Encouraging students to disclose a disability or health condition before starting a university placement will enhance their experience, as reasonable adjustments can be put in place. OH can play a key role but, as this case study of a midwifery student by Irene Boham and Professor Anne Harriss shows, the process may not always be straightforward.
This case study considers the health assessment undertaken for “Mary”, a pseudonym, an applicant for a place on a midwifery course. The Nursing and Midwifery Council (NMC) requires these applicants to declare to the education institution any health conditions and/or disability that could affect their ability to practice safely and effectively (NMC 2020).
About the authors
Irene Boham RN, BSC, PGC, PGD, SCPHN (OH), Associate Fellow HEA, is an occupational health and workplace wellbeing manager and Professor Anne Harriss MSc, BEd, RGN, OHNC, RSCPHN, CMIOSH, NTFHEA, PFHEA, FRCN is emeritus professor of occupational health and president of SOM
The student in this case study had mental ill health requiring support by the organisation, but she chose not to fully engage with the OH service.
Good health and good character are fundamental to fitness to practise as a midwife (NMC, 2019).
The disclosure or non-disclosure of health problems or disabilities by prospective students is sometimes problematic for universities. Some students may not consider they have a disability or may fear disclosure will result in rejection (Brothers et al, 2002).
Healthcare students experience higher levels of anxiety, depression, burnout, and personal distress compared to non-healthcare students. High workload, ethical conflicts, and the intensity of contact hours and clinical practice are significant stressors for healthcare students. There is also significant under-reporting of mental ill health from healthcare undergraduates (Mental Health Today, 2019).
Pressures impacting on first-year students include leaving home, adapting to higher education and financial and social pressures. Key to the recruitment process is evaluating whether healthcare students have the psychological and functional (physical) capacity for their clinical placements/practice learning opportunities fundamental to their studies (Everton et al, 2014).
Universities aim to provide supportive, stimulating learning environments for all students. In recognition of the requirements of the Equality Act 2010 they have strategies to ensure that students with a range of physical and mental health conditions can realise their academic potential.
In order to assess fitness for their clinical placements and to provide support for students with particular health considerations whilst in practice, prospective healthcare students complete a pre-study (occupational) health questionnaire with the aim of ensuring their suitability to complete their programme without risk to themselves or others.
This process identifies whether supportive modifications are required for those with long-term health conditions (Litchfield and Becker, 2012).
Healthcare students must also successfully complete OH clearance (HEOPS, 2015) and students complete a process of health screening before commencing clinical placements.
The standards for nursing and midwifery students undertaking healthcare courses are set by the Nursing and Midwifery Council (NMC, 2010) and in order to ensure patient safety are targeted at functions intrinsic to the discipline.
Assessment by occupational health
Mary’s completed health questionnaire disclosed several underlying health conditions but did not indicate any significant mental health concerns.
On attending OH to assess her fitness for clinical placements, Mary appeared evasive with her answers; further probing revealed eating disorders, self-harm and suicidal ideations, before and since arriving at university. Her body mass index (BMI) was 16. She was made aware of the university wellbeing services.
Having been involved in assessing and supporting healthcare students, it is the authors’ experience that it is not uncommon for students to withhold information when completing health questionnaires because of concerns that their offer of a place may be refused. Those with mental health issues highlight the stigma associated those conditions.
In Mary’s case, there was strong evidence suggesting that the Equality Act 2010 would apply, as her condition had been ongoing for many years and the exacerbation of her symptoms had adversely affected her ability to carry out normal daily living activities.
On graduation, the NMC (2010) expects midwifery students to be able to practice proficiently, safely and effectively without supervision. There is an obligation on the approved educational institution (AEI) to make reasonable adjustments for students with disabilities where the adjustment enables the midwife to achieve this.
When it became evident that Mary had health issues, the adjustments the university could implement to support Mary through the course were discussed. The importance of OH being aware of her health problems was also highlighted.
The NMC (2010) further clarifies within its standards for fitness to practise that students with disabilities can expect a university to implement reasonable adjustments for both academic work and practice placements to support them to achieve the programme outcomes.
