Textbook of Medical-Surgical Nursing 3e

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Unit 3   Applying concepts from the nursing process

CLINICAL REASONING CHALLENGE EBP  A 41-year-old woman with quadriplegia due to spinal cord injury (SCI) has never had a mammography and has not had a gynaecological examination in more than 15 years before the SCI. During a recent admission for treatment of a secondary condition due to her disability, you decide to encourage her to undergo preventive health screening, including screening for breast, cervical and colon cancer, as well as for low bone density. In discussing these issues with her, what evidence will you use to provide rec­ ommendations for screening? What is the research evidence about the patterns of women with disabilities undergoing preventive health screening and barriers to screening? How would you help prepare her for the health screening tests? Federal legislation The Australian and New Zealand governments have enacted legislation to address healthcare disparities because of wide­ spread discrimination against people with disabilities. This leg­ islation includes the Disabilities Act 1992 (Australia) and the Human Rights Act 1993 (New Zealand). Both Acts contain law that protects people from discrimination based on their dis­ abilities. The Acts apply to employers and organisations that receive financial assistance from any federal department or agency; this includes many hospitals, long-term care facilities, mental health centres, and human service programs. The leg­ islation forbids organisations from excluding or denying people with disabilities equal access to program benefits and services. It also prohibits discrimination related to availability accessi­ bility and delivery of services, including healthcare services. The Acts mandate that people with disabilities have access to job opportunities and to the community. They require that employers evaluate an applicant’s ability to perform the job and not discriminate on the basis of a disability. According to the Acts, communities must provide public transportation that is accessible to people with disabilities. The Acts also requires provisions to facilitate employment of a person with a disability. Facilities used by the public must be accessible and accommodate those with disabilities. Examples of reasonable accommodations in healthcare settings include accessible facilities and equipment (e.g. accessible restrooms, adjustable examination tables, access ramps, grab bars, elevated toilet seats) and alternative communication methods (e.g. telecommunication devices and sign interpret­ ers for use by people who are deaf). Although the Acts took effect in 1992 and 1993, compliance has been variable, and some facilities continue to be inaccessible. However, all new construction and modifications of public facilities must address Lack of financial resources, including health insurance, is an important barrier to healthcare for people with chronic illness and disabilities. In Australia, some programs such as the MBS Chronic Illness Managed (CDM) items enabled higher incentives for general practitioners to provide services for those with chronic and complex needs (ADHA, 2009a). A trial of a National Disability Scheme is soon to be undertaken. access for people with disabilities. Federal assistance programs

life within the limitations imposed by their disabling condi­ tions. Men and women with disabilities have the same needs and same rights for healthcare and preventive health screening as others, although in some cases, the consequences of their disability increase rather than decrease their need for health screening and for participation in health-promoting activities (Yankaskas et al., 2010). Many people with disabilities encounter barriers to full participation in life, including healthcare, health screening and health promotion (Smeltzer et al., 2007). Some of these barriers are structural and make certain facilities inaccessible. Examples of structural barriers include stairs, lack of ramps, narrow doorways that do not permit entry of a wheelchair, and restroom facilities that cannot be used by people with dis­ abilities (e.g. restrooms that lack grab bars and those that lack larger restroom stalls designed for people using wheelchairs) (Kirschner, Breslin & Iezzoni, 2007). Structural barriers to accessibility are most easily identified and eliminated. Other, less visible barriers include negative and stereotypical attitudes (e.g. believing that all people with disabilities have a poor quality of life and are dependent and non-productive) on the part of the public (Giddings et al., 2007). Healthcare provid­ ers with similar negative attitudes make it difficult for people with disabilities to obtain healthcare equal in quality to that of people without disabilities. People with disabilities have reported they often encoun­ ter barriers that prevent them from obtaining recommended healthcare screening and care. They have also reported lack of access to information and transportation difficulties. Others report inability to pay because of limited income, with 36% of people with chronic illness reporting they have not filled a prescription, missed a dose, not visited a doctor or skipped a test (ADHA, 2009b). Difficulty finding a healthcare provider knowledgeable about their particular disability, previous negative healthcare encounters, reliance on carers, and the demands of the disability itself are also reported (ADHA, 2009b; Smeltzer et al., 2007). These issues affect both men and women who have severe disabilities; however, women appear to be at higher risk for receiving a lower level of healthcare than men. Women with disabilities are significantly less likely to receive pelvic exam­ inations than women without disabilities; the more severe the disability, the less frequent the examination. In particular, minority women and older women with disabilities are less likely to have regular pelvic examinations and Papanicolaou (Pap) tests. Reasons given by women for not having regular pelvic examinations are difficulty transferring onto the examination table, belief that they do not need pelvic examinations because of their disability, difficulty in accessing the office, healthcare centre or clinic, and difficulty finding transportation (Smeltzer et al., 2007). Healthcare providers may underestimate the effect of disabilities on women’s ability to access healthcare, including health screening and health promotion, and they may focus on women’s disabilities while ignoring women’s general health issues and concerns. Furthermore, women with disabilities have also reported a lack of knowledge about disability and insen­ sitivity on the part of healthcare providers (Smeltzer et al., 2007). It is essential that nurses and other healthcare providers take steps to ensure that clinics, offices, hospitals and other healthcare facilities are accessible to people with disabilities because of the persistence of these barriers.