeltzer et al., 2005). Some questions were modified to make them more applicable to NP programs. The survey included questions that required respondents to select their responses by checking a box as well as open-ended questions asking for additional responses to a number of the survey items. The survey was reviewed by people with disabilities to ensure its completeness and sensitivity to the disability community; the original survey on which the modified survey was based was reviewed by 19 nursing faculty members (Smeltzer et al., 2005). Topics addressed included disability-related content included in NP curricula, populations of people with disabilities addressed, models of disability and resources used to teach about disability, facilitators and barriers to inclusion of disability, and respondents’ assessment of the adequacy of coverage of disability in their programs. The online survey was administered via Survey Monkey; data were downloaded to an Excel file and then to a statistical software program. Identifying information was obtained only from participants who asked to receive the results of the study. Although internal consistency reliability of the instrument could not be calculated because of the format of the items, the validity of the instrument was established by having nursing faculty and people with disabilities review the survey and provide specific feedback to ensure that it addressed issues of concern to the disability community. The people with disabilities who provided feedback not only had disabilities themselves, but also served as advocates for others with disability.
Data analysis Data were analyzed by descriptive statistics (means, standard deviations, frequencies, percentages); results of the analysis are reported in the aggregate. Responses to open-ended questions were reviewed and frequencies of responses identified. The results reported below were based on the number of responses to each item; thus, the denominator used in calculating percentages differed slightly from one response to the next.
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Results Demographic data Respondents who provided demographic data (n = 104) reported that they had been in their current position an average of 7.49 ± 6.31 years; range of years in position was less than half a year to 28 years. The 98 (88.3%) respondents who answered questions about the enrollment in their programs indicated that the number of graduates completing programs each year ranged from 5 to 225; the mean number of annual graduates was 41.65 ± 43. Respondents identified themselves as directors or coordinators of NP program (n = 33; 32.0%), coordinators of a track in the NP program (n = 17; 16.5%), or faculty members teaching in NP courses (n = 40; 38.8%). The respondents represented about one third (n = 111; 33.6%) of schools of nursing with NP programs. The most commonly reported NP track in the program reported by the respondents was family NP program (n = 97; 87.4% of respondents), followed by adult NP program (n = 58; 52.3%), pediatric NP program (n = 35; 31.5%), geriatric NP program (n = 34; 30.6%), psychiatric-mental health NP program (n = 34; 30.6%), acute care NP program (n = 24; 21.6%), women’s health NP program (n = 19; 17.1%), and neonatal NP program (n = 15; 13.5%). Several respondents did not identify the type of NP tracks offered by their schools of nursing. The mean number of NP tracks reported by respondents was 2.8 ± 2.1 with a range from 1 to 8 NP tracks within their schools of nursing. Thirty-four (30.6%) respondents indicated that their programs had four or more NP programs, the majority (n = 71; 63.9%) of the respondents indicated that they had one to three programs. Focus of NP programs on disability. Table 1 presents disability-related topics identified by respondents as included in their NP programs. Table 2 presents disability groups addressed in the respondents’ NP programs. In both tables, the results are ranked from highest to lowest frequency of NP programs reporting inclusion of the content or population groups. Models used to teach about disability. The overwhelming majority of respondents (n = 94; 84.7%) reported that they used the medical model in their NP curricula to teach about disability. Others reported that they used the social model (n = 58; 52.37%), rehabilitation model (n = 49; 44.5%), biopsychosocial model (n = 36; 32.4%), dependency model (n = 26; 23.6%), and interface model of disability (n = 24; 21.6%). Eightyone (73%) respondents indicated that they used multiple models in teaching about disability in their NP programs. Seventy-seven respondents (69.4%) indicated that they used one to three models of disability; seven (6.3%) respondents reported using all seven models of disabil216
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ity. Eight (7.2%) of the respondents added other models used in their programs to address disability; those reported included synergy, transitions and caring, chronic illness, family-centered care, science of unitary human beings, tidal model, Orem, Henderson, Newman’s theory of expanding consciousness models.
Resources and clinical sites used to teach about disability. Resources and clinical sites used in the NP programs to teach disability-related content and to provide NP students with experience with people with disabilities are presented in Table 3. Additional resources used in the classroom included speakers who were adolescents with disabilities or parents of children with disabilities (n = 1). Additional clinical sites added by respondents included a school for the blind (n = 1), children’s home (n = 1), and day care facility for children with special needs (n = 1).
Course objectives and use of disability models. Thirty-nine (35.1%) respondents indicated that their schools had overall objectives that mentioned disability; 36 (32.4%) respondents indicated that their NP programs had NP program or course objectives that specifically mentioned disability. Two respondents indicated in answer to the question about facilitators for addressing disability the fact that disability was a curriculum thread throughout their programs.