Although adjustments may be made to the way that a student meets a competency standard, the standard itself cannot be adjusted. There is a requirement within the university’s fitness to practice policy for students to “declare, during the application/admission process, any health issue or disability that might affect their fitness to practise”.
Where a health/disability issue arises post-admission, this should be reported at the earliest opportunity in order for appropriate support to be put in place to help the student manage their health, studies and placement requirements.
Where it is found that a student was aware at the time of application or admission of a health issue that might compromise his or her fitness to practise and/or the health, safety and wellbeing of the users of the service but the student did not declare this, the university reserves the right to withdraw them from their programme.
Medical and personal information disclosed during the assessment processes is held “in confidence” by the OH service, and this was explained to Mary.
Medical details are only disclosed to the school and others outside OH in exceptional circumstances and in accordance with the General Data Protection Regulations (GDPR, 2018).
Explicit informed consent must be obtained from the student if it is necessary for medical information to be shared more widely. This was discussed with Mary. Mary consented to further medical information being sought from her doctor and treating specialist.
Mary was further informed that her health information would not be shared outside of the OH service, except where this was necessary to protect the health, safety and wellbeing of patients and public or would benefit her.
Relevant managers responsible for her practice/academic learning would only be informed of any adjustments which would allow her to complete her course of study.
Mary was also informed that, in line with Department of Health and Social Care (DHSC) guidelines, testing for immunity and infection for tuberculosis, measles, mumps, rubella, hepatitis B and chicken pox would be carried out as required (DHSC, 2018).
Antibodies to Hepatitis B, C and HIV are offered to all healthcare students but, as midwifery students undertake exposure-prone procedures (EPP), in line with DHSC guidance additional checks are made for antibodies to HIV, hepatitis C and hepatitis B surface antigen.
Reluctance to access OH and other support
Mary was advised that students declaring specific functional impairments had further OH assessments, usually carried out by an accredited specialist in occupational medicine. The importance of obtaining additional information from her GP was discussed.
Mary was reluctant to access available support, stating that she had previously been cleared by another university’s OH service. She eventually consented to the OH request for additional information from her GP.
On receipt of this medical report, it was evident Mary had significant underlying health conditions and required further medical intervention. She was reticent with her answers on trying to explore this but eventually highlighted having been studying at another university when she became unwell.
Mary was made aware that her OH clearance by the previous organisation would be useful if she shared the information. This is supported by higher educational occupational practitioners (HEOPS) who have been working on the use of universal health questionnaires/OH clearances.
Having universally applied health clearance confirming that a student is fit to train and undertake exposure prone procedure highlights any adjustments that are necessary to allow the student to fulfil the required competencies for graduation and professional practice. It also speeds up health clearance for all UK universities (HEOPs 2015), so preventing the need for replicating screening for other placements and electives. Mary was reluctant to share the clearance information from her previous university.
Ongoing discussions with Mary revealed that, whilst studying at another university, she had been admitted to an inpatient psychiatric hospital under Section 35 of the Mental Health Act 1983.
It was clear from the medical reports that Mary was non-compliant with treatment; their opinion in regards to Mary’s ability to pursue a degree in midwifery was unclear.
Following further assessment by the occupational physician, it was decided that further psychological intervention would be required. The implications of Mary’s disability were considered in conjunction with her placement duties and work environment (Murugiah et al, 2002).
Reporting to the training school in a timely manner is essential for the necessary adjustments, and therefore recommendations to support Mary were put in place.
Students’ fitness to practise issues should be considered by the programme team to explore support to be provided for students in view of their health issues or disability, which could lead to students’ inability to demonstrate the necessary level of competence that cannot satisfy the required conditions of their programme.
All reasonable avenues open to the student have to be explored. The university and practice placement/learning providers should discuss a way forward and agree the position of the student considering these through their fitness to practise proceedings.
However, this process would normally be implemented as a last resort, where a student is struggling to understand the full implications of the effect of their health or disabling condition on their ability to practise their relevant profession.
