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Dyslexia, dyspraxia and dyscalculia:

a guide for managers and practitioners

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Acknowledgements

The author would like to thank all of thosewho have contributed to this guide and theassociated toolkit in a variety of ways. Thisincludes the individual RCN members andstewards who have shared their personalstories and provided a valuable insight intothe realities of living and coping with dyslexia,dyspraxia or dyscalculia on a day-to-day basis.For you the following quote – and thank youfor letting me in:

“First of all… if you can learn a simpletrick… You’ll get along a lot better with allkinds of folks. You never reallyunderstand a person until you considerthings from his point of view… until youclimb into his skin and walk around in it.”

To kill a mockingbird, Harper Lee (1960)

Colleagues from around the UK who share mypassion for this topic have also helped bychecking out ideas, spotting what I might havemissed and pointing me in the direction ofuseful resources. Particular thanks go to EADraffan, researcher in the Learning SocietiesLaboratory at the School of Electronics andComputer Science, University of Southamptonfor providing information about free assistivetechnology software. This has saved me hoursof work, thank you.

I would also like to personally thank JanetSkinner, Head of Dyslexia Services at theUniversity of Southampton (UoS). Your advice,support and peer review have been invaluable,as was permission to use the UoS bookletSupporting students with dyslexia in practiceplacements as the basis for this toolkit.

Finally, particular thanks go to BobbieChadwick, Deputy President of the RCN,Professor Dame Betty Kershaw, RCN EducationAdviser, and the RCN Education Forums, all ofwhom have fought to get this on the agendaand secure funding for this work to take place.Without you it would not have been possible.

Author

Michelle Cowen

Lecturer/Academic Lead for Disability andDyslexia at the Faculty of Health Sciences,University of Southampton

Consultant in dyslexia, dyspraxia anddyscalculia

Dyslexia, dyspraxia and dyscalculia:a guide for managers and practitioners

Published by the Royal College of Nursing, 20 Cavendish Square, London, W1G 0RN

© 2010 Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in aretrieval system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording orotherwise, without prior permission of the Publishers or a licence permitting restricted copying issued by theCopyright Licensing Agency, 90 Tottenham Court Road, London W1T 4LP. This publication may not be lent, resold,hired out or otherwise disposed of by ways of trade in any form of binding or cover other than that in which it ispublished, without the prior consent of the Publishers.

RCN Legal Disclaimer

This publication contains information, advice and guidance to help members of the RCN. It is intended for use withinthe UK but readers are advised that practices may vary in each country and outside the UK.

The information in this booklet has been compiled from professional sources, but its accuracy is not guaranteed.Whilst every effort has been made to ensure the RCN provides accurate and expert information and guidance, it isimpossible to predict all the circumstances in which it may be used. Accordingly, the RCN shall not be liable to anyperson or entity with respect to any loss or damage caused or alleged to be caused directly or indirectly by what iscontained in or left out of this guidance.

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R O Y A L C O L L E G E O F N U R S I N G

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Dyslexia, dyspraxia and dyscalculia:a guide for nursing managers and practitioners

Contents

Acknowledgements Inside front cover

Foreword 2

1 Background to the guide 21.1 Who is it for? 21.2 How to use it 31.3 Language 3

2 Introduction to neuro-diversity 42.1 What do we mean by

neuro-diversity? 42.2 Positive aspects 42.3 Unique nature 52.4 Coping strategies 5

3 Overview of dyslexia 63.1 What is dyslexia? 63.2 Potential challenges associated

with dyslexia 7

4 Overview of dyspraxia 94.1 What is dyspraxia? 94.2 Potential challenges associated

with dyspraxia 10

5 Overview of dyscalculia 125.1 What is dyscalculia? 125.2 Potential challenges associated

with dyscalculia 13

6 Employer and employee responsibilities 146.1 Legal responsibilities 146.2 Moral responsibilities 166.3 Professional responsibilities 176.4 Disclosure 18

7 Identification of a SpLD 197.1 Delays in identification 197.2 Testing for specific learning

differences 207.2.1 Identification of dyslexia 207.2.2 Identification of dyspraxia 217.2.3 Identification of dyscalculia 22

7.3 Obtaining funding for an assessment 227.4 Psychological impact of being

identified as having a SpLD 22

8 Supporting staff with a SpLD 248.1 Philosophy of support 248.2 Metacognitive awareness 248.3 Scaffolded learning 258.4 Multisensory learning 25

8.4.1 Auditory learners 268.4.2 Visual learners 268.4.3 Kinaesthetic learners 27

8.5 Equipment 278.6 Disabled Student Allowance/

Access to work funding 28

9 Recommendations for the future 29

10 Further information and sourcesof support 30

11 Further reading 33

12 References 34

13 Bibliography 38

14 Appendices 40

1 Examples of good practice 402 Personal stories 41

Find your way around: you can navigate through this document by clicking on the links in the contents pageor ‘Back to contents’ and ‘Back to start of chapter’ at the base of each page.

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D Y S L E X I A , D Y S P R A X I A A N D D Y S C A L C U L I A

Back to contents Back to start of chapter

Background tothe guide

For many years the Royal College of Nursinghas recognised the impact of dyslexia,dyspraxia and dyscalculia on its members,and has sought ways of supportingindividuals with these conditions to helpthem to reach their potential in whateverrole or setting they work.

In 2006 the RCN Practice Education Forumcommissioned a review of the literature ondyslexia in relation to practice (Dale andAiken, 2007) which highlighted a wealth ofissues and helped raise awareness,certainly in relation to dyslexia the mostcommon of the three conditions. Whilst theliterature review recognised the challengesit was not able to offer any real solutionsand there continued to be a need for apractical guide for managers, employers andthe nursing staff themselves, to identifystrategies which can help.

This led to a resolution being accepted byCongress 2009 which called on RCNCouncil to “influence employers torecognise and provide for the needs ofnursing staff with dyslexia and similarconditions”. This guide and theaccompanying toolkit aim to do just that.

1.1 Who it is for?

This guide has been designed to providebackground information for managers,human resources staff and RCNmembers. Itsets the scene for the toolkit, and identifieskey areas which require action in relation tothe introduction of the toolkit and in thefuture.

As the target audience for the guide andtoolkit are different, and both groups will

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Foreword

Over the years as an RCN representative,I have represented an increasing numberof nurses with dyslexia, dyspraxia anddyscalculia.

My experience is that there is awillingness by managers andorganisations to support nursing staffwith these specific learning differences tomaintain their practice. Unfortunately,there is always the problem of whatappears to be a lack of information andguidance to support this.

Nursing staff with specific learningdifferences have a huge contribution tomake to health care and they deserve theopportunity to do so. Many experiencesome form of discrimination, purelythrough lack of knowledge andunderstanding within an organisation.

My past experience within this field hasgiven me a passion for what we refer toas the 3Ds: dyslexia, dyspraxia anddyscalculia. As Deputy President of theRoyal College of Nursing, it has been adelight and privilege to lead on this pieceof work: at last, we have comprehensiveguidance. For me, this guidance formanagers and practitioners ticks all theboxes, answers the questions on a widerange of 3D issues and offers thesolutions.

This guidance will support nursing staffwith specific learning differences, theircolleagues and their managers to realisetheir full potential and continue to makea valuable contribution to health care.

Bobbie Chadwick

Deputy President of theRoyal College of Nursing

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3Back to contents Back to start of chapter

require background information, it isinevitable that material will be duplicated inboth documents. The toolkit – which it ishoped will be easily available in practicesettings – gives a broad overview of theissues, but its primary objective is toprovide practical strategies that individualscan use to help themselves or colleagues.This guide builds on the informationcontained within the toolkit and wherepossible draws on the evidence base,particularly surrounding dyslexia – the mostprevalent and researched of the threeconditions.

1.2 How to use it

To facilitate easy access to relevantinformation the guide is divided intosections which are designed to dip in andout of, as required. Additional sources ofinformation and support groups are alsoprovided, along with suggestions for furtherreading.

1.3 Language

One important area to consider, right at thebeginning, is the use of language whichremains a highly emotive and sensitive area.

The guide begins with a section on ‘neuro-diversity’ which is a relatively new term,encompassing a range of neurological anddevelopmental conditions (Pollak, 2009;Hendrickx, 2010). Since its introduction inthe United States in the 1990s this hasbecome the preferred term by many of thoseliving with these conditions as it reflects thenotion of a brain which is just wired slightlydifferently. It moves away from negativeterms such as ‘impairment’, ‘difficulty’ or‘disability’ and reminds us that we are allslightly different.

Historically we have been used to a ‘medicalmodel’ of disability which has categorised

things as ‘disorders’, ‘deficits’ or ‘difficulties’that the individual needs to overcome. Morerecently there has been a move towards the‘social model’ which suggests that if there isa problem it is created by a society whichfails to adapt to the needs of the individual(Riddick, 2001). This is a useful model whenconsidering dyslexia, dyspraxia anddyscalculia, all of which fall under the neuro-diverse umbrella and the essence of thisguide is to explore how we can supportcolleagues. Wherever possible the guideembraces the philosophy of the socialmodel. However there are situations wherethis may not be compatible withprofessional standards and these issues willbe explored further in section 6.3.

Other terminology which features within thisguide includes ‘specific learning differences’(SpLD) a more traditional term for dyslexia,dyspraxia and dyscalculia. Although neuro-diversity will be used initially, this in factcovers a much wider range of conditionsthan will be considered in the guide, so theabbreviation SpLD will be used as the guideprogresses. The term ‘condition’ is alsocontentious as it could be seen to imply amedical basis. However it is difficult toidentify an alternative preferable term, so itwill be used and I apologise now to anyoneoffended by it.

Finally, as nurses we are used to seeing theperson first and are often upset by termssuch as ‘dyslexic adult’, preferring to sayadult with dyslexia. However, it is interestingthat specialist groups such as the BritishDyslexia Association (BDA) prefer to use theterm dyslexic adult/child and therefore thisis the format that will be used.

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Introduction toneuro-diversity

For many adults with a specific learningdifference (SpLD) the challenges of livingwith, and overcoming difficulties in theirlives as a result of their dyslexia, dyspraxiaor dyscalculia are made worse by otherpeople’s attitudes. Sometimes theseattitudes exist as a result of prejudice butmore frequently as a result of ignorance.This next section is designed to give a broadgeneral overview of SpLDs to raiseawareness. A more detailed description ofeach condition can be found in subsequentsections.