Location of disability content in curriculum and in university. The most frequently identified location of disability content in NP programs was health assessment lecture and laboratory (n = 80; 72.1%) Other areas of the curriculum in which disability-related content was discussed included pediatric content (n = 71; 64%), geriatric content (n = 66; 59.5%), neurological issues (n = 65; 58.6%), health promotion content (n = 56; 50.5%), psychiatric-mental health content (n = 52; 46.8%), women’s health content (n = 35; 31.5%), and rehabilitation principles (n = 24; 21.6%). Responses to the open-ended questions indicated that specific disability content was taught in pathophysiology (n = 1), pharmacology (n = 1), women’s health (n = 1), and chronic illness (n = 1) courses. Another respondent indicated that disabling conditions (movement disorders, attention deficit hyperactivity disorder) were discussed in advanced pathophysiology, but that the focus was not on disability associated with these disorders. One respondent reported that disability content was included only in discussion about obtaining handicap tags for cars. Seven (6.3%) respondents indicated that courses that focused specifically on disability were available to nursing students through their university center or institute on disabilities and their school of education. The respondents indicated that they did not know the content of those courses and did not know if NP students enrolled in those courses. Courses on developmental disabilities, advanced
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Table 1 Disability-related content included in NP programs (n = 111) reported by rank Rank
Content Area
NP Programs Reporting Inclusion (%)
1 2 3 4 5 6 7.5 7.5 9 10.5 10.5 12.5 12.5 14.5 14.5 16.5 16.5 18 19 20 21 22 23 24.5 24.5 26 27 28 29
Impact of disability on growth and development Definitions of disability, impairment, limitation, handicap Identification of barriers encountered by PWD Personal, economic, and social costs of disability Effects of disability on the ability of PWD to obtain health care Ethical issues related to PWD (privacy, confidentiality, respect for dignity) Implications of the ADA related to health care Adaptation of physical exam techniques for PWD Discrimination within the healthcare system of PWD Rehabilitation act and ADA related to health care Adaptation of history taking for PWD Modifications needed to provide effective care to PWD Referral for assessment of need for assistive devices and technology Effective communication strategies with PWD Psychological and emotional abuse and neglect of PWD Epidemiology of disability in the United States Patient education and modifications in teaching approaches/materials needed for PWD Physical abuse of PWD Legal and justice issues of PWD Strategies for communicating with persons with various types of disabilities Role conflicts of PWD Sexual and reproductive concerns of PWD Caring for persons with severe disabilities Prevention of secondary disabilities on PWD Disability etiquette Sexual abuse of PWD Pregnancy, labor, and delivery in women with disabilities Parenting by women with disabilities Parenting by men with disabilities
62.5 60.6 58.8 57.7 54.8 51.0 50.0 50.0 48.1 46.2 46.2 45.2 45.2 44.2 44.2 40.4 40.4 39.4 37.5 36.8 32.7 31.7 26.9 24.0 24.0 22.1 13.5 6.7 5.8
PWD, persons with disabilities; ADA, Americans with Disabilities Act.
nursing for community dwelling disabled people, culture and diversity, and counseling were each identified once by faculty responding to an open-ended question about other courses on campus.
Gender-based health issues of men and women with disabilities. Specific health promotion needs of men (testicular exam, prostate exams, etc.) and women (pelvic exams, mammography, etc.) with disabilities were addressed by 39 (34.9%) and 59 (52.8%) of the NP programs that were represented in this study, respectively. Seventy-nine (71.1%) respondents indicated that their programs were ineffective in addressing the healthcare needs of men with disabilities or did not know how effective they were in doing so. Fifty-nine (53.2%) respondents indicated that their programs were ineffective in addressing healthcare needs of women with disabilities or did not know how effective their programs were in doing so. Barriers to health care. About one-half (n = 58; 52.3%) of respondents reported that discussion of barriers to health care and preventive screening was included in their NP programs. It is not clear from the questions asked or data collected where in the curriculum barriers
to health care were discussed or if the role of NPs in addressing those barriers in clinical settings was part of the discussion.
Facilitators and barriers to teaching about disability in NP programs. Facilitators and barriers to inclusion of disability content in NP programs were identified in response to two open-ended questions. The question about facilitators was answered by 59 (53%) respondents. Facilitators identified by respondents included faculty members’ awareness, expertise, and interest in addressing disability (n = 13; 22.0% of 59 responses). Three respondents (5.1%) identified new awareness of the issue as a result of completing the survey as a facilitator and stated an intention to include disability-related content in their programs. Other facilitators that were identified by single respondents included the following: disability as a curriculum strand, student interest in the topic, collaboration with schools of medicine and dentistry; availability of clinical facilities related to disability within the institution; focus on population health; university-wide support and availability of university services; and availability of university services, ethical and legal issues, including the 217
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Table 2 Population groups addressed in NP programs (n = 111) reported by rank
Population Group
NP Programs Reporting Inclusion of Group (%)
Persons with dementia Elderly persons with disabilities Persons with cognitive or intellectual disabilities (formerly referred to as “mental retardation”) Infants and children with disabilities Persons with developmental disabilities Persons who are deaf or hard of hearing Persons who are blind Adolescents with disabilities Persons with disabling psychiatric or mental health disorders Persons with learning disabilities Middle-aged adults with disabilities Persons with autism spectrum disorder Young adults with disabilities Persons who have disabilities that affect communication (severe CP, others) Women with disabilities Men with disabilities Persons with disability who are nonverbal (unable to speak) Persons from minority ethnic groups with disabilities
74.3 56.5 62.4 61.5 59.6 58.7 53.2 53.2 53.2 53.2 50.5 48.6 47.7 36.7 33.9 30.3 29.4 21.1
Rank 1 2 3 4 5 6 9 9 9 9 11 12 13 14 15 16 17 18
CP, cerebral palsy.