That is, the student may be unable to fully assess their own health issues and the possible risks to service users. They may, however, be willing to accept the value of being referred for treatment and to engage in any recommended treatment programmes to enable them to achieve the programme requirements.
Disagreement with the OH decision
In Mary’s case, collaborative discussions between OH and the midwifery school resulted. It was decided it would be safer for Mary to interrupt her studies, then be supported and to return when well enough to do so.
This difficult decision was made as it was felt it was in the best interests of the student, who clearly needed support. In the majority of cases the OH team would offer support to students with significant underlying health conditions while at the university, so supporting them to continue with their studies and engage in university life.
Mary, however, disagreed that it was in her best interests to interrupt her studies and was adamant there was nothing “wrong” with her; she considered herself fit to continue her studies and was keen to start her practice placement.
Some students may continue to perform adequately academically but at huge expense to their overall wellbeing. Therefore, considering an interruption in studies can ensure their health and wellbeing needs are addressed, as this is paramount.
Mary’s medical history made her more vulnerable to the challenges facing all students. The psychological support mechanisms available including confidential counselling, which was highlighted to Mary. With her consent, a request was made to her GP and treating specialist for further information to facilitate recommendations for strategies to support Mary.
This is a particularly important consideration when advising suitability for acceptance on a health care course of study.
Mary demonstrated poor insight regarding the impact of her health conditions on her current suitability to study midwifery. Healthcare students are sent information on OH requirements on receiving an offer from the university. This is followed by further information during the course induction programme,
Mary’s case indicates the importance of including mental health awareness within the initial talks for healthcare students. This can include self-awareness, suicide risk and prevention, and how to recognise when stressors might become a problem for healthcare students.
To further support healthcare students, wellbeing “check-ins” should be provided for all healthcare students within two weeks of starting each placement. Attending the student wellbeing team for ongoing support was recommended to Mary but, again, she refused the support, stating that she would be able to cope.
A few days after the decision was made, a call was received from a relation of Mary who threatened to come to the university to assault the OH manager as they had played a significant role in Mary’s OH assessment.
This had significant psychological impact not only on the OH manager but on the whole OH team, making them fearful and causing anxiety amongst the team.
The university security service, lawyers and the associate dean of school were made aware of this and supported the OH team. The decision to interrupt Mary’s studies was an organisational one, but the student perceived it to be an OH decision.
This was a very worrying development and, more widely, highlighted the risks to personal safety of what OH practitioners might encounter if decisions they make are not favourable to students or the workforce.
The role of the OH adviser (OHA) is a “multi-faceted and multi-disciplinary activity concerned with prevention of employees’ ill health in the working population” (Aw et al, 2007). It also takes into consideration the health and safety of others involved (Palmer et al, 2007).
Therefore, it is important to guarantee the functions such as assessment, review and providing advice are undertaken to ensure health and safety at workplace (World Health Organization, 2002).
Mary lacked full insight into her condition. Efforts had been made for her to have received appropriate health management by her healthcare providers prior to commencing her course but she was reluctant or non-compliant with treatment.
From an occupational health perspective, she was not well enough to commence midwifery training and it was important she was given support and treatment to improve her health, safety and wellbeing.
This case highlights the importance of support and health assessment being made available earlier in the training cycle to healthcare students, and the vital role OH professionals play in upholding good practice by facilitating excellent support, advice and maintenance of fitness to practice.
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.
It is important for approved educational institutions to ensure that prospective healthcare students have a clear awareness about what constitutes fitness to practise.
It is also essential for OH to ensure that those with a disability are assessed earlier on during the course to determine whether they can cope with the course requirements or need to seek further advice and support.
Addressing fitness to practise issues before students commence their programme can improve retention and avoid the effects unsuccessful completion have on the university as well as on the individual’s self-esteem and personal circumstances.
Admission tutors can benefit from up-to-date knowledge of the relevant HEOPS standards and enable them to advise applicants accordingly.
The added financial consequence of unnecessary student attrition is 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.
Finally, this case also raises awareness of some of the dilemmas and risks that OH practitioners can be exposed to in the course of their day-to-day work, and the importance of the NMC in highlighting the role OH practitioners play in nursing.
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