2.1 What do we mean byneuro-diversity/specificlearning differences?

The term ‘neuro-diversity’ is a relativelyrecent import from the United States whereit was selected by individuals with AutisticSpectrum Disorder to try and convey toothers that they were not disabled orabnormal, merely that their brain is wireddifferently (Pollak, 2009; Hendrickx,2010).Taking it to the full extent somepeople are now also using the term ‘neuro-typical’ to describe those whose brains areseen to be wired in a conventional manner.Whether this distinction is really necessary,and whether the term neuro-diverse will bewidely adopted remains to be seen; theterminology is merely being introduced herein case we move in this direction. It mustalso be acknowledged that the range ofconditions which fit under the neuro-diverseheading are much broader than the threeconditions which form the focus of thisguide. For clarity the termmore commonlyused within the UK at present – specificlearning differences (SpLDs) – will be used

throughout this guide. This is an umbrellaterm used to describe a range of conditionsincluding dyslexia, dyspraxia anddyscalculia. Whilst these three conditions allhave distinct areas of difficulty associatedwith them (which will be explored inSections 3, 4 and 5 of this guide) theirneuro-cognitive profiles often overlap. Thissometimes results in an educationalpsychologist choosing not to attach aspecific ‘label’ such as dyslexia or dyspraxiain their assessment report, but will instead‘diagnose’ the individual as having a specificlearning difference.

In terms of identifying which conditionaffects an individual it could be argued thatthe label itself is less important than theneed to recognise the specific areas ofdifficulty that they are faced with. Therefore,whether the individual is diagnosed with‘dyslexia’, ‘dyspraxia’, ‘dyscalculia’ or a‘specific learning difference’ is immaterial.All are classed as a disability underdisability legislation and individuals withany of these conditions will requireunderstanding and support to help them toreach their potential.

Of the three conditions dyslexia is arguablythe most common and also the one onwhich the most research has beenconducted and literature published, and asignificant amount of this relates to dyslexiain children or to students within highereducational settings. It is only relativelyrecently that an interest has started to beshown in the effects of any of theseconditions on adults in their workenvironment and there is clearly a need formore work on this area.

2.2 Positive aspects

Whilst there is inevitably considerableattention paid to areas that a person withdyslexia, dyspraxia or dyscalculia might finddifficult, it is important to recognise that

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there are specific strengths associated witheach of these conditions. Nursing oftenattracts individuals with these conditionsbecause of their caring and compassionatenature. We also know that in the case ofdyslexia, individuals are likely to be creativeand good at problem solving. Finally,perhaps because of the daily challengesthey face, there is a lot of evidence whichhighlights how hard working anddetermined to succeed they are.

2.3 Unique nature

One important factor to remember inrelation to each of the SpLDs is that everyindividual will present with their own uniqueprofile. Each of the conditions is multi-faceted, with individuals being placedsomewhere on a separate continuum foreach aspect. Reid (2003) emphasises theimportance of this in relation to dyslexia andreminds us that whilst they may share somecommon problems, dyslexic adults “do notrepresent an identical discrete entity.” Overthe years this has resulted in regularchallenges to its very existence by thosewho fail to recognise its complexity, or feelthat it is frequently offered as an ‘excuse’ forlaziness or low achievement. To these cynicsI would suggest that they look at the wealthof research (summarised in Section 3.1)which has clearly identified differences inboth brain structure and processing, byworld-renowned neuro-physiologists. Yes, itis complex; yes, people with SpLD are alldifferent, but that does not mean that wecan ignore it. Instead we need to be awareof its diversity and recognise that whatworks with one individual might not workwith the next.

2.4 Coping strategies

These individual variations are furthercompounded in adults by the development

of very successful and innovative personalcoping strategies which have beenhighlighted in several research studies ondyslexia (Lefly and Pennington, 1991; Miles,1993). These may be techniques that theindividual has developed or sometimes anavoidance of areas that are particularlychallenging. Avoidance may, on occasions,be an appropriate strategy. For example,choosing to avoid difficult spellings such as‘diarrhoea’ by substituting ‘loose stools’instead may work, at least in the short term.However it is important for the individual toacknowledge areas that are being avoidedand endeavour to find other ways ofconquering the difficulty. This is particularlyso in the case of a student nurse who willneed to function independently once theyqualify. Mentors must therefore ensure thatstudents are being assessed on all requiredcompetencies and that they are not avoidingareas they find difficult.

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Overview ofdyslexia

3.1 What is dyslexia?

Dyslexia has been defined in many ways asour knowledge and understanding of thecondition develops. The following definitionby Peer, written on behalf of the BritishDyslexia Association, has been chosen as itis concise, easy to understand and clearlyidentifies the major issues. She describesdyslexia as:

“...a combination of abilities anddifficulties which affect the learningprocess in one or more of reading,spelling and writing. Accompanyingweaknesses may be identified in areasof speed of processing, short-termmemory, sequencing, auditory and/orvisual perception, spoken language andmotor skills.”

Peer, (2002)

One important feature of this definition isthat it highlights the potential of individualvariations by including phrases such as“affect the learning process” and“weaknesses may be identified”. It isimportant to recognise that dyslexia, likeother SpLDs, is not a clear cut conditionproblem. As such it poses particularchallenges in its recognition and requires atailor-made intervention and teachingprogrammematched to the individual’spersonal profile.

Over the past 25 years research has begunto identify the biological, cognitive andbehavioural causes of dyslexia, and theCausal Modelling Framework proposed byMorton and Frith (1995) attempts to pull thekey underpinning theories of dyslexiatogether.

Under an umbrella of biological influenceson dyslexia, the framework puts forwardmultiple theories, all of which have beenhighlighted through a variety of researchstudies. It begins by suggesting a geneticpre-disposition to dyslexia (Gilger et al,1991; Castles et al, 1999). Variousneurological defects are then identified,including reduced left hemispheric activityin the brain during certain activities(Brunswick et al, 1999); visual disturbancesassociated with the magnocellular pathway(Stein, 2001); structural abnormalitiesbetween the two hemispheres of the brain(Geschwind and Galaburda, 1985) andfinally cerebellar immaturity (Nicolson andFawcett, 1999).

Morton and Frith (1995) also discusscognitive influences as a result of problemswith phonological processing (Wolf andObregon, 1992), poor metacognitiveawareness (Tunmer and Chapman, 1996);working memory (Miles, 1993; Beringer,2004) and automaticity (Nicolson andFawcett, 1990). Finally, they focus onbehavioural factors including poorphonological awareness as demonstratedby numerous authors (Pennington et al,1990; Hanley, 1997; Rack, 1997; Snowling etal, 1997). Spanning all aspects of theframework are environmental factors, whichinclude the impact of learning environment,educational policy, cognitive and learningstyles.

Of the three conditions covered in thisguide, dyslexia is probably the one thatmost people are familiar with. In a smallsurvey of RCNmembers attending anEducation Forum study day in January 2010,32 per cent said they felt very well informedof the issues surrounding dyslexia, asopposed to six per cent regarding dyspraxiaand 10 per cent for dyscalculia. This may be,at least in part, due to the review of theliterature commissioned by the RCN ondyslexia in nursing practice (Dale and Aiken,2007). This provides a comprehensive andvaluable overview and is highly

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recommended reading. However, despitethis apparent level of awareness, Salter(2010), has suggested that whilst mostpeople have heard of dyslexia very few canaccurately describe the skill areas that itaffects. The following section aims tohighlight those most commonlyexperienced.

3.2 Potential challengesassociated with dyslexia

Research has shown that adults withdyslexia have often developed a wide rangeof coping strategies which may mask thetrue extent of their difficulties (Lefly andPennington, 1991; Miles, 1993), What iswidely accepted however, is that thedyslexia will have affected the speed atwhich they are able to process information,which has implications for howmaterial ispresented, learnt and recalled (Reid andKirk, 2001). McLoughlin et al (1994) andJefferies and Everatt (2004) both highlightthis when they discuss general workingmemory difficulties, which include areduced ability to keep track of what is saidin a conversation or follow what ispresented in a meeting or lecture. Workingmemory is responsible for the short termstorage of incoming auditory, visual andmotor input; and the subsequent transferand encoding of that information within thelong termmemory (Chasty and Friel, 1991).Linking new concepts with prior knowledge,whilst exposed to further incoming data, isessential for all nurses and is highlydependent on a good working memory.

What may compound this further,particularly for student nurses, is the natureof the material to be learnt and thespecialised ‘language’ which they have toconquer to succeed. Despite variations incausal theory related to dyslexia, there isconsensus that individuals with dyslexiaexperience problems with phonologicalprocessing. From the beginning of their

training students are exposed to medicalterminology. Not only is this outside of theirnormal vocabulary but many of the wordsare very similar, but with very differentmeanings. Coltheart et al (1993) found thatdyslexic students had problems withgrapheme-phoneme correspondences, inother words the ability to sound out non-words. Whilst medical terminology is ‘real’its polysyllabic nature makes it particularlydifficult for the dyslexic student to read,understand and encode in long termmemory. Whilst students can cope with thisnew language if they are able to read andre-read it at their own pace, situations suchas handover reports or lectures are oftenpresenting the information at a faster pacethan the student would like. One of thechallenges for practitioners and lecturers isto find a way to overcome this and enhancelearning.

The other underpinning area of difficultyrelates to problems with a concept known as‘automaticity’ as described by Nicolson andFawcett (1990). As the name implies this isabout how we learn and ultimatelyinternalise processes until we can do themsub-consciously. Driving a car is a classicexample of this. When we first try to learn todrive the task seems overwhelming with allthe things that have to happensimultaneously to be a safe competentdriver. If you ask an experienced driver howoften they consciously think about all ofthose individual factors, it is not very often –as they have become automatic. We knowthat individuals with dyslexia will takelonger to reach the point of automaticity butthat once they get there they are as safe andcompetent as anyone else.

In summary, while it is important toremember that every individual withdyslexia will have their own personal profileof strengths and areas of difficulty, thefollowing lists highlight the main areas inwhich they are likely to experienceproblems, although it must be recognised



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that no one individual is likely to experienceall of these.

Memory difficulties:

� may take longer to ‘fix’ information intotheir long-termmemory

� may require information to be presentedmore than once

� dyslexic people often find it more difficultto discard irrelevant or redundantinformation which could lead to ‘memoryoverload’ and confusion

� may have problems rememberingcolleagues or patients names, drugnames and medical conditions

� may find it difficult to remember phonemessages or other information to pass onto colleagues

� may find it difficult to learn routines andprocedures

� may find it difficult to transfer learninginto a new setting.

Organisational difficulties:

� may appear to have a short attentionspan and be easily distracted

� may have difficulty following instructions

� may have difficulty in ordering their ideas

� may have problems sequencing the orderof tasks correctly

� may have problems with filing and lookingup information alphabetically orsequentially

� may find it difficult to react quickly in busyenvironments

� may find it difficult to multitask as thisrequires a good memory, timemanagement skills as well as the ability towork sequentially and be organised.