mandates of the ADA, having inclusion of disability as an expectation of teaching, the growing incidence of disabilities across the age spectrum encountered in clinical practice settings, availability of online programs, availability of community resources and access to clinical sites in the community, optional clinical rotation with patients with disabilities, and contact with veterans or soldiers on active duty. Two respondents (3.4%) indicated that they were unable to identify any factors that serve as facilitators for inclusion of disability in their curriculum. The question on barriers to inclusion of disabilityrelated issues or content in the curriculum was answered by 68 (61.3%) respondents. The most common barrier cited was lack of time or having too much content in the curriculum without room for additional content (n = 45; 68.3% of the 68 responses to this question). The next most frequently cited barrier was lack of faculty with expertise in disability (n = 8; 11.8%). Lack of specific curricular guidelines and lack of materials and resources related to disabilities, lack of awareness of disability as an issue, and lack of appropriate clinical placements for students were identified as barriers by six (8.8%), four (5.9%), and three (4.4%) respondents, respectively. The online format of two (2.9%) NP programs was identified as a barrier. Two (2.9%) faculty members indicated that disability was integrated throughout the NP program and one (1.5%) indicated that disability was covered extensively in undergraduate curricula, suggesting that there was no need to address it at the graduate level to prepare NP students. One respondent indicated that an emphasis
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of the NP program on wellness was a barrier and another that the NP program was focused on preparing generalists (presumably rather than those with specialty in disabilities; 1.5% for both responses).
Amount of time devoted to disability in NP programs. When asked about the amount of time devoted to teaching about disability-related issues in their NP programs, 52 (49.5%) reported that their programs devoted too little time to this discussion and 35 (33.3%) reported that far too little time was devoted to discussion of this content. Only 18 (17.1%) of the respondents reported that they spent about the right amount of time on this topic; none reported that too much or far too much time was spent on teaching about this topic. Assessment of NP students’ attitudes. A fifth (n = 22; 20.6%) of the 100 responses who answered the question asking about assessment of NP students’ attitudes toward persons with disabilities reported that they assessed their students’ attitudes. Only two (2%) respondents who reported assessing students attitudes indicated that they used existing instruments to do so. Others reported that they assessed NP students’ attitudes through qualitative data from student assignments (n = 18; 18%), evaluation of student performance in clinical courses (n = 23; 23%), and through teacher-developed assessment tools (n = 6; 6.0%). Reflective journals and general discussion were identified by two respondents each as methods used to assess NP students’ attitudes toward people with disabilities.
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Table 3 Summary of resources and clinical sites used in NP programs (n = 111) to teach about disabilities NP Programs Reporting (%) Textbooks Physical assessment textbooks NP-authored textbooks Evidence-based practice (EBP) textbooks General medicine/family medicine textbooks Practice guidelines Multidisciplinary textbooks None Articles Professional journal articles Newspaper articles Population/lay magazine articles None Electronic resources Internet web sites for healthcare professionals Internet web sites for people with disabilities CD-ROMs, DVDs, videotapes Personal slide sets Purchased/professional slide sets Other (wikis, threaded discussion) None Other literature Autobiographies of people with disabilities Biographies of people with disabilities Novels about disability-related issues Guest speakers Faculty members with specific expertise or interest in disability Faculty members with expertise in rehabilitation Persons with disabilities None Clinical sites used to address disability Psychiatric-mental health settings Nursing homes Rehabilitation settings Assisted living facilities Home health/visiting health services Residences for persons with disabilities Independent living centers General hospital units Group homes for persons with disabilities None/do not know
90.7 59.3 50.9 43.5 39.8 22.2 3.7 87.3 11.8 4.9 5.9 49.5 29.5 24.5 16.8 2.1
Inclusion of disability-related content in nurse practitioner curricula Suzanne C. Smeltzer, EdD, RN, FAAN (Professor and Director)1 , Elizabeth Blunt, PhD, RN, APRN-BC (Assistant Professor and Coordinator and Adjunct Clinical Instructor)2 , Heather Marozsan, MSN, APRN-BC (Nurse Practitioner)3 , & Lisa Wetzel-Effinger, MSN, RN (Project Coordinator)4 1
Center for Nursing Research, Villanova University College of Nursing, Villanova, Pennsylvania Nurse Practitioner Program, Villanova University College of Nursing, Villanova, Pennsylvania 3 Progressive Insurance Health Services, Mayfield Village, Ohio 4 Villanova University College of Nursing, Villanova, Pennsylvania 2
Keywords Disability; health promotion; nurse practitioners; education; primary care; curriculum. Correspondence Suzanne C. Smeltzer, EdD, RN, FAAN, Center for Nursing Research, Villanova University College of Nursing, Villanova, PA 19085. Tel: 610-519-6828; Fax: 610-519-7650; E-mail: [email protected] Received: 3 June 2012; accepted: 4 March 2013 doi: 10.1002/2327-6924.12140 Funding Inglis Foundation Innovation Award HRSA Grant 1 D09HO18998-01-00
