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Nurses with Sensory Disabilities: Their Perceptions and Characteristics (CE)
A survey design was used to explore the perceptions and characteristics of registered nurses (RNs) with sensory disabilities and their risk for leaving their jobs. An earlier study found that nurses with disabilities are leaving nursing and that employers do not appear to support these nurses. Work instability and the mismatch between a nurse’s perceptions of his or her ability and the demands of their work increase risk for job retention problems. This study’s convenience sample of U.S. RNs had hearing, vision, or communication disabilities. Participants completed a demographic form, three U.S. Census questions, and the Nurse-Work Instability Survey. Hospital nurses were three times more likely to be at risk for retention problems. Nurses with hearing disabilities were frustrated at work. Hearing difficulties increased with years spent working as a nurse. Many nurses with sensory disabilities have left nursing. Early intervention may prevent work instability and increase retention, and rehabilitation nurses are ideally positioned to lead early intervention programs.
Very little is known regarding registered nurses (RNs) with disabilities, including the number of nurses with disabilities. According to the U.S. Bureau of Labor Statistics, 12.9 % of people between 21 and 64 years of age and 30% of those between 64 and 75 years of age have a disability. Nurses are found in both of these age groups, so while the number of nurses with disabilities is unknown, it is likely that the number is significant (Maheady, 2005). The culture of the healthcare organizations in which nurses work can present behavioral, attitudinal, and structural barriers to people with disabilities (Schur, Kruse, & Blanck, 2005). The literature reports that people frequently leave their employment for reasons that are related to disability (Mitchell, Adkins, & Kemp, 2006; Neal-Boylan & Guillett, 2008a). Disability may prevent nurses from performing their usual duties to the expected standard. This mismatch between ability and expectation is termed work instability. According to Gilworth and colleagues (2007), work instability is defined as “the extent of any mismatch among functional (in)capacity, work demands and its potential impact on efficiency/productivity at work” (p. 544). As work becomes more difficult to perform, nurses are more likely to consider leaving their jobs. Early intervention may prevent work instability and decrease or eliminate the risk of nurses leaving their jobs (Gilworth et al.). Rehabilitation nurses are experts at working with people with disabilities and, in general, helping disabled people and society better understand and accept the contributions that people with disabilities can make to the home and workplace. In addition, rehabilitation nurses understand the culture of nursing and can be instrumental in breaking down barriers and facilitating change for their colleagues with disabilities.
Healthcare employees are more likely than other employees to work despite illness, and their absence from work seriously impacts the work environment (Johnson, Croghan, & Crawford, 2003). Work instability also can lead to increased risk for absence due to sickness that is related to the disability (Gilworth et al., 2007). To better understand RNs with disabilities and their risk for leaving their jobs, it is important to explore their perceptions of work instability.
There has been no research to date regarding RNs with sensory disabilities involving hearing, vision, or communication. The purpose of this study was twofold: to explore the perceptions and characteristics of RNs with sensory disabilities and their risk of job retention problems (as measured by the Nurse Work Instability Survey [WIS]) and to determine whether the Nurse-WIS is a reliable tool to measure work instability in nurses with sensory disabilities. This article will focus on the perceptions and characteristics of the nurses in the sample.
Little is known about the perceptions of nurses with sensory disabilities. This study was intended to be an exploratory, descriptive pilot study to determine whether the survey tool could be used for future research with nurses with sensory and musculoskeletal disabilities. The specific aims of this study were to determine the demographic characteristics of RNs with hearing, visual, or communication disabilities; explore work instability and the risk for job retention problems among nurses with sensory disabilities; and determine whether the Nurse-WIS is a reliable tool to measure work instability in nurses with hearing, visual, or communication disabilities.
According to the National Sample Survey of Registered Nurses, there are approximately 2.9 million nurses in the United States, 83% (1.6 million) of whom are employed in nursing (Health Resources and Services Administration, 2006). It is not known how many nurses are disabled. A qualitative study (Neal-Boylan & Guillett, 2008a, 2008b) of nurses with disabilities was conducted, and the results supported the need to further explore the characteristics and perceptions of RNs with disabilities. This study of RNs in Maine, Virginia, and Washington, DC, with self-reported permanent physical or sensory disabilities found that RNs were leaving their jobs for reasons related to their disabilities. Nurses reported hiding their disabilities from nurse recruiters. Nurse recruiters confirmed this finding, with many saying they often could not remember interviewing nurses with disabilities. Nurses with disabilities often left their jobs or sometimes left nursing altogether because they feared they could jeopardize patient safety and they lacked collegial or administrative support to stay. Some nurses went back to school to pursue graduate degrees with the hopes of obtaining less physically demanding nursing positions.