Time management – individuals withdyslexia may find it difficult to:

� plan ahead or plan their work schedule

� estimate howmuch time is needed for aspecific task

� complete tasks on time

� students may find it difficult to balancecoursework and placement commitments.

Reading – individuals with dyslexia may:

� feel embarrassed about reading aloud

� misread unfamiliar words

� read very slowly and find scanning orskimming difficult

� find text is distorted, particularly blackprint on white

� find it difficult to read with noisedistractions

� have difficulty understanding medical andpharmacological language particularlythose words which look or sound similar

� have difficulties with abbreviations

� have difficulty reading information fromwhiteboards

� have difficulty reading information oncharts

� need to re-read things several times to getthe meaning.

Writing and spelling – some individualsmay have difficulty with:

� legibility

� writing in an appropriate language

� writing concisely

� writing accurately their work may containfrequent spelling and grammatical errors

� writing under time pressure, someindividuals may write very slowly andneed to re-draft their work

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Overview ofdyspraxia

4.1 What is dyspraxia?

Dyspraxia is a developmental co-ordinationdisorder (DCD) which results when parts ofthe brain fail to mature properly as theydevelop – resulting in atypical braindevelopment (Kaplan et al, 1998). Reasonsfor this are complex and still the subject ofresearch, however theories existsurrounding factors affecting foetaldevelopment during pregnancy, prolongedlabour and the effects of prematurity (birthbefore 38 weeks) or postmaturity (birthafter 42 weeks) (Portwood, 2000).

As the brain develops complex connectionsbetween nerve cells (neural networks) arecreated. This process lasts from between 30weeks gestation to approximately two yearsof age and is influenced by factors such asmaternal diet. It is thought that a low intakeof long chain polyunsaturated fatty acids(LCPs) may result in delayed foetalmyelination and brain maturation. Inaddition the level of another essentialnutrient – docosahexanoic acid (DHA), achemical found in high levels in breast milk– is felt to play a part in the developing brain(Portwood, 2000). Intellectual ability isthought to be largely determined by thenumber of these neural networks, ratherthan the number of neurones themselves.

During the process of brain development anexcess of neural networks are created andby the age of three approximately a third ofthe connections will have been ‘pruned’ bythe body. At the same time appropriate(efficient) pathways are reinforced. Wherethis does not happen there is an opportunityfor messages to go along the extended

4� spelling technical terms such as drugsand medical terms, especially those whichlook or sound similar

� identifying numbers and letters and/orgetting them in the correct order

� filling in forms, especially when requiredto do so at speed.

Language – some individuals may:

� feel embarrassed about language

� struggle to find the right word to say

� mispronounce unfamiliar words

� find it difficult to express themselvesorally and talk in a disjointed way

� find it difficult to give clear instructionsand/or information and have a tendencyto ‘go off on a tangent’

� sometimes experience a ‘mental block’and be unable to express ideas clearly,particularly under stress

� take everything ‘literally’ or at face value(beware of words with double meanings).

Motor skills:

� may have right and left co-ordinationdifficulties

� some students may take much longer tolearn to follow a sequence (for example,wound dressing).

Sources: Reid and Kirk (2001); Reid (2003);Dale and Aiken (2007); Skinner (2008),along with extensive personal experience ofworking with nurses with dyslexia.

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(inefficient) pathway resulting in a delay inprocessing information (Portwood, 2000).This leads to the typical pattern ofdifficulties associated with dyspraxia, whichis thought to affect up to 10 per cent of thepopulation, with four per cent beingseverely affected (Colley, 2005). There isalso some evidence in children that boys aremore likely to be dyspraxic, at a ratio of fourboys to every girl (Portwood, 2000)although this is less evident in adults.

The Dyspraxia Foundation describesdyspraxia as an:

“...impairment or immaturity in theorganisation of movement. Associatedwith this there may be problems oflanguage, perception and thought.”

Dyspraxia Foundation, (2010)

There is evidence that dyspraxia frequentlyoverlaps with other developmentalconditions including attention deficitdisorder (ADD), attention deficithyperactivity disorder (ADHD) andAsperger’s syndrome.Whilst some adultswith dyspraxia will only display signs ofdyspraxia they are felt to be in the minorityand the co-existence of one or more of theseother conditions is much more likely (Colley,2005).

As some of the symptoms of dyspraxia arealso frequently associated with certainmedical conditions it is important that thecorrect diagnosis is obtained. A ‘diagnosis’is often reached where difficulties withmotor co-ordination are significant andcannot be attributed to a specificneurological condition such as musculardystrophy or multiple sclerosis.

4.2 Potential challengesassociated with dyspraxia

The motor coordination difficultiesassociated with dyspraxia affect both gross

and fine motor movements. These may leadto problems with balance, causing theperson to appear clumsy (gross), or result inpoor manual dexterity causing them tofrequently drop things or struggle tomanipulate instruments (fine). Finally, dueto the brain frequently using extended andless efficient neural pathways, individualswith dyspraxia may experience difficultieswith organisation. In adults, it is often theseweak organisational skills, either related tothe formulation of ideas or general planning,that create the most significant difficulties.The following lists highlight the main areasin which individuals might experienceproblems, although it must be recognisedthat no one individual is likely to experienceall of these. Indeed, those with milddyspraxia are only likely to exhibit a few ofthese symptoms.

Attentional problems, poorconcentration:

� may veer off at tangents during aconversation

� may find it difficult to answer directquestions

� concentration is poor and many adultsdisplay

� the symptoms of attention deficit disorder

� tend to be over sensitive to noise.

Language:

� speech can be loud and fast

� they may have problems organising thesequence of their speech, in other wordsramble and not prioritise key informationwhere necessary

� there can be problems with intonation

� may have problems pronouncing certainwords

� they may misinterpret what they hear

� can have problems picking up on non-verbal signs and in judging tone or pitchof voice.

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Obsessional characteristics:

� presence of obsessional behaviourspossibly as a result of developing routinesto give their lives structure; these may beidentified as an obsessional compulsivedisorder (OCD).

Coordination difficulties:

� problems in differentiating left from right

� problems using certain pieces ofequipment

� poor hand eye co-ordination

� poor handwriting due to problems withfine motor movement

� inadequate grasp causing problems withdropping things.

Emotional problems:

� low self esteem

� emotionally fragile (may become verydistressed at minor things)

� highly excitable, may find it difficult tocontrol emotions

� may suffer from clinical depression.

Problems with organisation and memory:

� poor concept of time, often late forappointments

� information processing problems

� poor sequencing

� problems recording information

� poor memory

� difficulty following instructionsparticularly when more than one at a time

� may be slow to finish a task due totendency to daydream.

Gross motor coordination problems:

� poor balance, posture and fatigue make itdifficult to stand for long periods

� can be clumsy, spilling things or trippingover.

Perception:

� poor visual perception

� over sensitivity to light.

Sources: Portwood (1999), Portwood (2000)and Colley (2005).

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Overview ofdyscalculia

5.1 What is dyscalculia?

Dyscalculia is probably the mostcontroversial of the three conditions coveredin this guide. There is widespread debatesurrounding its true nature, which makes itdifficult to both diagnose and to estimate itsincidence. The most widely quoteddefinition of dyscalculia was put forward bythe Department for Education and Skills in2001, in which it is stated that it is:

“...a condition that affects the ability toacquire arithmetical skills. Dyscalculiclearners may have difficulty understandingsimple number concepts, lack an intuitivegrasp of numbers, and have problemslearning number facts and procedures.Even if they produce a correct answer oruse a correct method, they may do somechanically and without confidence.”

DfES, (2001)

Based on this very broad definition someauthors estimate the incidence to bebetween four per cent and six per cent of thepopulation (Bird, 2007). However, it isinteresting that Geary (1993), an AmericanPsychologist, attributes the difficulties thatpeople with dyscalculia have with maths asdue to a poor long-term semantic memory(memory for facts) and poor workingmemory (a temporary storage facility forinformation that is currently beingprocessed), both of which are commonlyassociated with dyslexia. This leads to theinevitable question of whether someonereally has dyscalculia or if it is in factdyslexia which is causing their difficulties?

It must also be acknowledged that there area significant number of people who have

‘self diagnosed’ their dyscalculia becausethey are bad at maths. In some cases this isdue to poor teaching, anxiety or a lack ofinterest in the subject. While experiencingvery real problems, Butterworth and Yeo(2004) and Hannell (2005) suggest thatthese individuals will improve quickly whenthey receive appropriate instruction,whereas those with true dyscalculia willrequire much more intensive support.

This would suggest that the number ofpeople who have ‘true dyscalculia’may bemuch smaller than originally thought. If weview dyscalculia as being much more thanbeing bad at maths and linked to a muchmore fundamental problem, namely a totalinability to conceptualise numbers – if youask a person with dyscalculia which numberis bigger, 10 or 100, they would have no idea– and the number of people affected dropssignificantly.

As an employer or university wouldnormally require a formal diagnosis ofdyscalculia before they were obliged toconsider reasonable adjustments, thechallenge of obtaining that diagnosisneeds to be considered. Unlike dyslexiaand dyspraxia, for which a variety ofscreening tools and standardisedassessments are available to assist thediagnostic process, the situation is lessadvanced in relation to dyscalculia. Toolssuch as the Dyscalculia screenerdeveloped by Butterworth (2003) weredesigned to be used with children up tothe age of 14 and only give reliable resultsin this age group. Consequently, a moreadult focussed tool DysCalculiUM iscurrently being developed and tested byLoughborough University (Beacham andTrott, 2005). This focuses more on theunderstanding of concepts andinterrelationships associated with themore advanced mathematics required forhigher education. However, those involvedin its development have alreadyhighlighted that as a result it may not

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provide reliable or valid results forstudents studying science based courses.

5.2 Potential challengesassociated with dyscalculiaThe previous section highlighted thecomplexities of diagnosing dyscalculia, andhow it is often seen synonymously withweak maths skills. However for the purposeof this guide, dyscalculia is viewed as amuch more serious conceptual difficulty,where the individual has significantproblems even with very simple numberrelated tasks. Due to the significant impactthis is likely to have on a nurse’s ability tocarry out safe drug calculations it isessential that a correct diagnosis is made bya suitable expert and that individuals arenot labelled dyscalculic (either bythemselves or others) when they are merelyweak at maths.

General numerical problems:

� problems reading numbers

� problems writing numbers down (mayeven copy incorrectly)

� problems sequencing numbers (such assmall to large)

� looses track when counting

� conceptual difficulties with size (in otherwords, which is bigger? 10 or 100?