Abstract Purpose: To examine the integration of disability-content in a national sample of nurse practitioner curricula. Data sources: Responses of National Organization of Nurse Practitioner Faculties (NONPF) members to an online 34-item survey designed to assess disabilityrelated content included in nurse practitioner (NP) curricula; populations of people with disabilities addressed; models of disability; and resources used to teach about disability, facilitators and barriers to inclusion of disability, and respondents’ assessment of the adequacy of coverage of disability in their programs. A survey used previously to assess integration of disability content in undergraduate nursing programs was modified to make it relevant to NP curricula. Nursing faculty and people with disability validated the survey to ensure its completeness and sensitivity to the disability community. Participating programs represent 111 (33.6%) NP programs. Conclusions: Lack of disability-related content reported by NP faculty in the majority of programs suggests that there is considerable room for improvement in efforts to address this often vulnerable population. Because people with disabilities can be found in any setting where health care is provided, all NPs need to be prepared to care for people with disabilities across the life span. Implications for practice: Strategies need to be developed and implemented to increase the awareness of NP faculty about the health issues of people with disabilities and integration of disability-related content without disrupting existing overloaded NP curricula.
Disability affects 20%–30% of people in the United States (Centers for Disease Control and Prevention, 2009; U.S. Census Bureau, 2009). It is estimated that there are 60 million or more individuals across all age groups in the United States with one or more disabilities (Kirschner & Curry, 2009). The World Health Organization (WHO, 2011) recently reported that the number of people with a disability around the world currently exceeds 1 billion. These numbers are expected to increase with aging of the population, survival of many children with developmental disabilities and childhood illnesses well into adulthood, improved management of chronic illnesses and trauma,
Journal of the American Association of Nurse Practitioners 27 (2015) 213–221 C 2014 American Association of Nurse Practitioners
and adoption of healthy lifestyles by many. Recent and widespread military conflicts across the globe have also contributed to the rising numbers of people with disabilities. The WHO (2001) has defined “disability” as an umbrella term for impairments, limitations in activities, or restricted participation in the community. This definition moved away from the previous definition of WHO, which focused on consequence of disease, to focus on health, and factors that affect health. Based on this definition, disability is viewed as an interaction between health conditions (e.g., diseases, disorders, injuries, etc.) and
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personal and environmental factors that affect health. The WHO definition of disability is reflected in the inclusion of health promotion topics in the survey used in this study. Disability has been identified as part of the human experience and inevitable in nearly all people at some point during their lifetime (Kirschner & Curry, 2009). Although great variability exists among definitions, causes, severity, and consequences of disability, an experience shared by many is the likelihood that they have greater difficulty obtaining health care, including primary health care and screening, than people without disabilities. There is a strong and growing body of empirical evidence indicating that people with disabilities receive health care less often and of poorer quality than that provided to people without disabilities (Iezzoni, McCarthy, Davis, Harris-David, & O’Day, 2001; Iezzoni, McCarthy, Davis, & Siebens, 2000; Nosek, Howland, Rintala, Young, & Chanpong, 2001; Shabas & Weinreb, 2000). They also have unmet healthcare needs compared to those without disabilities in part because of unequal access to healthcare services. Available screening and treatment options are often not offered to or even discussed with those with disabilities (McCarthy et al., 2006; Smeltzer, 2006). The United Nations General Assembly (2006) reinforces the right of persons with disabilities to receive the highest standard of health care, without discrimination. Studies (Shakespeare, Iezzoni, & Groce, 2009; Smeltzer, Dolen, Robinson-Smith, & Zimmerman, 2005; Smeltzer, Robinson-Smith, Dolen, Duffin, & Al-Maqbali, 2010) have examined the inclusion of disability content in medical education and undergraduate nursing education and have revealed that discussion of disability and its impact on health often receives inadequate attention in medical and nursing education. Further, other health conditions that affect disabling conditions and disability are, in turn, often overlooked, ignored, and not addressed (Nosek et al., 2001; Smeltzer, Sharts-Hopko, Ott, Zimmerman, & Duffin, 2007). Because of continuing reports that people with disabilities receive inadequate health care despite the enactment of the Americans with Disabilities Act in 1991, the U.S. Surgeon General’s Office has issued several calls to action to improve the health and well-being of people with disabilities in general (U.S. Department of Health and Human Services [USDHHS], United States Public Health Service, 2005) and people with intellectual and cognitive disabilities in particular (USDHHS, 2002). Further, the Institute of Medicine (2007), the National Council on Disability Report (2009), and the WHO World Report on Disability (2011) have identified strategies to improve the health and health care of people with disabilities. Included
