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Research

Why do students fail to disclose health problems?

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Many student nurses fear disclosing information about disability or health. This study explored their concerns and developed a web zone to improve knowledge

Abstract

Background At the university where this study took place, pre-qualifying healthcare students had previously been enrolled on programmes and were found to have pre-existing and ongoing health problems, which caused difficulties for some students during clinical placements.
Aim To develop a web-based information zone dealing with students’ concerns about fitness-to-practise issues.
Method A three-stage study involving an online student survey, in-depth student interviews and development of a university web-based information zone was carried out.
Results The web zone’s content is based on key areas of importance identified by students who participated in the study.
Conclusion Early indications show that prospective and current students regularly use the web zone, demonstrated by the number of site hits.

Citation: Devereux J et al (2012) Why do students fail to disclose health problems? Nursing Times [online]; 108: 1/2, 18-20.

Authors: Julie Devereux is practice learning capacity coordinator; Pat Hosgood is senior lecturer/programme leader foundation degree integrated practice; Jennifer Kirton is research assistant; Barbara A Jack is director; Annette M Jinks is professor of nursing; all at Evidence-based Practice Research Centre, Edge Hill University, Ormskirk.

Introduction

Good health and good character are fundamental to fitness to practise as a nurse or midwife (Nursing and Midwifery Council, 2010). However, the number of fitness-to-practise allegations continues to rise each year, with an increasing number of referrals to the conduct and competence committee and, in particular, to the health committee (NMC, 2009). 
Prospective students’ disclosure of health problems or disabilities is sometimes problematic for universities; some students may not consider themselves to have a disability or may be afraid that disclosing it may lead to rejection (Brothers et al, 2002).

Literature review

The Disability Rights Commission (2007) investigated the barriers faced by disabled people who wanted to enter professional programmes in health, education and social care; it concluded that generalised health standards were ineffective in assessing and managing risk and promoted negative attitudes. Such attitudes are reinforced by the medical model approach used in occupational health clearance that relies on diagnosing a “problem” (Sin, 2009).

The DRC (2007) later identified that legislation and guidance for entry to health, education and social work professions was inconsistent with the Disability Discrimination Act 2005. Likewise, the 2006 Disability Equality Duty requires public sector employers to actively promote disability equality; this is a positive duty, which ensures disability equality is considered at the start of the process, rather than adjustments being made at the end.

However, published research on barriers faced by prospective healthcare students with a disability is sparse. Sin (2009) conducted a review of the statutory and regulatory frameworks in nursing, social work and teaching, and concluded that blanket fitness requirements that are not matched with the needs of professional practice are inappropriate.

While all students have a responsibility to declare any disability that may impair their ability to practise, Wright and Eathorne (2003) described how many do not disclose as they believe others’ perceptions will not be positive. Morris and Turnbull (2005) found that student nurses with dyslexia perceived the university environment to be a supportive setting to disclose their disability but the consequences of doing so in the clinical area were much less positive. Furthermore, while acknowledging that dyslexia affected their clinical practice, none perceived themselves as “disabled”.

It could be argued that despite increasing legislation on disability and employment opportunities, guidance from professional regulatory bodies on healthcare students is limited and places the onus on the university. However, universities need students to disclose a disability before starting their course so that reasonable adjustments can be made, particularly in the clinical setting. Clearly, prospective healthcare students need more information on fitness to practise issues to encourage them to identify and disclose any disability/health issue.

Aim

At the university where this study was carried out, there have been several cases of students not disclosing a pre-existing or ongoing illness or disability. This resulted in some having problems in clinical settings; one, for example, had physical problems that made manual handling difficult, while others took a lot of sick leave. Informal discussions with these students indicated a lack of awareness about disclosure and the fitness-to-practise requirements.

A study was, therefore, carried out to explore the information that prospective and current healthcare students with a disability/illness need about fitness to practise. The ultimate goal was to develop a web-based information zone sensitive to their needs.

Method and results

The study was carried out in three stages: an online survey; in-depth interviews; and the development of a university web-based information zone for healthcare students. University ethical approval was obtained before the study started.

Phase 1: online survey

The aim of the first phase was to identify the sources of information used by prospective and current healthcare students related to fitness to practise, and to explore their attitudes towards disclosing health issues or disabilities.

SurveyMonkey was used to develop a questionnaire that was distributed via students’ university email accounts. Piloting was conducted with a separate cohort of healthcare students who were not involved in the actual study.

A sample of one cohort of healthcare students (n=274) was invited to participate in the study. The cohort included pre-registration adult, child, mental health and learning disability student nurses, as well as midwifery and operating department practice students.

Seventy-five responded, giving a response rate of 27%. The sample characteristics were broadly representative of the total cohort, although no learning disability student nurses responded.

The survey showed that students used a range of sources to obtain information about pre-qualifying healthcare programmes. The majority said they had accessed the university’s website, although they also used the UCAS website and information from colleges of further education and schools. Most also said they had had the opportunity to discuss any specific health needs before starting their course.

Of those who had an existing disability or illness, seven said they had not disclosed it until after the interview; 13 had failed to disclose it until after starting the course.

Phase 2: interviews

The aim of the second phase was to explore students’ attitudes to, and experiences of, disclosing health concerns or disabilities.

Those who had said they had an illness or disability (n=20) in the survey were invited to participate in an interview study; 10 agreed, giving a 50% response rate.

Semi-structured, individual, face-to-face, digitally recorded interviews were conducted. Most participants were female and the age range was 20-44 years. Interviewees represented all pre-registration healthcare programmes offered by the university, aside from learning disability nursing.

