Up to the Challenge
Nurses with disabilities overcome legal, social and mental hurdles to flourish in their careers

By Karen J. Coates
March 12, 2002

A storm stirred outside the hilltop home of Connie Churchill, RN. Evergreens swayed in gusty winds, shedding mossy branches on jade ground. Rain breezed across the Oregon hillsides framed in wide windows lining her living room wall.

But she couldn't see the details. Churchill is blind in the left eye and has no peripheral or bottom vision in the right.

Churchill lost her vision two years ago in a "series of medical errors" at the Seattle hospital where she worked. She wouldn't elaborate because of pending litigation, but she was clear: The impairment doesn't dictate her life. "I still wanted the view," she said of the house. And she still wanted her nursing career, although it wouldn't be easy.

"For the first four months, I shut myself up in my house," she said. She gave her scrubs and stethoscope to a friend who "kept it all, because she knew."

The friend knew Churchill would work again. Churchill's former employer said it couldn't accommodate her. She tried telephone consulting, but that didn't suit her. Then a colleague offered her a part-time medical/surgical position at the VA Roseburg Healthcare System, where she had worked previously.

"I needed someone to give me a chance to prove that I could still do it," she said.

Workplace hurdles

Her story mirrors others. Beyond physical challenges, nurses with disabilities face legal, social and mental hurdles in the workplace. But persistence and drive can inspire success.

Almost 20 percent of the U.S. population-close to 50 million people-have a disability. The 1990 Americans with Disabilities Act requires employers to make "reasonable accommodations" for employees with disabilities. But in January, the U.S. Supreme Court narrowed the definition.

Workers must prove that their disabilities limit major life activities, as well as job tasks. The related questions are tricky: What are the employee's limitations? What are the essential job functions? Can the employee move to another position? Is the employee qualified? What accommodations are reasonable?

Each case is different.

If employees fit the legal definition of a disability, employers must try to accommodate them in their positions, said Chuck Davis, associate director for training and technical assistance for Northwest ADA/IT Center. If employers cannot accommodate, they can consider vacant positions for which the employees qualify. They are not required to create new positions.

"This is an issue of great concern to many," said E. Carol Polifroni, Ed.D., RN, an associate professor at the University of Connecticut School of Nursing. "I experience it on the end of students as well. The law says that we must accommodate individuals with disabilities if they are able to fulfill the responsibilities of a position. So, if I have a back injury and the position I am applying for requires me to move individuals, carry heavy objects, etc., then there is no obligation for the potential employer to hire me.

"However, if heavy lifting, or any other such activity causing potential aggravation to a back disability is not required or so stated, then they need to work with me in terms of providing what is necessary for me to do the job."

On-the-job injury-a particular concern for nurses who do lifting-is another matter.

"The ADA issue most of the time does not come into play when it's a work injury," said Glenda Evans-Shaw, RN, a nurse case manager in Northern California for Strategic Health Alliances. It's usually a workers compensation >> issue. In her state, "employers are really under the gun to accommodate injured workers." But that varies from state to state.

Often, it's "cheaper to settle the case than it is to accommodate," said Larry Kontosh, Ph.D., a rehab counseling specialist in the department of counselor education at Florida Atlantic University. Some states require accommodation under workers compensation; others don't. There's no simple formula.

"The issues for nurses aren't any different than they are for anybody else with a disability in a job situation," Davis said. But nursing does raise particular concerns because the work directly affects other lives. If a nurse presents a direct threat to another person, that nurse is not considered qualified for the job, Davis said.

Such complexities make for confusion-and sometimes discrimination:

The hearing-impaired nurse whose employer bought her an expensive amplified stethoscope-then said she must stay a year or reimburse the company.
n The nurse who was instructed to tell patients she "talked funny" because she was deaf.
n The student with a back injury who was told, "People like you shouldn't bother taking slots from people like us who don't have disabilities."

But hopeful stories abound as well. Take Christine O'Dell, a deaf nursing student at Research College of Nursing/ Rockhurst University, who uses interpreters, digital hearing aids and an amplified stethoscope.