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in these calls to action and strategies was the recommendation to pay greater attention to the health care of people with disabilities in health professions’ education and training in order to improve knowledge, attitudes, and skills of healthcare professionals. Although a number of authors and researchers have examined and discussed strategies to include disabilityrelated content in undergraduate nursing programs (Cervantez Thompson, Emrich, & Moore, 2003; Goddard & Jordan, 1998; Webb, Tittle, & VanCott, 2000), no studies have addressed inclusion of disability-related content in nurse practitioner (NP) curricula. Thus, it is not known if and how content about care of people with disabilities is addressed in NP programs in the United States. It is also unknown how well NP students are prepared to care for patients with disabilities they encounter in clinical practice upon completion of their programs. Because it is anticipated that the Patient Protection and Affordable Care Act (2010) and recent Institute of Medicine report (2010) will increase the focus on the importance of NPs in the delivery of primary care of patients across settings, there is a need to ensure that NPs entering clinical practice in primary care settings are prepared to provide quality care to people with disabilities. Previous research (Smeltzer et al., 2005) indicates that nursing students completing undergraduate nursing programs receive inadequate content and little exposure to people with disabilities during the course of their study; thus, the majority of nurses enter NP programs with little previous exposure or knowledge about care of people with disabilities. Thus, there is a need to address disability issues in NP programs. This study is part of a broader project that has as its primary goal the preparation of NP students to care for people with disabilities by improving the skills and knowledge of NP students in caring for this population. The specific goal of this study was to fill a significant gap in the knowledge base about how NP programs address this issue.
Methods Design This study builds on a previous study conducted by the first author that examined inclusion of disability-related content in undergraduate nursing curricula (Smeltzer et al., 2005). The study of integration of disabilityrelated content in undergraduate nursing programs revealed that lack of time, overloaded curricula, and lack of faculty interest or expertise in the area of disability were major barriers to its inclusion. More than half of the respondents from 234 schools of nursing
Disability content in NP curricula
S.C. Smeltzer et al.
indicated that their programs were not effective in teaching about disability. The least frequent areas of curriculum in which disability was addressed included heath assessment, health promotion, and women’s health (Smeltzer et al., 2005). In the present study, a descriptive quantitative design was used to conduct an online survey of NP program directors or chairpersons listed in the membership database of the National Organization of Nurse Practitioner Faculties (NONPF). Following approval of the study by the researchers’ institutional review board, an e-mail was sent by NONPF to all NP program directors (n = 330) in the NONPF database with an invitation to participate in the study. A link was provided in the e-mail invitation and took the respondents to a consent form that asked them to indicate if they understood the study and agreed or did not agree to participate in the study. The consent form indicated that their involvement would be approximately 15 min in length, the estimated time required to complete the online survey. The initial e-mail was followed by a reminder e-mail in 3 weeks later to encourage those who did not complete the survey to do so. Two months later a second round of e-mail invitations was sent to individual NP members of NONPF.
Sample To be eligible, participants had to be included on the NONPF Program Director or membership e-mail list and be willing to participate in the study. The purpose of the study was described in detail in the consent form. Although the number of schools of nursing with NP programs on the NONPF database was 330, the first invitation and reminder yielded only 50 responses. This plus the e-mail sent to individual NP members of NONPF yielded a total of 160 responses. To eliminate duplicate responses from NP programs, responses from duplicate zip codes were randomly deleted unless one represented the program director and a second from the same zip code represented a faculty member teaching in the NP program; in such cases, the program directors’ responses were retained and the faculty members’ responses were deleted to avoid more than one response from a school of nursing. Of the remaining 152 respondents who had indicated agreement to participate, 38 respondents were deleted because they completed no questions or responded to no more than two questions on the survey and exited from the online site less than 3 min after beginning the survey. It is not known if these respondents elected not to complete the survey because their programs did not address disability or for other reasons. The final number of completed surveys analyzed was 111, which represented a response rate of 33.6%.
No information that could be used to identify respondents was collected; all responses were anonymous. One respondent answered no questions but asked for results of the study.