In light of the ongoing nursing shortage and the aging nursing population, it is vital to retain experienced nurses and to intervene before nurses leave their jobs. The current study was an attempt to learn more about nurses with disabilities and discover whether nurses with sensory disabilities are at risk for leaving their jobs.
The Integrative Model of Health Care Working Conditions on Organizational Climate and Safety (Stone et al., 2005) was used as a framework for this study; this model reflects a larger research program of nurses with disabilities. Stone and colleagues define organizational climate as “member perceptions of organizational features like decision making, leadership, and norms about work” (p. 468). Organizational culture is viewed as “norms, values, beliefs, and assumptions shared by members of an organization” (Stone et al., p. 468). Organizational climate and culture ultimately influence processes and outcomes, but organizational climate is easier to change than organizational culture (Stone et al.).
Although Stone and colleagues’ model does not address disability, it suggests that structural and process domains influence healthcare worker and patient outcomes. According to the model, manageable workload is an aspect of nursing work that influences these outcomes. The physical ability of a nurse to manage his or her workload may influence the intent to leave and patient outcomes. Stone states that based on the studies used to develop the model, manageable workload can be operationally defined as “the provider’s ability (or perceptions) that they are able to manage their workload to provide quality care” (P. W. Stone, personal communication, January 3, 2008). If the workload is not manageable, work instability may result.
Press releases, Web links, and e-mail were used to solicit participation in the study. Articles and announcements were placed in regional nursing magazines and newspapers throughout the United States. Nursing associations posted the announcement of the study on their websites, and word of mouth also aided in solicitation. Criteria for participation included current RN license; residency in the United States; and a hearing, vision, or communication disability (unrelated to a cognitive deficit). Nurses either phoned in or e-mailed their interest in participating. They then received (via mail or e-mail) the survey packet with informed consent, a cover letter, demographic form, the U.S. Census Questions on Disability, and the Nurse-WIS survey. Nurses who chose to receive the survey packet in the mail were sent a stamped, self-addressed envelope to mail the survey packet back to the researcher. Originally, the study was to include nurses in New England only. After solicitations for participation were launched, however, the principal investigator began to receive responses from RNs from throughout the United States who had left their jobs or were considering leaving their jobs because of their disabilities and wanted their voices heard. This same phenomenon was found in the qualitative study described above (Neal-Boylan & Guillett, 2008a).
Participation posed no risks. However, participants were reminded in the informed consent that the security of e-mail and phone communication could not be guaranteed. The researcher kept identifying information in a locked file. The Yale University Institutional Review Board approved the study.
All of the instruments were printed in 18-point type. Participants who received the study materials via e-mail were able to alter the type for their comfort. The U.S. Census Questions on Disability that pertain to sensory disabilities were used to screen for eligibility for participation in the study. Demographic questions were included in the survey packet along with the Nurse-WIS. There was no effort to determine whether the nurse’s disability was sustained since becoming a nurse or before nurse training because the objective was to study work instability related to current nursing work and the intent to leave the current job. Preliminary research did not find a difference in the experience of being a nurse with a disability based on when the disability started. This condition will be explored further in future, larger studies. Participants were encouraged to add narrative qualitative comments. A panel of nurses who have expertise with disabilities tested the demographic questions, the readability of the Nurse-WIS, and the administration process. The panel reached 98% agreement.
Census Questions on Disability
The United Nations derived its question set from the questions the U.S. Census Bureau uses to collect data regarding persons with disabilities (U.S. Census Bureau, 2008). The questions focus on six areas: vision, hearing, walking or climbing steps, remembering or concentrating, self-care, and communication. Possible responses for each question are No—no difficulty, Yes—some difficulty, Yes—a lot of difficulty, and cannot do at all. For the purposes of this study, only the questions that focus on vision, hearing, and communication were used. Participants were asked to evaluate whether they had difficulty hearing or seeing despite the use of a hearing aid or glasses. The communication question asked if the participant had difficulty (using one’s customary language) understanding or being understood. If the participant answered “no” to all three questions, then he or she was not eligible to participate in the study.