"But I don't see deafness as a disability," she said. "It brings with it so many opportunities and abilities." If challenges stymied her, "I would never cross the street, go to a restaurant, learn to drive." She is determined to succeed. "That is my approach to getting a job as well."

Dedication is key. "I wanted to be a nurse since the age of 4, and people said, 'You can't, you're deaf, you can't, you're deaf," said Morag MacDonald, MSW, RN, an outpatient psych nurse in Connecticut. "You've got to have the guts to challenge those subtle discriminations."

Disclosure issues

Negative attitudes can deter employees from revealing their disabilities. "I believe there is no need to disclose a disability if the issue is corrected," Polifroni said. "But if there is a need for special equipment, modification of the environment ... then there is a moral and legal imperative to disclose."

Telling patients is another matter. "A patient operates on the premise that those caring for him or her have the appropriate skill and ability," she said. "As long as the disability does not impair practice, there is no need to disclose."

Furthermore, Jane Archer, RN, who works in a Minneapolis urgent care clinic, said informing all patients of her hearing impairment "would feel contrived and artificial" because it's not an issue unless she's triaging in a noisy room.

"It would make as much sense to tell every one that I am severely nearsighted and wear contacts," Archer said. "I don't see much difference, as long as the disability is corrected and I am able to function within the expectations of my job. It is my responsibility to recognize when I am having difficulty with a task as a result of my hearing."

Patient safety must not be compromised, said Donna Maheady, Ed.D., NP, RN, founder of the Web site exceptionalnurse.com. In 1999, Maheady published a report in the Journal of Nursing Education titled "Jumping Through Hoops, Walking on Egg Shells: The Experiences of Nursing Students With Disabilities."

It describes hearing-impaired students missing patients' calls for help, a student who almost fell because of a gait disturbance, a diabetic student who was dizzy and confused and students who graduated despite disabilities that kept them from meeting admission standards and graduation guidelines.

Davis agreed that nurses are obligated to disclose disabilities that affect patient safety. Nurses should learn their rights under the ADA and approach employers with "a game plan" of ideas. Legally, employers must discuss accommodations with them.

"It was a real challenge getting a master's and being hard of hearing," said Patricia Carlson, MS, RN, at Northwestern Memorial Hospital in Chicago. "At the time, I had no idea that I could have asked for note takers or an assistive listening device."

Sometimes, though, nurses take different positions.

"I knew I could never make it in a hospital setting with intercoms, call bells, lots of telephone work, so I looked at home health," said Dana Yelverton, MPH, RN, whose hearing diminished for unknown reasons 10 years ago. "I was very upfront about my hearing and told them I was not sure I could do the work but would like to try," she said.

Preventing workplace injuries helps, too. The University of Washington Medical Center in Seattle started a lift team about 2½ years ago. When heavy lifting is required, the staff calls in a trained two-person team with specialized equipment. "It's really been wonderful," said Judy Shorr, MS, RN, manager of nurse recruitment. It's worked so well, the team is expanding its hours.

Barriers and benefits

The biggest challenge, though, is social many agree. Despite wonderful examples of sensitive patients and co-workers, barriers remain.

"I really can't be part of the social scene," Yelverton said. "They jabber in groups and I don't understand. They lower their voices for the punch line or for the off-color joke and I don't hear. I'm really on the fringes ... It's a big investment to get to know a hard-of-hearing person well enough to be real friends."

Misinformed attitudes also linger, said Elizabeth Clubb Cohen, RN, who works in the telemetry unit at Cleveland Regional Medical Center in North Carolina. "My hearing disability has not affected my ability to be a conscientious, professional nurse."

In that respect, Churchill returned to work with an advantage. "They knew me before and they knew I would never put a patient at risk." Most often, she said, a person with a disability asking for work can do the job. "No one inherently wants to set themselves up to fail. They know their limitations."

They also know their strengths. "I pay closer attention to changes in patient condition, have the ability to lip-read ventilator and tracheostomy patients, and older patients who are hard of hearing are more comfortable talking with someone who has a hearing impairment as well as those who were born with one," Cohen said.