� no appreciation of the concept of decimalplaces

� conceptual problems with units ofmeasurement (mcg, mg, g)

� dfficulty learning times tables

� difficulties remembering and diallingphone numbers

� difficulties in interpreting results

� difficulties reading graphs/charts and soforth

� difficulties understanding writtennumbers (in word rather than numericalformat)

� find it difficult to estimate or giveapproximate answers (this is often taughtas the first stage in performing acalculation)

� unable to recognise that an answer isunreasonable (something that often acts asa safety net when performing drugcalculations)

� paraphasic substitutions (where onenumber is substituted for another eitherwhen writing or using a calculator – theperson may verbally say the correct numberbut push a totally different button).

Calculation related problems:

� problems aligning numbers in sums

� problems understanding what is meant byword based mathematical questions in atest or exam

� needs to use fingers to work out simplesums

� much slower to work out answers

� problems performing calculations

� problems remembering and applyingformulae

� difficulties remembering what symbolssuch as ‘+’, ‘-’, or ‘x’ mean.

Time related problems:

� may have problems rememberingappointment times

� may have difficulties in interpreting a 24hour clock.

Day-to-day living:

� may have problems identifying clothes size

� may get confused between left and right

� problems handling money

� may have problems recognising faces asthey are seen as a form of symbolrecognition.

Sources: Poustie (2000); Hannell (2005); Bird(2007); and Hendrickx (2010).

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(HMSO, 1995) Specific learning differences(SpLD) such as dyslexia, dyspraxia anddyscalculia are all classified as a ‘disability’under this definition. It is therefore unlawfulto discriminate against anyone with one ofthese conditions on the basis of theirdisability. This covers a range of areasincluding employment, education andaccess to goods and services.

More recently the Act was updated to takethings a step further and requiredorganisations to have a ‘positive duty’ to“promote equality of opportunity andpositive attitudes; eliminate unlawfuldiscrimination and encourage disabledpeople’s participation” (HMSO, 2005). It istherefore imperative that everyone workingwith staff who have dyslexia, dyspraxia ordyscalculia, whether as an employer,manager, colleague or mentor/preceptor arefully aware of their legal responsibilities.

All of the existing legislation related toequality and diversity has now been broughttogether under the Equality Act (HMSO,2009) which aims to clarify key terminologyand make the responsibilities of bothindividuals and organisations much easierto understand. This is classed as a‘Consolidatory Act’ which became law inApril 2010 and will come into effect fromOctober 2010. It will replace the previouslegislation including the DisabilityDiscrimination Act which will be repealed1.

Reasonable adjustments

Under the terms of disability legislationindividuals are entitled to receive“reasonable adjustments” to help themovercome their difficulties. The key wordhere is ‘reasonable’ and the challenge ishow to decide what constitutes areasonable level of adjustment. There is nolegal definition of reasonable in thiscontext, and it is up to the individual to

Employer andemployeeresponsibilities

Over the last decade there has been agrowing level of awareness of the difficultiesexperienced by people with a SpLD, andfrequent calls for employers to improve thesupport they offer. This lead to a motionbeing debated in the House of Lords in 2005calling for help for people with dyslexiathroughout their education and workinglives (Hansard, 2005). At RCN Congress2009 a resolution was passed calling on theRCN Council to “influence employers torecognise and provide for the needs ofnursing staff with dyslexia and similarconditions.”While there are numerousexamples of good practice (see Appendix 1)the reality is often very different despite theexistence of key policy drivers including theDisability Discrimination Act.

However it is not just employers that needto be aware of their responsibilities and actin a supportive manner. Individualsthemselves need to be aware that they haveprofessional responsibilities in accordancewith their code of conduct (NMC, 2008). Thefollowing sections aim to summarise the keyissues.

6.1 Legal responsibilities

In 1995 the UK Government passed theDisability Discrimination Act in an attempt toensure that those with an accepteddisability were not discriminated against inany way. Under the terms of the Act a personhas a disability “if he has a physical ormental impairment which has a substantialand long-term adverse effect on his ability tocarry out normal day-to-day activities.”

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1 Except in Northern Ireland where the DisabilityDiscrimination Act remains on statute.

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decide whether they consider something tobe reasonable or not. However, it isimportant to point out that individuals mustbe prepared to potentially defend anydecisions that they have made if required todo so. It is therefore essential that adecision to judge a requested adjustmentas ‘unreasonable’ is only taken after verycareful thought, and if necessaryprofessional and/or legal advice. There arewell documented cases of individuals whohave received significant amounts ofcompensation where adjustments havebeen either refused or subsequentlyignored.

Whilst all requests must be considered, thelaw does not expect us to makeunreasonable levels of adjustment and thisneeds to be taken into account whenassessing ‘fitness to practice’ (see Section6.3). The RCN toolkit suggests ‘reasonable’strategies that could be used to support anemployee. However, even these can become‘unreasonable’ if required to excess. Forexample a nurse with dyslexia may need tobe shown how to do something severaltimes before it ‘clicks’ and this acceptable,but if they have been shown 10 times in amorning and still cannot remember, it hasbecomemore of a problem. Intensivesupport is not sustainable and thereforemay be considered as unreasonable, unlessit is for a very specific task, on a short termbasis.

Requests for adjustments may come from avariety of sources. In the case of dyslexiaand dyspraxia the individual will have aspecialist report from an educationalpsychologist or other approved person,which details the areas of ‘need’ and theadjustments required. However thesereports very rarely make recommendationsrelated to the workplace as the personcompiling the report is unlikely to have therelevant experience to do so. Furthermore,the assessment has often taken place whenthe individual was at university, and the

main focus therefore may be related more tothe academic aspects of the course theyundertook than their clinical role.Recommendations may also come from anoccupational health department or fromsuitably qualified professionals includingdoctors and occupational therapists.

For dyscalculia the situation is morecomplex as at present there is no officiallyrecognised screening tool that isappropriate for adults. It is thereforeunlikely that specific recommendations willhave been made. Individuals withdyscalculia will require highly specialisedsupport, and it is likely that this will need tobe provided outside of the workplace. Itmust therefore be considered whether it isreasonable, within the individual’s role, toallow them not to perform calculations untilthey receive this support. Note: this onlyrelates to people with ‘true’ dyscalculia andnot more general problems with calculationsincluding those associated with dyslexia(see Section 5.1 and 5.2 on dyscalculia).

Finally, a request for a specific adjustmentmay come directly from the individualconcerned as they will have the greatestinsight into their particular areas of need.These requests should be considered in thesame way as recommendations frommoreformal sources. The key factor indetermining eligibility for an adjustment isthe formally diagnosed presence of adisability, not the source of the request.

Having seen that disability legislationrequires organisations to promote equalityof opportunity and demonstrate positiveattitudes towards disability, it is theresponsibility of everyone within thatorganisation to help this to happen.However, those in a management,supervisory or mentorship/preceptorshiprole will need to ensure that colleagues andthose for whom they are responsible areallowed any reasonable adjustments whichhave been agreed.

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Employers also have a responsibility to helpstaff where areas of difficulty have beenidentified. The NMC expects staff to haveregular performance appraisals (at leastannually) during which aspects of poorperformance are dealt with. In itspublication Reporting lack of competence: aguide for employers and managers (NMC,2004a) the NMC states it would notnormally become involved in a case under‘fitness to practice’ unless the employer hadalready taken “considerable measures” totackle the situation in the workplace first.Employers are therefore expected to identifytraining needs, set clear objectives, andprovide the employee with sufficientopportunity to improve their areas ofweakness.

Some individuals with dyslexia, dyspraxia ordyscalculia will find certain clinicalenvironments more challenging than others.For example ITU or an emergencydepartment (ED) with their high level ofnoise and distractions, may not suit someindividuals, whilst others may find loneworking in a community setting difficult.Where possible members of staff who havefound their working environmentexacerbates their difficulties should behelped to find employment in a moresuitable environment.

Finally, although there is often concernexpressed regarding safety issues it shouldbe noted that nurses with dyslexia,dyspraxia and dyscalculia are usually veryaware of their strengths and potentialchallenges. As a result they are extremelycareful about checking things they are lessconfident about in order to avoid makingmistakes, particularly those that involvepatient safety (Morris and Turnbull, 2006).While an employer has a legal responsibilitythis is balanced with the member of staff’sown professional responsibilities (see alsoSection 6.3).

6.2 Moral responsibilities

In addition to their legal responsibilities itcould be argued that employers also have amoral responsibility in relation to the level ofsupport they offer. This could includecreating a real culture of inclusivity whereindividuals are supported to progress intheir careers. Morris (2007) highlighted thatalthough career progression was stillachievable for those with a SpLD, comparedto their peers it was perceived to takelonger. For a significant proportion of thenurses questioned (44.8 per cent) this wasattributed to a lack of confidence toundertake ‘career enhancing academicstudy’. This demonstrates a need for highereducation providers to help make thosecontemplating further study more aware ofthe support that is now widely availablewithin universities.

There are those who feel that employerscould do more to raise awareness byoffering staff development sessions on thetopic of dyslexia, dyspraxia and dyscalculia,although the challenge of persuading staffto attend will always be an issue. Morgan(2001), although referring to staffdevelopment within a university, suggeststhat staff may avoid staff developmentsessions which they feel cater for the needsof a minority group. These sessions, shecontinues, are often poorly attended, andoften only attract those already sensitive tothe issues – preaching to the converted.

Similar views are held by Klein, whorecognised motivation as a difficult issue.She identified a range of common excusesoffered by academic staff, which included:

“It’s not my job….”

“I have too many more important thingsto do….”

“I don’t have the time to do all thisextra work for one student.”

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“She shouldn’t be on this course if shecan’t do the work.”

Klein (2001)

In clinical practice, where the opportunity torelease staff to attend a formal session iseven more difficult, innovative ways to meetthis professional development need areurgently required.

6.3 Professionalresponsibilities

Whilst disability legislation requires us tonot discriminate against an individual with adisability, it does recognise that certainprofessions need to set and maintainprofessional or competence standards.Section 54 (6) of the Equality Act (HMSO,2009 p 36) defines a competence standardas “an academic, medical or other standardapplied for the purpose of determiningwhether or not a person has a particularlevel of competence or ability”.

The Nursing and Midwifery Council (NMC) inits Standards of proficiency for preregistration nursing education (2004) statesthat the required level to enter the registeris the ability to:

“...manage oneself, one’s practice, andthat of others, in accordance with TheNMC code of professional conduct:standards for conduct, performanceand ethics, recognising one’s ownabilities and limitations”.

NMC (2004b)

This clearly puts a professional onus on theindividual to acknowledge any areas wherethey would not feel competent to practice,and to take a personal responsibility to notput themselves in these situations.

