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Competence standards and reasonable adjustments: nursing

The Nursing and Midwifery Council (NMC) reviewed its competence standards in light of the Equality Act 2010. They published guidance aimed at helping HEIs shape their course programme.

Students need to demonstrate NMC requirements that a qualified nurse is capable of independent practice. The HEI must be satisfied of this at the point of registration. Course validation includes the NMC representative, who may also audit implementation and look at how decisions are made.

Consideration is given by nursing schools to explaining the competencies and mapping the assessments to the learning outcomes, including the availability of alternative assessment tasks to meet the need of a range of students. To this end most schools of nursing have a disability liaison representative who is in regular touch with disability services.

HEIs may have in place rules necessary for the smooth running of the programme. For example:

All students must undertake one nursing placement outside the city boundaries

Student are expected to undertake placements up to 90 minutes travel from the university

This is helpful to those managing the placements and sends a clear message to students about what is expected.  However, it is not a competence standard, and a disabled student may need reasonable adjustments related to travel or flexible placement hours. It is recommended that a review group test the course requirements to ensure that necessary administrative rules are not written into the learning outcomes.

Assessment >

In nursing, assessments will be both course based within the university, and practice based. Under the Equality Act 2010, HEIs are required to make reasonable adjustments to assessment processes wherever possible in order to ensure that disabled students are not disadvantaged.

Assessments should be designed to be as inclusive as possible by building in flexibility for all students whilst meeting the course and NMC competence standards.

Nursing course based assessments are able to be adjusted in a broadly similar manner to those of all disabled students in the university. This might be extra time in exams, using assistive technology, providing note-takers. Support for students within the academic environment can be more straightforward to put in place. A range of methods for submitting assignments should be in place and available to students.

Assessments in clinical placements enable students to demonstrate their knowledge and understanding and acquisition of essential practical skills. The way that they demonstrate this can be adjusted, but not the competence. For example, students may use manual or digital methods of patient monitoring but must demonstrate understanding of the results by meeting the competence looked for.

In some situations, time is an essential part of the competence standard, for example CPR, and in others time is not such a critical element. For example, some institutions have moved away from timed Objective Structured Clinical Examination/Assessment which created difficulties as to whether or not allowing extra time would be reasonable.  Instead they have created a more flexible inclusive assessment for all students in which time was not such a key element.

Placements >

Working with placement providers

During our research, problems were described where nursing mentors were not always comfortable with the reasonable adjustments proposed for a particular student. This might be about the practicality of the adjustment in the placement environment or about whether the adjustment compromised the assessment of the student’s practice.

To make decisions on whether an adjustment is reasonable, and the application of the learning outcome is proportionate, it is recommended that a process for reaching a common understanding on HEI support and placement practice is in place on a general basis.

This could include demonstrations with placement staff of how technology can be used by students with different impairments. This can then be communicated  to students prior to placement  in discussion on the adjustments that can be expected, and how they may differ from the adjustments made within the HEI.

Use of technology

The pace of technology is fast moving and some staff may be uncomfortable with some of these approaches. A team approach with tutors, practice mentors and disability services in discussing these reasonable adjustments and the implications for competence standards will assist in making decisions on whether or not the standard has been met. Examples included:

  • Apps for smart phones and IPads for reminders, note taking and interaction with patients
  • Amplified stethoscopes
  • Audio recorded handover procedures
  • Preparing the student in advance of placement

The research identified benefits of advance preparation for individual students to identify where reasonable adjustments are needed and are possible. For example

  • A placement handbook detailing the competencies to be assessed and methods of assessment and possible reasonable adjustments is provided to each student
  • Pre placement meetings and visits are arranged, including the student, the academic advisor/course director, disability officer, placement officer, staff from hospital/trust
  • Placement mentors give students examples of the forms/reports that they will use on placement in advance of their start date.

Reasonable adjustments during placements

Placement mentors are responsible for ensuring reasonable adjustments are in place. Some HEIs have established placement protocols which identify the reasonable adjustments which have been agreed and are signed by the student, nursing school, the placement mentor and disability services.

Placement mentors will also have a role in helping colleagues of disabled students develop strategies to support students and to encourage students to develop self help strategies. For example:

  • a student could take home some spare equipment to perfect a practical task in their own time;
  • a colleague could provide opportunities for practice and explore the availability of alternative equipment
  • Breaking night duty in smaller components such as twilight shifts
  • Flexible placement hours

Students will still need opportunities to discuss the implementation of reasonable adjustments or other issues whilst on placement.

In several universities, disability services had adapted their advisory service opening hours to be open later, for example from 7 – 9pm on certain days, or tutors and disability services kept in touch via skype.

Evaluation >

The progression of disabled students and success of reasonable adjustments should be evaluated. Individual students should be encouraged to provide feedback on their experiences. This can provide vital information for the nursing school team and the practice mentors on whether reasonable adjustments are effective. It can also contribute to a course review of how inclusive assessments can be developed, reducing the need for individual adjustments. In one HEI, the nursing school disability liaison tutor produced an annual report, and made it available to relevant committees, for example, the nursing school teaching committee.

Pre course information for prospective students >

The NMC competence requirements for practice need to be clearly advertised and accessible to prospective disabled students. The course competence standards, which may be expressed as learning outcomes, need to be set out clearly in course handbooks, including placement handbooks and made easily available to students before starting course modules. Flexibility, module choice and reasonable adjustments should be discussed in the materials in relation to the competence standards.

Failure to achieve registration >

There will be instances where despite the application of reasonable adjustments and flexible working, a student may not succeed. Disability services and placement mentors should be included in this discussion, but the responsibility for the final decision and communicating this to the student will be with the nursing school.