Instrument The 34-item questionnaire was based on the survey used in the previous study to assess the integration of disability content in undergraduate nursing curricula (Smeltzer et al., 2005). Some questions were modified to make them more applicable to NP programs. The survey included questions that required respondents to select their responses by checking a box as well as open-ended questions asking for additional responses to a number of the survey items. The survey was reviewed by people with disabilities to ensure its completeness and sensitivity to the disability community; the original survey on which the modified survey was based was reviewed by 19 nursing faculty members (Smeltzer et al., 2005). Topics addressed included disability-related content included in NP curricula, populations of people with disabilities addressed, models of disability and resources used to teach about disability, facilitators and barriers to inclusion of disability, and respondents’ assessment of the adequacy of coverage of disability in their programs. The online survey was administered via Survey Monkey; data were downloaded to an Excel file and then to a statistical software program. Identifying information was obtained only from participants who asked to receive the results of the study. Although internal consistency reliability of the instrument could not be calculated because of the format of the items, the validity of the instrument was established by having nursing faculty and people with disabilities review the survey and provide specific feedback to ensure that it addressed issues of concern to the disability community. The people with disabilities who provided feedback not only had disabilities themselves, but also served as advocates for others with disability.
Data analysis Data were analyzed by descriptive statistics (means, standard deviations, frequencies, percentages); results of the analysis are reported in the aggregate. Responses to open-ended questions were reviewed and frequencies of responses identified. The results reported below were based on the number of responses to each item; thus, the denominator used in calculating percentages differed slightly from one response to the next.
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Disability content in NP curricula
Results Demographic data Respondents who provided demographic data (n = 104) reported that they had been in their current position an average of 7.49 ± 6.31 years; range of years in position was less than half a year to 28 years. The 98 (88.3%) respondents who answered questions about the enrollment in their programs indicated that the number of graduates completing programs each year ranged from 5 to 225; the mean number of annual graduates was 41.65 ± 43. Respondents identified themselves as directors or coordinators of NP program (n = 33; 32.0%), coordinators of a track in the NP program (n = 17; 16.5%), or faculty members teaching in NP courses (n = 40; 38.8%). The respondents represented about one third (n = 111; 33.6%) of schools of nursing with NP programs. The most commonly reported NP track in the program reported by the respondents was family NP program (n = 97; 87.4% of respondents), followed by adult NP program (n = 58; 52.3%), pediatric NP program (n = 35; 31.5%), geriatric NP program (n = 34; 30.6%), psychiatric-mental health NP program (n = 34; 30.6%), acute care NP program (n = 24; 21.6%), women’s health NP program (n = 19; 17.1%), and neonatal NP program (n = 15; 13.5%). Several respondents did not identify the type of NP tracks offered by their schools of nursing. The mean number of NP tracks reported by respondents was 2.8 ± 2.1 with a range from 1 to 8 NP tracks within their schools of nursing. Thirty-four (30.6%) respondents indicated that their programs had four or more NP programs, the majority (n = 71; 63.9%) of the respondents indicated that they had one to three programs. Focus of NP programs on disability. Table 1 presents disability-related topics identified by respondents as included in their NP programs. Table 2 presents disability groups addressed in the respondents’ NP programs. In both tables, the results are ranked from highest to lowest frequency of NP programs reporting inclusion of the content or population groups. Models used to teach about disability. The overwhelming majority of respondents (n = 94; 84.7%) reported that they used the medical model in their NP curricula to teach about disability. Others reported that they used the social model (n = 58; 52.37%), rehabilitation model (n = 49; 44.5%), biopsychosocial model (n = 36; 32.4%), dependency model (n = 26; 23.6%), and interface model of disability (n = 24; 21.6%). Eightyone (73%) respondents indicated that they used multiple models in teaching about disability in their NP programs. Seventy-seven respondents (69.4%) indicated that they used one to three models of disability; seven (6.3%) respondents reported using all seven models of disabil216
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ity. Eight (7.2%) of the respondents added other models used in their programs to address disability; those reported included synergy, transitions and caring, chronic illness, family-centered care, science of unitary human beings, tidal model, Orem, Henderson, Newman’s theory of expanding consciousness models.
Resources and clinical sites used to teach about disability. Resources and clinical sites used in the NP programs to teach disability-related content and to provide NP students with experience with people with disabilities are presented in Table 3. Additional resources used in the classroom included speakers who were adolescents with disabilities or parents of children with disabilities (n = 1). Additional clinical sites added by respondents included a school for the blind (n = 1), children’s home (n = 1), and day care facility for children with special needs (n = 1).
Course objectives and use of disability models. Thirty-nine (35.1%) respondents indicated that their schools had overall objectives that mentioned disability; 36 (32.4%) respondents indicated that their NP programs had NP program or course objectives that specifically mentioned disability. Two respondents indicated in answer to the question about facilitators for addressing disability the fact that disability was a curriculum thread throughout their programs.