It must also be stressed that all studentnurses, including those who have declared a

disability, will still be expected todemonstrate that they are “fit for practice”.This means that they must meet all of thelearning competencies and skills that otherstudents are required to do. However, thefundamental difference is that ‘reasonableadjustments’ should be in place beforecompetence is assessed. It is also importantto remember that the application ofcompetence standards is not a defenceagainst direct discrimination. Stereotypicalassumptions should not be made,particularly in the case of ‘what if’ typesituations. For example, that a nurse ‘mightnot’ be able to perform in certain emergencysituations, unless there is clear evidence tosupport this.

Once on the register nurses have anongoing professional responsibility, throughthe code of conduct (NMC, 2008) to workwithin the limits of their abilities. Failure todo so can result in an allegation that thenurse is unfit to practice through a ‘lack ofcompetence’. This new category wasintroduced through the Nursing andMidwifery Order of 2001 and came intoeffect in August 2004. It was designed todeal with “intractable cases of lack ofcompetence after all other avenues havebeen exhausted” and defines lack ofcompetence as:

“…a lack of knowledge, skill orjudgment of such a nature that theregistrant is unfit to practice safely andeffectively in any field in which theregistrant claims to be qualified, orseeks to practice.”

NMC (2004a)

This assumes that an employee will onlyseek employment in areas in which they feelable to practice safely. For the vast majorityof nurses this will not cause any particularproblems, but there may be occasionswhere an individual has identified specificareas of difficulty that may be made more

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challenging by the environment. This mightbe as a result of background noise, frequentdistractions or lone working. While it ishoped that the employee will be able todevelop strategies to overcome thedifficulties (as outlined in the RCN toolkit)there may be cases when the individual mayneed to request moving to a more suitableenvironment or role.

6.4 Disclosure

The choice of whether or not to disclose aspecific learning difference is a personal oneand is something that needs to beconsidered carefully. Employers need topromote a culture of inclusivity, whereindividuals feel able to discuss their specificneeds without fear of discrimination ornegative attitudes. Sadly there arenumerous reports of negative opinionshighlighted in the literature, some based onsmall scale research studies whilst othersare anecdotal but no less powerful.Blankfield (2001) described negativeattitudes by employers, whilst McLaughlinet al (2004) suggested that co-workers werenot always understanding. A more recentstudy of 18 student nurses by Morris andTurnbull (2007) showed that six of thestudents had chosen to conceal theirdiagnosis and that although the remaining12 had disclosed, it was with somereticence. Of the 18, most (n=16) sawdisclosure as potentially threatening andstressful. Their decision of whether or not todisclose was based very much on thepersonal and professional qualities of theirmentor. Where mentors were perceived asempathetic and receptive, levels ofdisclosure were higher, conversely wherethey were viewed as patronising and lackingin insight, students were less likely toconfide in them.

Legally employees (or students) have noobligation to disclose a disability to theiremployer. The Data Protection Act (1998)

overrides disability legislation, therebyallowing an employee to choose to keep itprivate, although it should be noted thathealth and safety legislation takesprecedence over both. There could thereforebe situations where an employee mustdeclare a disability (such as a Latex type 1allergy) although it is unclear as to whetherthis could ever be used in relation to alearning difference.

Whilst they therefore have a right not todisclose, the individual needs to be awarethat unless they do, and in certain casesprovide evidence, they will not be able toreceive the ‘reasonable adjustments’ thatthey require and are therefore puttingthemselves at a disadvantage.

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Identificationof a SpLD

In order to receive reasonable adjustmentsit is normally expected that an individualwill have been formally diagnosed with oneor more of the conditions. Staff are oftenheard to declare that they are “a little bitdyslexic” or have “dyslexic tendencies”,which when questioned, often reveals thatthey have never been formally diagnosed.In some cases the ‘label’ they have giventhemselves was suggested during theirschool years, although no formalassessment had taken place. Reasonsbehind this are complex and multi-factorial, and in future years it is hopedthat changes to the law will lead to a higherrate of recognition and diagnosis at school.In the meantime it is likely that adults willcontinue to need a formalassessment/diagnosis in the workplaceand the implications of this need to beconsidered.

7.1 Delays in identification

In terms of the scale of ‘late recognition’ itis important to examine the situation inuniversities, where many student nursesare picked up. This could be in part due toa strong level of commitment to diagnoseand support students with specific learningdifferences within higher education (HE), orbecause as the task gets more complex thestudent starts to struggle. Earlier sectionsof this guide highlighted the copingstrategies which adults develop. However,it is well known that these strategies willusually only take an individual to a certainlevel. For some this is GCSE, or A level,whilst for others it is further along in theiracademic career. It is not unknown for anindividual to be diagnosed with dyslexia in

7the final stages of a PhD, although clearlythey will have developed extremelyadvanced ways of coping.

A study by the National Working Party onDyslexia in Higher Education included datafrom 195 institutions and exposed the“true” extent of the problem when itdiscovered that 43 per cent of the totaluniversity dyslexic population were onlyidentified as dyslexic after their admissionto university (Singleton, 1999). Even thiscould be potentially considered as anunder-estimate, as it only takes intoaccount those identified as dyslexic. Theremay be many more, who not only “slippedthrough the net” during their school years,but have done so again.

The implications of this are potentiallycatastrophic to the individual concernedand were highlighted by Stanovich (1986)when he described a concept known as the‘Matthew effect’, based upon a biblicalreference to the poor becoming poorer. Herelated this to the difficulties that dyslexicindividuals experience with reading andsuggests that these are likely to result inthem reading less. The inevitableconsequence of this is that their ability toincrease their vocabulary is limited, andwith it their reading skills. This effect wasalso recognised by Farmer et al (2002) whofound that the difficulties that highereducation students were experiencingreduced their confidence to attempt taskswell within their capability, and often led tounder performance. They highlight adistorted picture of disability that thiscreates, with the true deficit, and theadditional secondary effects.

However, recognition of the difficulties thatan adult with a SpLD is experiencing is notalways straight forward, and this oftendelays the identification of their condition.Not only will they have developed copingstrategies which mask their difficulties, butthe problems which they present with are

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often different to those experienced bychildren with the same condition.

Finally, a significant factor in non-diagnosisis the lack of funding for the detailed andcostly assessment by those approved tocarry it out. For dyslexia, the most commonof the three conditions, currently only aneducational psychologist or a specialistteacher who holds a ‘practicing certificate’are able to formally assess and diagnosethe condition. Although the cost variesaround the country the average is likely tobe between £300 and £500. Whilst mostuniversities are willing to fund thisassessment, at least in part for theirstudents, the situation is often verydifferent within the workplace. It istherefore important to identify potentialsources of funding and these will beexplored in Section 7.3.

7.2 Testing for specificlearning differences

The earlier definitions and subsequentoverview of theoretical perspectives ondyslexia, dyspraxia and dyscalculia havealready begun to highlight how complexthey each are. This is further compoundedby the wide individual variations that exist,both in degree of personal difficulty (Miles,1993; Hanley, 1997), and in levels ofcompensatory strategies developed,particularly by adults (Lefly and Pennington,1991; Reid and Kirk, 2001). As a result,identification of a specific learningdifference is a highly complex activity andno single test will provide us with all theinformation that we require.

7.2.1 Identification of dyslexia

Historically, assessment for dyslexia tendedto be based on a comparison betweengeneral conceptual ability (IQ) and theindividual’s assessed level of achievementin literacy skills, particularly in reading. This

was generally known as the ‘discrepancytheory’ and its use became widespread forthe assessment of dyslexia in children overseveral decades (Beaton et al, 1997).However despite its initial popularity, therehas been a great deal of criticism of thediscrepancy definition of dyslexia by authorssuch as Siegel (1989) and Stanovich (1991)who suggest that the acquisition of literacyfosters the very cognitive skills that areassessed on aptitude measures. Morerecently Miles and Miles (1999) added theirsupport to the body of criticism and it is nowconsidered that an over reliance on thediscrepancy definition is at the very leastunreliable.

There was therefore a need to devise arobust method, which was bothcomprehensive and which was felt toprovide an accurate assessment. Thiscurrently comprises a full diagnosticassessment by an educational psychologist,lasting several hours, and is consequentlyseen as both a costly and time-consumingprocess. Within higher education a two tiersystem has evolved where a shorter‘screening’, lasting between one and 1.5hours, is conducted first. The scores from abattery of tests, along with an analysis ofthe individual’s development and schoolhistory (to eliminate general learningdeficits from poor schooling) are thenaggregated to give an overall ‘at risk’ indexand determine if a full assessment iswarranted, (Nicolson and Fawcett, 1997). Ifthe results of the screening indicate alikelihood that dyslexia is present theindividual would be referred on for anindepth professional assessment which hasthree main purposes; it will provide ‘insight’into the individual’s strengths andweaknesses, support the development of aplan to provide appropriate and targetedsupport, and finally help ‘secure funding’ bysupporting an application for the DisabledStudent Allowance (DSA) or Access toWorkfunding (Grant, 2002). Despite the obviousadvantages of the two tier system there are

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those who are concerned that the resultsfrom the preliminary screening test might beaccepted as a diagnosis (Grant, 2002) andthis must be resisted.

For those not within a higher educationsetting, the opportunity for a screening isunlikely to exist, and individuals will only beoffered the full assessment. This is becausethe time involved to complete the fullassessment is not significantly longer, andrequires the same educational anddevelopmental history. It is therefore notreally time or cost effective to split theprocess. There is also a very real risk thateither insufficient information would begathered to reach a firm diagnosis or thatthere would be pressure to rely on thescreening and not proceed to a fullassessment giving the potential forinaccurate results.

Similarly, the widespread availability ofself assessment checklists has resulted inindividuals “self diagnosing” which mayalso result in inaccurate results (both falsepositives and false negatives) and fails toexplore the wider issues associated withassessment, namely the support required.The following table, based on one devisedby Reed (2003), expands on the threebenefits identified by Grant and provideseight key aims of the assessment (seeTable 1). The terminology in the table hasbeen slightly modified to reflectindividuals in the workplace, as theoriginal version refers tolearners/students however the sameprinciples clearly apply. Even the laststatement which refers to an educationalcurriculum could be adapted to reflectaspects of the nurses’ role which interestand motivate them.

7.2.2 Identification of dyspraxia

Due to its potential overlap with certainneurological conditions, the diagnosis ofdyspraxia may be organised by a generalpractitioner (GP), once they have eliminatedother possible causes. The GP, if willing,could refer the individual to an appropriatespecialist, such as those included on thefollowing list devised by Colley (2005) whocan then assess the individual for dyspraxiaand make a formal diagnosis:

� psychologists – educational,occupational, neuro or clinical

� psychiatrists

� neurologists (although this is mainly inthe case of acquired dyspraxia)

� paediatricians who specialise indevelopmental disorders (although theirmain work is with children, paediatricianswill see adults when asked to assess for adevelopmental disorder such asdyspraxia).