Questions were developed from the findings of phase 1 and included topics such as student awareness about fitness to practise, why students might not want to disclose disability/illness, and what subjects would be useful to include in a web-based information zone. A non-teaching member of staff who is part of the faculty research team carried out all the interviews. Data was analysed using a thematic analysis approach (Miles and Huberman, 1994).

Main themes: During the interviews it became clear that not all students understood that being fit to practise did not just relate to knowledge and skills. For example, when one was asked her thoughts about the implications of “fitness to practise” she said:
“I didn’t even know it [my previous illness] was an issue. It just didn’t enter my head. When they [the programme lecturers] said I had to go [to occupational health], I was shocked.” (Student 7)

An overseas student was the best informed about the need to be fit to practise and had sought advice from his GP.

As many participants were unaware of the importance of being fit to practise, it is not surprising that some had not disclosed what would later be identified as fitness-to-practise issues.

Five said they had not disclosed a pre-existing medical condition on their university application form; the main reason they gave was fear of not being accepted on the course. They also highlighted the perceived stigma attached to some conditions, such as mental health problems. One student said she had revealed a history of depression on her pre-course occupational health service clearance form:

“Well I said on the form that I’d had postnatal depression [but I thought to myself] ‘please don’t let this stop me getting on’. That holds a lot of people back from applying to universities because they think there’s going to be a big cross by their name.” (Student 2)

Students with physical illnesses made similar comments:

“I thought they [the university] would reject me because of my asthma, but in the end it was fine.” (Student 5)

Other students said they did not think they had a fitness-to-practise issue. A student with a previous mental health problem said:
“I wouldn’t go looking for disclosure or disability stuff because I don’t regard myself as disabled. So up to starting [the programme] I didn’t think I had a problem at all.” (Student 10)

Some students said they had special learning needs (dyslexia). One told how she had contacted the university before applying to find out what support would be available and, once she started the course, the support was put in place. However, she had been unsure about whether she needed to disclose it on the occupational health service questionnaire.

Another theme that emerged was the fact that students appeared unsure about the role of occupational health services. In some cases they were unaware that they would have to undergo health screening before starting their course. For example, one student said she thought she would have to undergo a physical fitness test:

“I thought, ‘Oh my word they are going to ask me to lift things’. I think that’s what a lot of people said: ‘Well you must have to lift things’. Or, you know, just check your strength and things like that, [or] physical tests. When you get your appointment it doesn’t actually say. I was ready for going in tracksuit and trainers” (Student 7)

A further theme was a delay in assessing medical suitability. Some students who had disclosed a health issue said there appeared to be a long delay between attending the occupational health service screening appointment and a decision being made about their medical suitability to continue on the course. Another said:

‘It was maybe two months before I actually got to occupational health [after my initial interview]. It made me constantly worried.” (Student 1)

Phase 3: developing the web-based information zone

During the interviews students were asked what sort of information they would like to see on fitness to practise in a university web-based information zone before applying to a course. Key areas of importance were identified as:

  • Explanation of the term “fitness to practise”;
  • Definitions of disability and examples of the sorts of learning needs or health conditions that the university needs to be aware of when students apply for a pre-qualifying healthcare programme;
  • Why prospective students need to disclose any disabilities, learning needs or pre-existing/ongoing illnesses;
  • Student stories of fitness-to-practise concerns and their outcomes;
  • Easy access to information already available on the university website about learning support;
  • The role and necessity of occupational health service clearance before admission to healthcare programmes.

The content of the web zone is based on these key areas. A main premise of the design was to provide information specific to the university, and give a local feel to that made available by national bodies such as the NMC and Royal College of Nursing.

Student views on how to present the material were also incorporated. As well as having links to written information, student stories and experiences are also provided.

The web zone is designed to be easy to use and visually appealing, and has links to other websites such as that of the NMC and RCN. The content focuses on fitness-to-practise information, including positive encouragement to disclose an existing disability, health or learning need at the earliest opportunity. Detailed information on the occupational health screening process, with further information to signpost applicants to appropriate resources is also given.

Discussion

The NMC (2010) stated that good health is necessary to practise as a nurse or midwife, and that this means practitioners must be capable of safe and effective practice. However, this does not mean those with a disability or health condition are precluded from practising; with reasonable adjustments, it may be possible for those with disabilities or health conditions to practise. However, the ability to undertake safe practice without the need for supervision is crucial. This study showed some students are, at best, ill-informed about how personal health and disability issues may affect practitioners’ ability to deliver safe and effective practice.
Early indications show that, according to the number of site hits, prospective and current students regularly use the university web information zone. While it provides more detailed information than was available before this project, it is too early to tell whether the zone is solving previous problems regarding students’ lack of awareness about fitness-to-practise issues.

Conclusion

Ensuring that prospective healthcare students have a clear awareness about what constitutes fitness to practise is essential to ensure those with a disability determine whether they can cope with course requirements or need to seek advice. Encouraging students to disclose a disability or health condition undoubtedly enhances their experience as reasonable adjustments can be put in place from the start of their course.

Addressing fitness-to-practise issues before students start their programme can improve retention and avoid the effects that unsuccessful completion has on individual self-esteem and personal circumstances. The added financial consequence of unnecessary student attrition is clearly also an important issue for universities. Protecting the public and preventing practitioners who are unfit to practise from qualifying is of paramount importance to the healthcare professions, universities and employers alike.

Key points

  • Good health and good character are key elements of a nurse or midwife’s fitness to practise
  • Students’ disclosure of health issues or disabilities can be problematic for universities
  • Prospective and current healthcare students lack awareness about the scope and implications of fitness to practise
  • Students need more information on fitness to practise issues to encourage them to identify and disclose any disability or health issue
  • A web-based information zone can improve students’ knowledge on health-related fitness to practise issues
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