The Nurse-WIS tool (Gilworth et al., 2007; Figure 1) has face validity, criterion validity, interrater reliability, test-retest reliability, and construct validity. Rasch measurement resulted in chi-squared interaction p = .169. The person separation index (reliability) was 0.9. The Nurse-WIS was developed from the analysis of qualitative interviews and mailed surveys involving RNs and healthcare assistants in England. All of the participants had been respondents to a screening questionnaire of the entire nurse workforce. Purposive sampling was used to recruit participants with a variety of musculoskeletal symptoms. Qualitative interviews made up stage 1 of the study to develop the instrument. Participants in the qualitative interviews had to experience recent musculoskeletal symptoms (during the past 3 months). For stage 2, respondents from the original questionnaire were place into two groups to receive mailed surveys. It was possible to participate in only one stage of the study. After the development of the final 30-item survey, the developers of the instrument mailed the questionnaires to 296 nurses on two occasions 2 weeks apart. The results confirmed test-retest reliability. Using Rasch analysis, construct validity was confirmed.
The Nurse-WIS is worth testing for reliability with nurses with nonmusculoskeletal symptoms because the questions in the tool address work instability or the mismatch among the (in)ability to perform the work, the demands of work, and the potential impact on the performance and efficiency of the work that is done. This tool does not address musculoskeletal symptoms, nor do the questions require respondents to have a physical disability to be relevant to work instability.
To use the tool, respondents can choose to mark true or not true for each statement listed in the Nurse-WIS. The “true” responses are then tallied and a total score is obtained. The score is measured against a scoring range that estimates risk of job retention problems for that respondent. Participants do not have access to the scoring range.
The cover letter of the Nurse-WIS instrument was revised. It previously read, in part: “Thinking about your musculoskeletal symptoms please choose the response that applies to you.” It was revised to read: “Thinking about your visual, hearing, and/or communication disability please choose the response that applies best to you.” In addition, the cover letter instructed participants to “tick” the answer. This was changed to be more appropriate for American subjects to read “check” the answer. Also, within the document, the participant was told: “Please remember to read each statement thinking about your musculoskeletal symptoms” and then answer the questions. This was changed to read: “Please remember to read each statement thinking about your hearing, visual, and/or communication disability.”
Eighty nurses between 26 and 77 years of age from 21 states representing all regions within the United States participated in the study (Figure 2). The mean age was 52 years. Participants had worked as nurses for 1 to 55 years, with a mean of 24 years. Nurses with various levels of education were about equally represented (diploma/associate degree = 27, bachelor’s degree = 31, master’s/doctorate = 21). Among the 64 nurses who were currently working, 41 (51%) worked in a hospital. Eight percent of the nurses worked in the community, and 5% in nursing home settings. The remainder of nurses represented a variety of work settings and positions (Figure 3). Those who were not working had recently left their jobs and responded to the survey to describe why they left. Leaving nursing jobs appears to be a common feature of nursing with a disability. Consequently, it was a challenge to survey nurses with disabling physical conditions who had not left their job. Most (91%) nurses who responded were White; Black, Asian, and Hispanic nurses comprised the remainder (4%, 1%, and 4%, respectively). The sample included nurses with hearing, visual, and communication disabilities, with hearing disability most common (Table 1). Participants did not state how the disability manifested. However, the census questions on disability clarified the level of difficulty the disability caused the nurse. Participants responded anecdotally and via e-mail that their disabilities included, but were not limited to, deafness, low vision, slurring, and other speech impediments.
Because this was a population (nurses with sensory disabilities) that had not previously been studied and there is no literature documenting the number of RNs in the U. S. who have sensory disabilities, it was difficult to ensure a representative population. However, it was hoped that with a national sample and a large enough response rate, the results could be generalizable. It was determined that, given an effect size of .2 and a power of .80, that 393 people would be required for an alpha of .05. Given a likely response rate of 30%, it was estimated that the sample size should consist of 1,000 nurses. Only 80 nurse respondents were obtained within the study time period (approximately 50 nurses responded after data collection ended and before announcements could be made that the study was over); consequently, results are not generalizable but serve to provide a foundation for future larger studies.