Joseph Smith, MA, a hearing-impaired respiratory therapist in Nebraska, agrees. "Many patients see the ability to cope as a strong point and some patients are encouraged by the fact that there are others with 'problems.' "

Churchill is learning to turn her impairment into a strength. She better understands her patients' pain. She's been on their side.

"It's made me a different nurse as far as being able to relate to my patients," she said.

The Lowdown on Depression

Depressive illness is one of the most costly, destructive and expansive health problems in the world. It affects millions of Americans from all walks of life-including nurses.

"This is an illness like any other illness," said Judith Saunders, DNSc, FAAN, a primary care integration specialist at PacifiCare Behavioral Health in California. "Depression is horribly painful."
Everyone has transient depressed moods, but that's different from chronic, diagnosable depression. "It is a biological and chemical change," Saunders said.

According to the National Foundation for Depressive Illness Inc., "Prolonged depression that interferes with the ability to function, feel pleasure or maintain interest is not a mere case of the blues." The illness results from biochemical imbalances in the brain. It runs in families, and the most severe form, bipolar disorder, is most likely inherited. Stress can add to it. But 80 percent of cases can be treated successfully.

The foundation reports that 35 million to 40 million Americans alive today will suffer from depressive illness, and an estimated $15 billion to $35 billion a year is lost to depressive illness in medical care, lost productivity and other costs.

In nursing, Saunders said, depressive disorders present serious issues. "I think when you're depressed, you don't have the energy. It takes energy to pay attention to detail." The health care system already has a problem with errors, and "the nurse is the pivotal point" for catching mistakes that may have already slipped through. If nurses are depressed, "they're simply not going to be as good."

But she said employees often are hesitant to seek treatment because they fear losing their jobs. They grow sicker, as with any untreated disease. "Most nurses who are depressed seek treatment outside their workplace-which is wise," said Sharon Valente, Ph.D., NP, RN, FAAN, an assistant professor at the University of Southern California. Treatment programs can be found through a primary care provider, referral or employee assistance program.

Saunders said 15 to 20 varieties of anti-depressant drugs are equally effective. But the side effects vary, so people tolerate them differently. Patients must find the right fit, and continue treatment. "Unfortunately, even when it's recognized, it's undertreated," she said. If treatment doesn't continue for several months, people are more susceptible to chronic depression "which can be lifelong," Saunders said. In addition, patients often start to feel better, so they stop taking medication.

Depression can be a barrier to employment. Valente said a competent and well-known nurse was not hired when the dean learned she had a history of depression. "This should not happen-but it does," she said.

If a job candidate has a history of depression, Saunders said, that shouldn't come up in an interview unless specifically asked on the application. "You can't lie about it," she said.

But people don't have to volunteer information if not asked. If it comes up, she said, the job candidate should state the condition, how long it lasted and what he or she learned from it. When hired, employees should learn the company's regulations regarding job termination.

The National Mental Health Association has an anonymous online survey to determine whether a person suffers from diagnosable depression (www.depression-screening.org). "It's all very private and safe," Saunders said. "It will give them immediately their score."

The stigma associated with mental illness has long hindered treatment. According to a World Health Organization report in November, "Stigma can be defined as a mark of shame, disgrace or disapproval which results in an individual being shunned or rejected by others. The stigma associated with all forms of mental illness is strong but generally increases the more an individual's behavior differs from that of the 'norm.' "
Saunders said depression is common, diagnosable and treatable. Attitudes are changing as more is learned. "There is not as much stigma now as there used to be," she said. It's gradually being eaten away "by replacing myths and fears with actual information."

~Karen Coates

Signs of Depressive Illness

• Loss of energy and interest
  
• Diminished ability to enjoy oneself
  
• Decreased, or increased, sleeping or appetite
  
• Difficulty in concentrating; indecisiveness; slowed or fuzzy thinking
  
• Exaggerated feelings of sadness, hopelessness or anxiety
  
• Feelings of worthlessness
  
• Recurring thoughts about death and suicide

SOURCE: National Foundation for Depressive
Illness Inc., www.depression.org