Table 1: Aims of assessment

• Identification of the individual’sstrengths and weaknesses.

• Indication of the individuals currentlevel of performance in attainments.

• An explanation for lack of progress.

• Identification of aspects of theindividual’s performance in reading,writing and spelling, which may typify a‘pattern of errors’.

• Identification of specific areas ofcompetence.

• Identification of individual’s learningstyle.

• Understanding of the individual’slearning strategies.

• An indication of specific aspects of thecurriculum and curriculum activities thatmay interest and motivate theindividual.

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� in addition specific areas of difficultymight be assessed by physiotherapists,occupational therapists, speechtherapists or behavioural optometrists.

It is likely that information would begathered in relation to different aspects ofthe condition by several of the specialists onthis list. A psychologist would use a range oftools (psychometric and other) to start tobuild a picture of cognitive ability focussingin particular on aspects likely to be affected.The other specialists would then add infeedback related to aspects such asmovement, balance, manual dexterity andso on.

7.2.3 Identification of dyscalculia

Of the three conditions dyscalculia is themost difficult to diagnose formally, whichprobably accounts for the large numbers ofpeople who self diagnose. Unlike dyslexiaand dyspraxia where there are a variety ofscreening tools and standardisedassessments to assist the diagnosticprocess, the situation is less advanced inrelation to dyscalculia. While a screeningtool exists for children , it is known to onlygive reliable results up to the age of 14.Loughborough University is currently testinga more adult focussed tool DysCalculiUM foruse within higher education, although earlyindications are that it might not providereliable results for those on science basedcourses due to the areas it seeks to assess(Beacham and Trott, 2005).

7.3 Obtaining funding for anassessment

A diagnostic assessment for dyslexia islikely to cost between £300 and £500 andobtaining the necessary funding can be acomplex process. Whilst an employer has alegal obligation to support employees whoare known to have a disability, they do notnecessarily have to fund a diagnostic

assessment. This often creates a dilemmafor the individual, who may have to considerpaying for the assessment themselves tosubsequently obtain the desired help.However, it must be remembered that thedifficulties discussed in Sections 3, 4 and 5are not unique to these conditions andwhilst some assessments confirm asuspected SpLD others do not.

Although they do not have a legal obligationto fund the assessment, some employersmay be willing to so do, in order to help anemployee to identify a reason for difficultiesthey are having in the workplace. It istherefore worth approaching relevantdepartments to see if they can offer anyadvice and/or funding. Occupational healthand human resources departments oftenbecome involved and if unable to help mightbe able to point the employee/manager inthe right direction.

As an assessment of dyspraxia is usuallyorganised through a GP, the individualshould approach their GP and enquire abouta referral. This will hopefully be fundedthrough their primary care trust. Privateassessments can be carried out and the costwould be similar to that for a dyslexiaassessment.

7.4 Psychological impact ofbeing identified as having aSpLD

For many adults with a specific learningdifference one of the greatest challenges iscoping with a late diagnosis which has oftenbeen triggered by academic failure duringtheir training or further studies. Whilst thediagnosis often brings relief, as it explainswhy things might have been difficult, thereis often also anger and frustration that ithad not been recognised and help providedmuch sooner (Cowen, 2005).

In addition, the fact that these conditions

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are classed as disabilities brings its ownchallenges and requires a great deal ofsensitivity. The ‘disability’ label is a highlyemotive one and it is easy to see how thismight make people feel. Nevertheless thereare times when the ‘label’ can be a positivething – it is a necessity in order to accesscertain types of support, such as provisionof some types of equipment or other formsof reasonable adjustment. We need torecognise that neuro-diversity exists andthat individuals with the conditions thatcome under its umbrella are just the sameas everyone else.

Finally, individuals may experience stress ifthey fear discrimination and thereforestruggle to conceal their problems. Theymay also lack self confidence and feelisolated. Having the opportunity to talk toothers in the same situation may bebeneficial, not only for the emotionalsupport, but also the opportunity to sharehelpful tips and strategies. The developmentof ‘self help’ groups within an organisation isan area which needs to be explored (seeAppendix 1 for an example of a trust which isdoing this).

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Supporting staffwith a SpLD

History and research have shown us thatpeople with specific learning differences canachieve great things, as is clearlydemonstrated when we look at famouspeople such as Albert Einstein, RichardBranson,Winston Churchill, Tom Cruise andMichael Heseltine (to name but a few). Whatwe also know is that they have had to worksignificantly harder to achieve what theyhave. There is therefore a need for thoseworking with them, whether as a manager,lecturer, or colleague to help them andwhere possible reduce the obstacles whichimpede their progress. We can only do this ifwe are both aware of the issues andresponsive to them.

The following sections draw on the literaturesurrounding the support of individuals withdyslexia, as this is the most researched ofthe three conditions. Consequently for manyareas the only information we have as towhat will help relates specifically todyslexia. Even then the majority of thestrategies were developed for use in aneducational context (whether school oruniversity) and may need to be adaptedslightly. However it is likely that they willalso have benefits in the work environment,and whilst not yet formally evaluated for theother conditions are certainly worthconsideration.

8.1 Philosophy of support

Adults are used to functioning asindependent, autonomous individuals inmany aspects of their daily life. Thephilosophy behind support for those with aSpLD is therefore to continue to promotethis independence by helping the individual

to develop appropriate strategies tosucceed. This is done through developingtheir metagognitive awareness, providingscaffolded learning (which can later bewithdrawn) and encouraging a multisensoryapproach to learning.

8.2 Metacognitive awareness

Back in 1984 Benner identified that nursesoften learn new things by acquiring a set of‘rules which are subsequently discarded aspractice becomes more expert and intuitive(Benner, 1984). However, for dyslexiclearners we know that providing them with aset of rules to follow is nearly alwaysineffective due to their inability tospontaneously generalise learning andtransfer it to other contexts. This is thoughtto stem from the problems that they havewith automaticity, identified by Nicolson andFawcett (1990) and described earlier insection 3.2.

As a result they will often have difficulties inconsolidating new learning and changinginappropriate habits. This led to Tunmer andChapman (1996) advocating the need tohelp dyslexic individuals to understand howthey learn, a concept known as‘metacognition’. Interestingly the term‘meta’ stems from Roman times when it wasthe name given to the conical column set ateach end of the circus to mark the turningpoint in a race. Fisher (1998) suggests thatthis notion of a turning point is fundamentalto helping the individual change. Withoutthis change, Reid and Kirk (2001) submitthey will “perpetuate the sameinappropriate learning patterns throughouttheir life.”

The challenge therefore is to identify howwe can help individuals to recognise whatthey are doing (both well and areas needingimprovement), see the need for change andhelp them to achieve this. This process wasfirst described by Freire (1972) as “praxis”

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and has since been developed into the “artof reflection”. (Schön, 1983, 1987; Bould etal, 1989). This concept is familiar to nurseswho are regularly asked to use a reflectivecycle to explore their clinical practice inacademic assignments and in the clinicalarea. Whilst the focus is slightly different theprinciples are the same when asked toreflect on their own learning. To supportthem in this several authors have putforward frameworks which would provide agood starting point. One example is thatproposed by Reid and Kirk (2001) whosuggest that individuals should consider“self direction”, “self-monitoring” and “self-assessment”, using the following questionsto guide them.

Self-direction:

� what is my goal?

� what do I want to accomplish?

� what do I need?

� what is my deadline?

Self-monitoring:

� how am I doing?

� do I need other resources?

� what else can I do?

Self-assessment:

� did I accomplish my goal?

� was I efficient?

� what worked?

� what did not work?

� why did it not work?

Reid and Kirk (2001)



8.3 Scaffolded learning

Underpinning the whole approach tosupporting an individual with a SpLD, and inparticular dyslexia, is the concept of‘scaffolded’ teaching. This was originallyproposed by Vygotsky (1978), a Russianteacher, turned psychologist. Althoughmuch of his work centres around hisexperiences with children, it offers somesalient ideas for supporting adults, albeitusing slightly different strategies. Vygotskystrongly advocates the need for socialinteraction as a means to cognitivedevelopment. He proposes that a gap oftenexists between the “here and now” andpotential future achievements, and suggestshow the ‘teacher’ can help close this gap byproviding a scaffold. This, as the namesuggests entails providing a support thatcan be removed when the structure, orindividual, is secure on its/their own. It isabout leading the learner and helping themto develop understanding.

Vygotsky (1978) also alerts us to the need toconsider the individual’s ‘Zone of ProximalDevelopment’ when helping others todevelop their knowledge and skills. This isthe level, which at any particular point intime they have the potential to reach, andcould be used to provide a series ofstepping stones towards an ultimate goal.

8.4 Multisensory learning

The final principle of support was describedby McLoughlin (2001) when he advocatedthe “Three M” approach to helping adultswith dyslexia learn; the three M’s beingmanageable, multisensory and memory. Heuses the model with students to help themplan their own learning and even to managetheir lives, but it would also seem to offer auseful framework for the work environment.McLoughlin describes the strategy further asfollows:

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� make it manageable – reduce the load onworking memory; avoid dual processingwherever possible

� make it multisensory – increase the powerof encoding by using a variety of stimuli

� make use of memory aids – to facilitaterecall.

McLoughlin (2001)

Of these three strategies the first and thirdare fairly self explanatory. The need to breakcomplex tasks down into smaller moremanageable steps has long been advocatedwhen helping patients/clients to achievetheir goals, so is a concept we are allfamiliar with. Similarly the use of memoryaids needs little explanation, although moreconcrete examples are given in the toolkit.

The second strategy put forward byMcLoughlin (2001) – make learningmultisensory – does require a little moreexplanation however. This has long beenestablished as the most suitable approachfor teaching dyslexic learners (Pumfrey andReason, 1991; Turner, 2002; Peer and Reid,2003). Learning has three principleelements – input of information, cognitionand output (Reid, 2003). It is thought thatby using all the senses to input information,the channels and pathways to neurologicalprocessing and retrieval are most effective(Turner, 2002). This is because, asindividuals we all have a preferred learningstyle and cognitive style through which welearn best. Unfortunately we are not alwayssufficiently self-aware to be able to identifyand utilise our preferred style, so amultisensory approach is crucial. It is clearlyevident that with careful planning even abusy clinical environment can incorporatetechniques that enhance the learningprocess for auditory, visual and kinaestheticlearners.

8.4.1 Auditory learners

In nursing the issue of application to

practice is crucial, and is an areapredominantly developed through auditorylearning. The ability to analyse clinicalexamples through reflection andsubsequent discussion is a valuable tool inenhancing understanding for individualswith a SpLD. It can help build on what theindividual has previously read or seen inpractice and through verbal explanationscomplex material can be clarified. Theimpact of auditory learning is thereforeenormous in helping individuals to link newknowledge with previous understanding,something they find particularlychallenging.