Participants who were licensed RNs who respond “yes” or “cannot do at all” to any of the three Census (sensory) Questions on Disability were included in the analysis. Surveys were electronically scanned into an Excel spreadsheet. Data were double-entered into ACCESS. Data from the two databases were compared using PROC COMPARE in SAS, and any discrepancies were verified and corrected. Univariate statistics were used to perform logical data checks and to assess distributions and describe the data. Bivariate analyses included using contingency table analysis for categorical variables. General associations were examined using chi-square and Fisher’s exact tests. For categorical variables with an ordinal scale (Nurse-WIS category, degrees of disability), a mean score test Qs also was used in assessing associations. ANOVA and Kruskal Wallis tests were used to examine differences in continuous outcomes by categories. Assumptions of normality and constant standard deviation were assessed through residual analyses. Outcome variables were transformed when assumptions did not hold. If transformations were not adequate to meet model assumptions, nonparametric tests were used.
This was a descriptive, exploratory study, so an alpha of .10 was used. All analyses were carried out using SAS version 9.1. Rasch analysis (Rasch, 1960) was used to test the Nurse-WIS with nurses with sensory disabilities. As a result of this analysis, the survey was shortened to an 18-item scale, and the comparative cut points for measuring medium and high risk of sickness absence and job retention problems were slightly altered. Qualitative participant comments that were sent via e-mail or added to the survey instruments have been included in this article. Two researchers independently analyzed the comments for any ambiguity before including them in this article (the researchers concluded there was no ambiguity). It is important to add that there was no formal qualitative component in the study’s design, so no formal analysis of themes took place. This study was intended to explore work instability. Future studies will explore the experience of being a nurse with a sensory disability. The analysis and refinement of the tool will be discussed in depth in a subsequent article.
Results and Discussion
Only the statistically significant findings are described and discussed in this article. Interestingly, nurses (56%) who have some or severe difficulty hearing, seeing, or communicating are not currently working as nurses. Conversely, if you are currently working as an RN, you are less likely to have substantial difficulty seeing, communicating, or hearing. Seventy-three percent of the nurses in the study who are currently working have no difficulty seeing. It is mere conjecture to say that nurses who experience severe difficulty with any of these senses may have left nursing or did not feel able to participate because the study announcement and materials required vision that was sufficient for reading. Earlier research found that nurses with disabilities are leaving the profession (Neal-Boylan & Guillett, 2008a), so it is worthwhile to question whether nurses with sensory disabilities also are leaving the profession.
Among respondents, the older the nurse was, the more likely that he or she had difficulty communicating. The mean age of nurses with difficulty communicating was 60 years. However, in this study, age was not associated with difficulty hearing. Length of time spent as an RN was associated with difficulty hearing (21 years = some difficulty; 28 years = a lot of difficulty), begging the question of whether working as a nurse contributes to hearing loss.
Nurses with graduate degrees (85%) were more likely to have difficulty hearing as opposed to those with bachelor’s degrees (74%). Previous research found that nurses with physical disabilities often pursue higher education in an effort to remain in nursing despite their disabilities (Neal & Guillett, 2008b). This also may be the case for nurses with sensory disabilities.
Nurses who worked in hospital settings were three times more likely than nurses who worked in nonhospital settings to be at risk for retention problems. Furthermore, nurses with severe difficulty hearing who worked in hospitals (68%) were at greater risk for job retention problems than nurses with hearing disabilities who worked in nonhospital settings. These nurses said they “feel frustrated that I can’t do things for myself.” Risk of job retention problems (as measured by the Nurse-WIS) was not associated with length of time the participant had been a nurse.
Respondents’ anecdotal comments included “I often feel that [my hearing disability] disrupts my ability to carry out my responsibilities as a nurse….On one job I held, the nurse manager felt that it placed the patients I worked with at risk. I felt rejected and disappointed in myself, eventually leaving that job to go to another.” A nurse with blindness in one eye wrote “I have to work twice as hard as others to do reading, writing, and communicating that others take for granted.”
Seven men and 73 women participated in this study. More men (67%) than women (29%) reported difficulty with vision. Men (54%) reported greater difficulty hearing than women (22%).
The Nurse-WIS demonstrated good internal consistency with a Cronbach’s alpha of .888. Study data added to the tool’s overall reliability and demonstrated reliability for measuring work instability with nurses with sensory disabilities.