Location of disability content in curriculum and in university. The most frequently identified location of disability content in NP programs was health assessment lecture and laboratory (n = 80; 72.1%) Other areas of the curriculum in which disability-related content was discussed included pediatric content (n = 71; 64%), geriatric content (n = 66; 59.5%), neurological issues (n = 65; 58.6%), health promotion content (n = 56; 50.5%), psychiatric-mental health content (n = 52; 46.8%), women’s health content (n = 35; 31.5%), and rehabilitation principles (n = 24; 21.6%). Responses to the open-ended questions indicated that specific disability content was taught in pathophysiology (n = 1), pharmacology (n = 1), women’s health (n = 1), and chronic illness (n = 1) courses. Another respondent indicated that disabling conditions (movement disorders, attention deficit hyperactivity disorder) were discussed in advanced pathophysiology, but that the focus was not on disability associated with these disorders. One respondent reported that disability content was included only in discussion about obtaining handicap tags for cars. Seven (6.3%) respondents indicated that courses that focused specifically on disability were available to nursing students through their university center or institute on disabilities and their school of education. The respondents indicated that they did not know the content of those courses and did not know if NP students enrolled in those courses. Courses on developmental disabilities, advanced
Disability content in NP curricula
S.C. Smeltzer et al.
Table 1 Disability-related content included in NP programs (n = 111) reported by rank Rank
Content Area
NP Programs Reporting Inclusion (%)
1 2 3 4 5 6 7.5 7.5 9 10.5 10.5 12.5 12.5 14.5 14.5 16.5 16.5 18 19 20 21 22 23 24.5 24.5 26 27 28 29
Impact of disability on growth and development Definitions of disability, impairment, limitation, handicap Identification of barriers encountered by PWD Personal, economic, and social costs of disability Effects of disability on the ability of PWD to obtain health care Ethical issues related to PWD (privacy, confidentiality, respect for dignity) Implications of the ADA related to health care Adaptation of physical exam techniques for PWD Discrimination within the healthcare system of PWD Rehabilitation act and ADA related to health care Adaptation of history taking for PWD Modifications needed to provide effective care to PWD Referral for assessment of need for assistive devices and technology Effective communication strategies with PWD Psychological and emotional abuse and neglect of PWD Epidemiology of disability in the United States Patient education and modifications in teaching approaches/materials needed for PWD Physical abuse of PWD Legal and justice issues of PWD Strategies for communicating with persons with various types of disabilities Role conflicts of PWD Sexual and reproductive concerns of PWD Caring for persons with severe disabilities Prevention of secondary disabilities on PWD Disability etiquette Sexual abuse of PWD Pregnancy, labor, and delivery in women with disabilities Parenting by women with disabilities Parenting by men with disabilities
62.5 60.6 58.8 57.7 54.8 51.0 50.0 50.0 48.1 46.2 46.2 45.2 45.2 44.2 44.2 40.4 40.4 39.4 37.5 36.8 32.7 31.7 26.9 24.0 24.0 22.1 13.5 6.7 5.8
PWD, persons with disabilities; ADA, Americans with Disabilities Act.
nursing for community dwelling disabled people, culture and diversity, and counseling were each identified once by faculty responding to an open-ended question about other courses on campus.
Gender-based health issues of men and women with disabilities. Specific health promotion needs of men (testicular exam, prostate exams, etc.) and women (pelvic exams, mammography, etc.) with disabilities were addressed by 39 (34.9%) and 59 (52.8%) of the NP programs that were represented in this study, respectively. Seventy-nine (71.1%) respondents indicated that their programs were ineffective in addressing the healthcare needs of men with disabilities or did not know how effective they were in doing so. Fifty-nine (53.2%) respondents indicated that their programs were ineffective in addressing healthcare needs of women with disabilities or did not know how effective their programs were in doing so. Barriers to health care. About one-half (n = 58; 52.3%) of respondents reported that discussion of barriers to health care and preventive screening was included in their NP programs. It is not clear from the questions asked or data collected where in the curriculum barriers
to health care were discussed or if the role of NPs in addressing those barriers in clinical settings was part of the discussion.
