Disability as Diversity: A Guidebook for Inclusion in Medicine, Nursing, and the Health Professions

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Book Review
Disability as Diversity: A Guidebook for Inclusion in Medicine, Nursing and the Health Professions, by Lisa M Meeks, & Leslie Neal-Boylan (Eds.), Springer, 2020, ISBN 978-3-030-46186-7 (Hardback)  Globally, increasing numbers of students with disabilities are attending tertiary education (Moriña et al., 2020;Salmi, 2018). Despite this trend, students with disabilities are less likely to graduate and those who do, have lower employment success in the professions than those without disabilities (Kutscher & Tuckwiller, 2019;Salmi, 2018;Williams et al., 2019). For students with disabilities in the health disciplines, gaining equal access into higher education and success entering into professional practice can be particularly challenging, particularly as these students often need to navigate significant barriers regarding their fitness to practice (Clouder et al., 2016;Easterbrook et al., 2015;Jain, 2020).
Institutions offering health professional qualifications are called upon to provide inclusive programs which recognise that there is diversity within the disability experience, while ensuring standards for professional practice are met. How clinician-focused programs can achieve disability inclusion while addressing legislative, institutional and professional standards requires contextual, evidence-informed and nuanced understanding. To date there have been limited texts to provide guidance. The publication of Disability as Diversity: A Guidebook for Inclusion in Medicine, Nursing and the Health Professions, edited by Meeks and Neal-Boylan, represents an important entry into the field. It focuses specifically on providing leaders, faculty and administrators in health sciences programs with a comprehensive guide for implementing inclusive educational strategies to support people with disabilities into careers in the health professions.
Disability as Diversity takes an ambitious approach seeking to be scholarly, legally thorough, pragmatic and extensive in content. It offers thirteen chapters spanning the conceptual through to the very practical: commencing with a transformative model for disability inclusion in the first chapter, through to pointers on how to support graduating nurses with disabilities transition into their professional careers in the final chapter. Although set within the United States higher education landscape and legislative framework, there is much here that is relevant for a broader context with several chapters providing excellent detail on inclusive disability considerations and deserving of attention.
The Introduction immediately positions the text as innovative, calling on those in tertiary health professional education to embrace dynamic definitions of disability and to understand learners' full social context and intersectional identities. It declares Disability as Diversity as "a pioneering textbook, the first of its kind" where "the authors challenge us intellectually and emotionally" by offering a roadmap to a new possibility for disability inclusion (Mangrulkar, 2020 p. xvi). It also calls for a reflexive approach, on completion of the book, by stepping back and reflecting on any discomfort and how we might enable change within our own areas of responsibility.
Chapter 1, Frameworks for Inclusion, continues in this vein while providing a strong conceptual underpinning to the book as a whole. The author outlines the need to move beyond the traditional medical model of disability, which sees it as a problem with the individual that can be treated or normalised. Jain (2020) argues for alternative ways of knowing disability, grounded in social justice where disabled people are understood as different rather than lesser (p.2). From this perspective, drawing on social-, cultural-, and rights-based models, Jain asserts the need to consider environmental, cultural and attitudinal barriers that exclude those with disabilities and the need to reconfigure the conditions that create disadvantage. Jain then shifts to considering three models of disability inclusion in health professional programs: the "strict compliance" approach; the "spirit of the law" and the "transformative" approach (Jain, 2020, p.3). The rich discussion of these approaches and their implications provide a thought-provoking set of issues that deserve our consideration in terms of what currently constrains, and what is perhaps practical and potentially possible. By doing so, they asks us to reimagine health professional education that is transformative by embracing diversity where inclusion is the starting point for policies and practices. This chapter alone, makes Disability as Diversity a text worthy of attention.
Chapter 3, Intersectional Identities, is also a key conceptual contribution to the book, addressing the important area of intersectionality and the implications for disability inclusion. The authors define intersectionality as an "analytical framework that identifies how an individual's identity markers (such as race, class, religion, gender, sexuality, and disability) overlap in unique ways to shape that person's experience of marginalization" (Stergiopoulos & Rosenburg, 2020, p.34). They assert that an intersectional approach is essential to health professional education, allowing us to move beyond the treatment of students with disabilities as a homogeneous category to attending to the unique diversity of all students with disabilities. The chapter provides examples of the complexity of marginalization that health sciences students from multiple underrepresented backgrounds can experience and offers a cultural safety model to address intersectionality in health professional education programs, including in practice settings.
Not all chapters in Disability as Diversity are likely to be of equal interest given some chapters are narrowly directed to the U.S. context and contain highly technical detail. Chapter 2 for example, is focused principally on U.S. data related to the prevalence of disabilities and health care disparities. Chapter 8 is devoted to technical guidance on U.S. statutes that prescribe the legal responsibilities programs need to take to ensure students with disabilities are not inappropriately excluded. Chapter 10 also takes a U.S. legally-focused approach to advise institutions on the risks and issues when students with disabilities fail in health science programs.