Conclusion and Implications
This was an exploratory, descriptive study. Much work needs to be done to further assess work instability in nurses with disabilities. This study was limited by gender and ethnicity inequality and small sample size. However, the statistically significant findings are worth reporting because they provide a foundation for further research. In addition, these findings should give administrators, educators, and clinicians pause as they contemplate ways in which to retain nurses. The results of this study confirm a previous finding that nurses with disabilities are leaving nursing or are at risk for leaving nursing. Efforts to increase, acknowledge, and value diversity in the workplace should take into consideration people with disabilities and misconceptions, fears, and prejudice (Ferguson et al., 2009). Perhaps acknowledgment of these emotions can increase the perceived value of these nurses and help to retain them. It is vital to the profession that interventions to accommodate nurses with disabilities and support their retention be implemented. An earlier article (Neal-Boylan & Guillett, 2008b) suggested re-evaluating the education of nurses with disabilities to permit tracks that include clinical and nonclinical work that use a nurse’s strengths and minimize the impact of the disability. Rehabilitation nurses are experts at increasing disability awareness and in disability education and can be instrumental in changing perceptions among nurse educators, colleagues, and administrators.
Administrators, especially those in hospital settings, may need to rethink the way the environment is designed and whether mechanisms may be put in place to allow nurses with disabilities to use their expertise to care for patients without experiencing frustration that could encourage them to leave their jobs.
In addition, although there are no reported patient injuries attributable to a nurse with a disability, changes in the environment to accommodate nurses with sensory disabilities may enhance patient safety by decreasing the risks associated with bedside care, in particular. For example, acutely and seriously ill patients may be surrounded by equipment that can be hazardous to nurses with sensory disabilities. If a nurse trips or falls on unseen wires or tubes, the patient’s safety also is put at risk. Nurses with sensory disabilities may not be able to function safely in certain environments. It is not known whether or not they can be accommodated sufficiently to allow them to remain in all areas of nursing. Rather than removing them from or not hiring them into certain positions, these nurses should be given the opportunity to demonstrate they are capable of doing their work well (in the same way that nurses without disabilities are allowed to do).
It may be relatively easy to accommodate nurses with hearing disabilities by making sure that administrators and staff speak directly to the person to enable lip reading as an adjunct to hearing. Flashing lights and other adaptations that have been used by schools for deaf students can be put into place to enable nurses to perform their work with less difficulty. One nurse with hearing problems had this to say regarding concerns about missing a code red: “I advised my students to please tap me on the shoulder…even if I was standing under the loud speaker.” This worked quite well. Improved awareness that nurses with hearing, visual, and communication disabilities are leaving nursing may help administrators find creative ways to keep them.
Clinicians should consider providing support to colleagues with disabilities in return for their expertise and assistance with work that does not require physical or sensory rigor. For example, a nurse with a sensory disability might be enabled to complete work by using minor adjustments such as large type and lights instead of call bells. If nurses without disabilities can exercise patience when a nurse with a communication disability is trying to speak, this also will go a long way. Rehabilitation nurses should lead the way to redesign of work space and work methods to better enable nurses and others with disabilities to feel comfortable in the workplace.
Nurses contribute to patient and clinical outcomes and, most importantly, to patient safety. No documentation demonstrates that nurses with disabilities jeopardize patient safety or care. However, retaining these nurses may positively influence patient care as those in the healthcare system benefit from their expertise, experience, and presence. This study did not review targeted recruitment of disabled nurses; this topic was briefly addressed in an earlier study and is another area that requires further investigation. More research is needed, but the clinical relevance is clear: The profession cannot afford to lose experienced nurses who have a lot to offer the profession and patients. As one nurse said, “There is a big need to help nurses fit in and find jobs that they are comfortable with.”
Assistance with Nurse-WIS and statistics: Alan Tennant, PhD BA, professor of rehabilitation studies, faculty of Medicine and Health, The University of Leeds.
Funding: Delta Mu Chapter of Sigma Theta Tau, Yale University School of Nursing, New Haven, CT.
About the Authors
Leslie Neal-Boylan, PhD CRRN APRN-BC, is a professor of nursing at Southern Connecticut State University in New Haven, CT. Address correspondence to her at nealboylanL1@southernct.edu.
Kristopher Fennie, PhD MSC MPH, is a research scientist and lecturer at Yale University School of Nursing in New Haven, CT.
Sara Baldauf-Wagner, MS APRN-BC CNM MSN (candidate), is a recent graduate of Yale University School of Nursing in New Haven, CT.
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