Facilitators and barriers to teaching about disability in NP programs. Facilitators and barriers to inclusion of disability content in NP programs were identified in response to two open-ended questions. The question about facilitators was answered by 59 (53%) respondents. Facilitators identified by respondents included faculty members’ awareness, expertise, and interest in addressing disability (n = 13; 22.0% of 59 responses). Three respondents (5.1%) identified new awareness of the issue as a result of completing the survey as a facilitator and stated an intention to include disability-related content in their programs. Other facilitators that were identified by single respondents included the following: disability as a curriculum strand, student interest in the topic, collaboration with schools of medicine and dentistry; availability of clinical facilities related to disability within the institution; focus on population health; university-wide support and availability of university services; and availability of university services, ethical and legal issues, including the 217
Disability content in NP curricula
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Table 2 Population groups addressed in NP programs (n = 111) reported by rank
Population Group
NP Programs Reporting Inclusion of Group (%)
Persons with dementia Elderly persons with disabilities Persons with cognitive or intellectual disabilities (formerly referred to as “mental retardation”) Infants and children with disabilities Persons with developmental disabilities Persons who are deaf or hard of hearing Persons who are blind Adolescents with disabilities Persons with disabling psychiatric or mental health disorders Persons with learning disabilities Middle-aged adults with disabilities Persons with autism spectrum disorder Young adults with disabilities Persons who have disabilities that affect communication (severe CP, others) Women with disabilities Men with disabilities Persons with disability who are nonverbal (unable to speak) Persons from minority ethnic groups with disabilities
74.3 56.5 62.4 61.5 59.6 58.7 53.2 53.2 53.2 53.2 50.5 48.6 47.7 36.7 33.9 30.3 29.4 21.1
Rank 1 2 3 4 5 6 9 9 9 9 11 12 13 14 15 16 17 18
CP, cerebral palsy.
mandates of the ADA, having inclusion of disability as an expectation of teaching, the growing incidence of disabilities across the age spectrum encountered in clinical practice settings, availability of online programs, availability of community resources and access to clinical sites in the community, optional clinical rotation with patients with disabilities, and contact with veterans or soldiers on active duty. Two respondents (3.4%) indicated that they were unable to identify any factors that serve as facilitators for inclusion of disability in their curriculum. The question on barriers to inclusion of disabilityrelated issues or content in the curriculum was answered by 68 (61.3%) respondents. The most common barrier cited was lack of time or having too much content in the curriculum without room for additional content (n = 45; 68.3% of the 68 responses to this question). The next most frequently cited barrier was lack of faculty with expertise in disability (n = 8; 11.8%). Lack of specific curricular guidelines and lack of materials and resources related to disabilities, lack of awareness of disability as an issue, and lack of appropriate clinical placements for students were identified as barriers by six (8.8%), four (5.9%), and three (4.4%) respondents, respectively. The online format of two (2.9%) NP programs was identified as a barrier. Two (2.9%) faculty members indicated that disability was integrated throughout the NP program and one (1.5%) indicated that disability was covered extensively in undergraduate curricula, suggesting that there was no need to address it at the graduate level to prepare NP students. One respondent indicated that an emphasis
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of the NP program on wellness was a barrier and another that the NP program was focused on preparing generalists (presumably rather than those with specialty in disabilities; 1.5% for both responses).
Amount of time devoted to disability in NP programs. When asked about the amount of time devoted to teaching about disability-related issues in their NP programs, 52 (49.5%) reported that their programs devoted too little time to this discussion and 35 (33.3%) reported that far too little time was devoted to discussion of this content. Only 18 (17.1%) of the respondents reported that they spent about the right amount of time on this topic; none reported that too much or far too much time was spent on teaching about this topic. Assessment of NP students’ attitudes. A fifth (n = 22; 20.6%) of the 100 responses who answered the question asking about assessment of NP students’ attitudes toward persons with disabilities reported that they assessed their students’ attitudes. Only two (2%) respondents who reported assessing students attitudes indicated that they used existing instruments to do so. Others reported that they assessed NP students’ attitudes through qualitative data from student assignments (n = 18; 18%), evaluation of student performance in clinical courses (n = 23; 23%), and through teacher-developed assessment tools (n = 6; 6.0%). Reflective journals and general discussion were identified by two respondents each as methods used to assess NP students’ attitudes toward people with disabilities.
Disability content in NP curricula
S.C. Smeltzer et al.
Table 3 Summary of resources and clinical sites used in NP programs (n = 111) to teach about disabilities NP Programs Reporting (%) Textbooks Physical assessment textbooks NP-authored textbooks Evidence-based practice (EBP) textbooks General medicine/family medicine textbooks Practice guidelines Multidisciplinary textbooks None Articles Professional journal articles Newspaper articles Population/lay magazine articles None Electronic resources Internet web sites for healthcare professionals Internet web sites for people with disabilities CD-ROMs, DVDs, videotapes Personal slide sets Purchased/professional slide sets Other (wikis, threaded discussion) None Other literature Autobiographies of people with disabilities Biographies of people with disabilities Novels about disability-related issues Guest speakers Faculty members with specific expertise or interest in disability Faculty members with expertise in rehabilitation Persons with disabilities None Clinical sites used to address disability Psychiatric-mental health settings Nursing homes Rehabilitation settings Assisted living facilities Home health/visiting health services Residences for persons with disabilities Independent living centers General hospital units Group homes for persons with disabilities None/do not know
90.7 59.3 50.9 43.5 39.8 22.2 3.7 87.3 11.8 4.9 5.9 49.5 29.5 24.5 16.8 2.1