While other chapters refer to aspects of the U.S. context, this does not detract from their broad relevance and value. Chapters 5-7 and 10 stand out as recommended chapters, regardless of one's geographical location in health and social care. These four chapters address critical areas of importance for disability inclusion in health professional programs: student disability and wellbeing; the needs of students with specific learning disorders; Universal Design in Education (UDE) and inclusivity; and accommodations/adjustments in clinical based settings.
Chapter 5, Wellness and Disability, thoughtfully tackles the complex area of mental health issues that can confront all students in health professional programs and how the very concept of a 'disability' can fluctuate given that: Regardless of the type of health science program a student enters, they will have a high probability of experiencing a period of stress, burnout, anxiety, depression, or other mental health concerns. If the mental health condition is severe and the student experiences significant functional limitations that interfere with their ability to engage in the curriculum without accommodations, classifying the student as having a psychological disability is appropriate (Lee et al., 2020, pp.84-85) The authors note due to the high prevalence of mental health conditions in nursing and medicine, attention needs to be given to the impact of the environment on students with psychological disabilities and presents a brief discussion on wellness and resilience interventions for programs. They also provide a set of useful examples of common accommodations/adjustments for clinical practice settings that can be provided to students who have been determined to have a psychological disability. The chapter concludes by exhorting educators to look beyond just accommodations and wellness and resilience programs to address students' diversity needs and to consider the "often-toxic culture of our institutions and our professions" (Lee et al., 2020, p.99) to bring about systemic change.
Chapter 6, Realizing Academic Success is a detailed chapter on recent research for supporting health sciences students with specific learning disorders (SLD) and attention-deficit/hyperactivity disorder (ADHD). It outlines the neurological variations that characterize SLD and ADHD that can impact on students' cognitive processing, motivation, and use of learning strategies in ways that pose barriers to academic achievement . Drawing on a depth of research studies, examples of the physical and attitudinal barriers to learning are provided, followed by examples of evidence-informed accommodations to address specific types of neurological disabilities in both didactic and clinical learning contexts. The chapter's excellent scholarly approach is reflected in the extensive reference list of 298 sources.
Chapter 7, Increasing Accessibility through Inclusive Instruction and Design provides an up-to-date discussion of the features of Universal Design in Education (UDE) and why it is important for disability inclusion in health professional programs. The author demonstrates the limits of an accommodations-only approach as being "prescriptive and tailored" in only meeting the needs of individual students with disabilities, compared to UDE which is focused on "intentional accessibility for all" (Petersen, 2020, p.145). The core principles of UDE are outlined and the central argument is that inclusive education not only assists students with disabilities but supports all students with diverse learning needs. Petersen concludes the chapter with useful guidelines on pedagogical strategies for inclusive learning related to different teaching formats including lectures, Problem Based Learning (PBL) and the flipped classroom, noting specific considerations for students with disabilities.
Chapter 10, Clinical Accommodations and Simulations aims to provide the reader with a holistic understanding of the process for determining equal access to reasonable accommodations that mitigate barriers to learning and assessment in clinical practice settings. Given that a core feature of health professional education is undertaken in practice settings and it is here where competence needs to be demonstrated for fitness to practice (Hargreaves & Walker, 2014), it is a critical issue for disability inclusion and fitting that this is the book's largest chapter. Here key strategies for determining accommodations are outlined within clinical settings including for assessments as well as useful examples for planning and implementing Objective Structured Clinical Examinations (OSCEs). The chapter also provides detailed practical advice on a range of adaptive technology and support that can be provided for a diversity of disabilities, whilst keeping to its core tenet that "diagnosis alone does not fully dictate the range of accommodations that might be appropriate for a student" (Moreland et al., 2020, p. 213) as each student needs to be involved and understood within their own social context. The final section of the chapter briefly discusses the use of simulation providing the potential to open up possibilities for students with disabilities for practice settings while noting there can still be accessibility barriers in simulated clinical environments. Although this chapter has been written principally to guide someone who occupies a specialist disability support role in a U.S. health sciences program, there is plenty of valuable content for informing faculty in other roles and contexts interested in considering disability inclusion in clinical placements.
As a whole, Disability as Diversity provides a needed and welcome addition to the field of health professional education in tackling the important issue of equity and disability inclusion. The book certainly excites reflection and opens possibilities for inclusive educational approaches for students with disabilities. Despite the claim that the book "will challenge us intellectually and emotionally" it succeeds more with the former than the latter. Without a stronger sense of the student's voice and the faculty who need to navigate the landscape and participate in the strategies presented in the guidebook, the emotional dimensions of the text are not fully realised. The volume would have benefited by more fully embedding the philosophy of the disability movement, 'Nothing about us without us'.