Auditory learners may also like to useequipment they have been provided with,such as a digital voice recorder, to record arange of materials. This not only caters fortheir preferred style of receiving informationbut allows them to re-listen to the materialas many times as they wish, for examplewhen walking the dog or doing the ironing.This “over-learning” has been found to bebeneficial in promoting automaticity indyslexic learners (Nicolson and Fawcett,1990).

8.4.2 Visual learners

The next group of individuals to beconsidered are those who prefer the visualroute to input information, whether it isthrough words or pictures. In many cases aflow chart will help them to understand thesteps in a complex procedure, and get themin the correct order! However it must beremembered that some people with dyslexia(and dyspraxia) will suffer from visualdisturbances and it is important toremember some key rules when preparingwritten information. These are to:

� write in a logical sequence

� avoid small print (use point size 12 orabove)

� use a dyslexia friendly font (such as arial,verdana, tahoma or lucinda sans)

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� use bullet points in preference tosentences where possible

� use simple words/avoid overuse of jargonor uncommon words

� do not justify the right hand margin – thismakes the spaces between words unevenand harder to read if you are dyslexic

� space the information so it is notcramped; use short paragraphs to breakup dense text

� where possible print documents on offwhite/cream paper.

8.4.3 Kinaesthetic learners

The final group to be considered are thosewho learn best through movement. The ideabehind this being that a link exists betweensensory and motor responses which can bestimulated through movement. Dennisonand Dennison (1989) have developed thisthinking into a series of exercises known as“brain gym” which are designed to integratethe two hemispheres of the brain. Whilstthere has been some success using thiswithin the primary school sector, it is notlikely to be a technique adopted elsewhere.However, if the idea of physical movement isbroadened to the notion of “learning bydoing”, then it immediately becomes morerelevant.

8.5 Equipment

In our increasingly technological world agreat of equipment is currently available toassist individuals with a specific learningdifference. However, for many the challengeis being fully aware of what is out there ormaybe in gaining access to it. For mostindividuals their first exposure to theavailable technology is as a student whetherpre or post registration. Most universitiescurrently provide access to ‘assistivetechnology’ on-campus for students with arecognised disability; and most students

would like to be able to use the sametechnology home or at work.

There are also issues which need to beconsidered regarding the use of certainequipment in a clinical area or in a patient’sown home. In these situations permissionwill need to be obtained in advance. Forexample the use of a digital voice recorderto record your own voice/ideas tends not tobe a problem but colleagues might wish notto be recorded and this should berespected. The situation is even morecomplex, and controversial when anindividual might wish to record aconversation with a patient/client, such asan admission interview. If there is a localpolicy this should be followed, althoughtrusts contacted in relation to this have alladmitted that it is not an area they haveconsidered and none have yet created anyguidance for staff in relation to this.

Hardware available:

� computers – whether desktop, laptop,notebook or netbook

� digital voice recorders – can be used torecord audio files which can then beuploaded into a computer. (see also voicerecognition software)

� electronic dictionaries – standard ormedical version

� mobile phone – particularly new stylesmartphones

� personal digital assistant (PDA)

� digital cameras – when used withappropriate software (see below) they canbe used to take pictures of text, select anarea and have it read back to you.

� digital pens – used to highlight areas oftext. Depending on the software used,individual words can then be explained oreven synthesised into speech to aidpronunciation. Areas of scanned text canalso be uploaded into a computer.

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� electronic note making devices such asDigiscribble or a tablet PC – these workwith a digital pen and can be used totransfer a hand drawn mind-map into thecomputer.

Software available:

� note taking programmes such as AudioNotetaker (lansyst) – help students toorganise recordings from a digital voicerecorder and add annotation.

� reading programmes such as TexthelpRead andWrite Gold, ClaroRead Plus orKurzweil 3000 – read scanned or typedtext out loud

� voice recognition software such asDragon NaturallySpeaking – allows theperson to dictate notes into a computer.Some programmes also transcribe from adigital voice recorder, however as thesoftware needs to be trained to recognisethe individuals voice it does not alwayscope well with a variety of voices such asfrom lectures and meetings

� claroview – coloured overlay feature forcomputer screens

� mind mapping software such asInspiration, Mind Genius, Claro Mindfull,Spark Learner and Mind Manager – can beused to create mind-maps in a range ofstyles.

It should also be noted that commonly usedsoftware packages such as MicrosoftWindows or Apple Mac offer the facility tochange background colours and theappearance of the screen. Evenstraightforward procedures such aschanging font size and style can make adramatic difference.

Other equipment:

� coloured overlays – semi transparenttinted sheets used to reduced visualdisturbances by placing them over a pageof text

� tinted glasses – same principle ascoloured overlays but in spectacle form

8.6 Disabled StudentAllowance/Access to Workfunding

Having identified a need for specialistequipment, the next stage is normally toseek funding to enable the individual toobtain access to what they require. Thistends to come through two main fundingstreams depending on whether theindividual is a student nurse or employee.

Disabled Student Allowance (DSA)

For the majority of students funding isobtained through the Disabled StudentAllowance (DSA) and is secured whilst theyare undertaking formal education. Studentswho are enrolled on a course whichrepresents 50 per cent or more of a full-timedegree programme are normally eligible forthe DSA. This would currently include thoseregistered on a Diploma in HE programmesas they would exit with 240 credits whichequates to two thirds of a degree.

Qualified staff who wish to undertake a postgraduate degree are also likely to beeligible. However those wishing to ‘top up’from a diploma to a degree will not as theyrequire 120 credits, which only represents athird of a degree. More informationregarding the Disabled Student Allowance isavailable from www.direct.gov.uk

Access to work

For those who cannot access funds throughthe DSA there are two other main options –to rely on the free version of certain types ofsoftware that are available (see section 10)or to apply for funding through the access towork fund.

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Recommendationsfor the future

This guide has attempted to raiseawareness of the impact of dyslexia,dyspraxia and dyscalculia on an individual,particularly in relation to the workplace.Whilst these three conditions no doubtpresent challenges for those affected it mustbe remembered that in themselves they arenot a barrier to achievement, merely anobstacle which needs to be overcome. Inorder to help our colleagues to succeedthere is a need for the followingrecommendations to be considered.

1. Employers need to recognise thecontribution that those with dyslexia,dyspraxia and dyscalculia can make,whilst acknowledging the areas whichmight pose a particular challenge.

2. Employers need to listen to their staffwhen they identify areas of difficulty andbase support on the member of staff’sunique needs and not stereotypical ideasof what dyslexia, dyspraxia anddyscalculia are.

3. The RCN toolkit should be freely availableand staff encouraged to use thestrategies suggested within it, whetherfor themselves or to support others.

4. Staff involved in recruitment andselection have diversity awarenesstraining.

5. Employers should consider providingstaff development sessions to inform allstaff of their responsibilities towardscolleagues/students with disabilities. Inaddition to content related to dyslexia,the condition they will encounter mostoften should be included, along with abrief overview of dyspraxia anddyscalculia.

9Access to work is available to help overcomework related problems which arise as aresult of a disability. It can be used to helpfund equipment and other support that anemployer would not normally be expected toprovide. For those starting a new job (withinthe first six weeks) the fund will provide 100per cent of the additional costs incurred.After this it will offer a grant of up to 80percent of additional costs over the first £300.It is therefore in both the employer andemployees best interest to apply as soon aspossible. This needs to be considered whendeciding whether to declare a disability to aprospective employer, something thatindividuals are often reticent to do.

Examples of support that the funding mightprovide include assistive software for acomputer, and maybe even the computeritself if this is not standard issue. A supportworker might also be employed to help theindividual. One of the stories included inAppendix 2 describes how secretarial helpwas provided for 10 hours per week to typeup ‘notes’ dictated on a voice recorder.

It should be noted that the equipment andsoftware provided through Access toWorkdoes not belong to the individual and mayonly be available for use in the workingenvironment and not at home. Furthermoreit would usually need to be returned whenthe employee moves job. Furtherinformation can be obtained fromwww.jobcentreplus.gov.uk/employers

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www.jobcentreplus.gov.uk/employers

6. Clear processes are developed to identifystaff who are struggling in their currentrole as a result of a specific learningdifference. Where issues are identified,the employer should attempt to obtainspecialist advice as to how to bestsupport their employee.

7. Staff are given advice to help them toselect appropriate career options.

8. Effective partnerships are establishedwith HEI’s to ensure that student nursesare appropriately supported both duringcampus based learning and whilst onplacement.

9. All mentors, but particularly sign offmentors, receive appropriate training andsupport to help them to makeappropriate judgements relating tofitness to practice where students have adisability. This needs to informmentorsabout the requirement to ensure thatreasonable adjustments areimplemented but stress that if thestudent is still not reaching the requiredstandard that it is then appropriate to failthe student.

10.Newly qualified staff with formallyidentified dyslexia or dyspraxia aresupported for an agreed period of timeby a named preceptor to help themmakethe transition into their new role.

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10

Further informationand sourcesof support

Organisations

Dyslexia

The British Dyslexia Association98 London Road, Reading RG1 5AU

www.bda-dyslexia.org.uk

Dyslexia ActionPark House, Wick Road, Egham, SurreyTW20 0HH

www.dyslexia-inst.org.uk

The Helen Arkell Dyslexia CentreFrensham, Farnham, Surrey GU10 3BW

www.arkellcentre.org.uk

Independent Dyslexia Consultantswww.dyslexic-idc.org

PATOSS Professional Association ofTeachers of Students with Specific LearningDifferences

www.patoss-dyslexia.org

ADSHE Association of Dyslexia Specialistsin Higher Educationwww.adshe.org.uk

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www.adshe.org.uk

www.patoss-dyslexia.org

www.arkellcentre.org.uk

www.dyslexia-inst.org.uk

www.bda-dyslexia.org.uk

The Dyslexia Teaching Centre23 Kensington Square, LondonW8 5HN

www.dyslexiateachingcentre.co.uk

The Dyslexia UnitUniversity of Wales Bangor, Bangor,Gwynedd LL57 2DG

www.dyslexia.bangor.ac.uk

Dyspraxia

The Dyspraxia Foundation8West Alley, Hitchen SG5 1EG

www.dyspraxiafoundation.org.uk

Dyscalculia

The Dyscalculia Centrewww.dyscalculia.me.uk

General

www.equalities.gov.uk

Equality Act 2010What do I need to know?Disability quick start guide

iansyst Limited (assistive technology)www.iansyst.co.uk

Skill: National bureau for students withdisabilitieswww.skill.org.uk

Equality and Human Rights Commissionwww.equalityhumanrights.com

Employers Forum on Disabilitywww.efd.org.uk

Access to work: information for employersleaflet

www.jobcentreplus.gov.uk

NHS Employerswww.nhsemployers.org

Royal College of Nursing: diversity andequalitywww.rcn.org/support/diversity

The British Psychological Society (toobtain a list of chartered psychologistswho can undertake a formal assessmentfor a SpLD)www.bps.org.uk

Association of Educational Psychologists(to obtain a list of educationalpsychologists who can undertake a formalassessment for a SpLD)www.aep.org.uk

Other useful resources

Loughborough University: Dyscalculia andDyslexia Interest Group (DDIG)Collaborative group originally set up by stafffrom Loughborough University, CoventryUniversity and De Montfort Universityproviding advice and support in relation tomathematical problems associated withdyscalculia or dyslexia.

www.ddig.lboro.ac.uk

University of Nottingham School ofNursing, Midwifery and PhysiotherapyHave a resource known as RLO’s – ReusableLearning Objects – related to a range oftopics. These provide a multi sensoryapproach to learning which often benefitsthose with specific learning differences.



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www.aep.org.uk

www.bps.org.uk

www.rcn.org/support/diversity

www.nhsemployers.org

www.jobcentreplus.gov.uk

www.efd.org.uk

www.equalityhumanrights.com

www.skill.org.uk

www.iansyst.co.uk

http://www.equalities.gov.uk

www.dyscalculia.me.uk

www.dyspraxiafoundation.org.uk

www.dyslexia.bangor.ac.uk

www.dyslexiateachingcentre.co.uk

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There are also two RLO’s on the topic ofdyslexia itself.

www.nottingham.ac.uk

University of Southampton DyslexiaServicesYou can download the booklet ‘Supportingstudents with dyslexia in practiceplacements’ (on which this toolkit wasmodelled) from the website. There is also auseful booklet Dyslexia in the workplacewhich can be accessed through the site.

www.southampton.ac.uk

University of Worcester Institute of Healthand SocietyContains a link on the nursing course pages(Dip HS or BSc or Graduate Diploma) – to anadvice booklet, written by a student nursefor students with dyslexia on clinicalplacements.

www.worcester.ac.uk

Assistive technology

Digiscribble

www.scanningpensco.uk

ClaroRead andWrite, ClaroView, ScreenRuler

www.clarsoftware.com

Dragon Naturally Speaking

www.nuance.com

EndNote Bibliographical Software(organises reference lists)

www.adeptscience.com

Inspiration

www.inspiration.com

Kurweil Reader

www.sightandsound.co.uk

Mind Manager

www.mindjet.com.uk

Mindgenius

www.mindgenius.com

Reading Pen and Oxford Dictionary

www.wizcom.com

Spark Learner

http://spark-space.com

TextHelp Read andWrite Gold

www.texthelp.com

Free versions of software

Somemanufactures offer free versions ofassistive technology software. These areusually a more basic format than thosecommercially available and they maytherefore lack some of the advancedfunctionality. Nevertheless, these areextremely useful and offer a valuableresource to those unable to secure funding.The following websites offer a range ofassistive technology programmes – justfollow the on-screen links and menus toaccess those that will help with identifiedareas of difficulty.

www.abilitynet.org.uk/atwork-resources

www.techdis.ac.uk/getfreesoftware

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www.techdis.ac.uk/getfreesoftware

www.abilitynet.org.uk/atwork-resources

www.texthelp.com

http://spark-space.com

www.wizcom.com

www.mindgenius.com

www.mindjet.com.uk

www.sightandsound.co.uk

www.inspiration.com

www.adeptscience.com

www.nuance.com

www.clarsoftware.com

www.scanningpensco.uk

www.worcester.ac.uk





Further reading

To avoid unnecessary duplication thefollowing list contains easily availablecore resources suitable for a generalaudience. The books, articles andwebsites identified within the referencelist represent useful further reading, someof which are more specialised oraccessible than others.

Dyslexia

Bartlett D and Moody S (2000) Dyslexia inthe workplace, London:Whurr.

Burden R (2005) Dyslexia and self concept:seeking a dyslexic identity, London:Whurr.

Dale C and Aiken F (2007) A review of theliterature into dyslexia in nursing practice,London: RCN.

Edwards J (1994) The scars of dyslexia: eightcase studies in emotional reactions, London:Cassell.

Goodwin V and Thomson B (2004) Dyslexiatoolkit: a resource for students and theirtutors (2nd edition),Milton Keynes: OU.

McLoughlin D, Fitzgibbon G and Young V(1994) Adult dyslexia: assessment,counselling and training, London:Whurr.

McLoughlin D, Leather C and Stringer P(2002) The adult dyslexic: interventions andoutcomes, London:Whurr.

Morris D and Turnbull P (2006) Clinicalexperiences of students with dyslexia,Journal of Advanced Nursing, 54(2), pp.238-247.

Morris D and Turnbull P (2007) Thedisclosure of dyslexia in clinical practice:experiences of student nurses in the UnitedKingdom, Nurse Education Today, 27(1),pp.35-42.

Reid G (2003) Dyslexia: a practitioner’shandbook (3rd edition), Chichester: Wiley.

Reid G and Kirk J (2001) Dyslexia in adults:education and employment, Chichester:Wiley.

Dyspraxia

Colley M (2005) Living with dyspraxia, aguide for adults with developmentaldyspraxia, (3rd edition), London: DANDA.

Portwood M (2000) Understandingdevelopmental dyspraxia: a textbook forstudents and professionals, London: DavidFulton.

Dyscalculia

Bird R (2007) The dyscalculia toolkit:supporting learning difficulties in maths,London: Paul Chapman.

Butterworth B and Yeo D (2004) Dyscalculiaguidance: helping pupils with specificlearning difficulties in maths, London:nferNelson.

Generic

Health Professions Council (2006) Adisabled persons guide to becoming ahealth professional – a guide for prospectiveregistrants and admissions staff, London:HPC. Available at www.hpc-uk.org (lastaccessed 28 March 2010).

Hendrickx S (2010) The adolescent andadult neuro-diversity handbook: aspergerssyndrome, ADHD, dyslexia, dyspraxia andrelated conditions, London: Jessica Kingsley.

Her Majesty’s Stationery Office (1995) TheDisability Discrimination Act, London:HMSO.

Her Majesty’s Stationery Office (2005) TheDisability Discrimination Act, London:HMSO.

Kane A and Gooding C (2009) Reasonableadjustments in nursing and midwifery: aliterature review, London: NMC.

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Nursing and Midwifery Council (2004a)Reporting lack of competence: a guide foremployers and managers, London: NMC.

Nursing and Midwifery Council (2004b)Standards of proficiency for pre registrationnursing education, London: NMC.

Pollak D editor (2009) Neurodiversity inhigher education: positive responses tospecific learning differences, Chicester:Wiley-Blackwell.

White J (2007) Supporting nursing studentswith disabilities in clinical practice, NursingStandard, 21 (19), pp.35-42.

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12

Beacham N and Trott C (2005) Developmentof a first-line screener for dyscalculia inhigher education, SKILL Journal, 81, pp.13-19.

Beaton A, McDougall S and Singleton CH(1997) Humpty Dumpty grows up?Diagnosing dyslexia in adulthood, Journalof Research in Reading, 20, pp.1-12.

Benner P (1984) From novice to expert:excellence and power in clinical nursingpractice, Menlo Park: Addison Wesley.

Berninger V (2004) Brain basedassessment and instructional intervention,in Reid G and Fawcett A (editors) Dyslexiain context: research, policy and practice,London: Whurr.

Bird R (2007) The dyscalculia toolkit:supporting learning difficulties in maths,London: Paul Chapman.

Blankfield S (2001) Thick, problematic andcostly? The dyslexic student on workplacement, Skill, 70, pp.23-26.

Bould D, Keogh R. and Walker D (1989)Reflection: turning experience intolearning, London: Kogan Page.

Brunswick N, McCrory E, Price CJ, Frith CDand Frith U (1999) Explicit and implicitprocessing of words and pseudowords inadult developmental dyslexics: a search forWernicke’s wortschatz? Brain, 122, pp.1901-1917.

Butterworth B (2003) Dyscalculia screener,London: nferNelson.

Butterworth B and Yeo D (2004)Dyscalculia guidance: helping pupils withspecific learning difficulties in maths,London: nferNelson.

Castles A, Datta H, Gayan J and Olson RK(1999) Varieties of developmental reading

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disorder: genetic and environmentalinfluences, Journal of Experimental ChildPsychology, pp. 72-73.

Chasty HT and Friel J (1991) Children withspecial needs, London: Jessica Kingsley.

Colley M (2005) Living with dyspraxia, aguide for adults with developmentaldyspraxia (3rd edition), London: DANDA.

Coltheart M, Curtis B, Atkins P and Haller M(1993) Models of reading aloud: dual routeand parallel distributed processingapproaches, Psychological Review, 100,pp.589-608.

Cowen M (2010) Dyslexia, dyspraxia anddyscalculia: a toolkit for nursing staff,London: Royal College of Nursing.

Cowen M (2005) How do student nurses,who are facing possible discontinuation oftheir training, feel about being screened fordyslexia and are those feelings influencedby the outcome of the screening?Unpublished MSc thesis, SouthamptonUniversity.

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Dyspraxia Foundation (2010)What isdyspraxia? Hitchin: DF. Available atwww.dyspraxiafoundation.org (lastaccessed 28 March 2010).

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Fisher R (1998) Thinking about thinkin :developing metacognition in children, EarlyChild Development and Care, 141, pp.1-13.

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Geschwind N and Galaburda A (1985)Cerebral lateralisation biologicalmechanisms associations and pathology: ahypothesis and a programme for research,Archives of Neurology, 42, pp.428-459.

Gilger JW, Pennington BF and De Fries JC(1991) Risk for reading disability as afunction of parental history in three familystudies, Reading andWriting, 3, pp.205-218.

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The following areas have been identifiedas offering particularly good support tostudents or staff with a specific learningdifference. It is hoped that this list willcontinue to grow.

The Employers’ Forum on Disability(EFD)

celebrates the work of employers thatunderstand the value in getting it right ondisability. Seventeen employers from acrossthe public and private sector wereshortlisted for EFD’s Disability Standard2009 awards. The awards celebrate goodpractice in disability and employmentamong participants in the DisabilityStandard. It is the only business-ledbenchmark that measures an organisation’sperformance on every aspect of disability asit affects a business.

The following NHS employers were amongstthose shortlisted for the Disability StandardMost Improved Award in 2009:

� Bradford and Airedale Teaching PrimaryCare Trust

� Plymouth Hospitals NHS Trust

� Portsmouth Hospital NHS Trust.

Loughborough University: Dyscalculiaand Dyslexia Interest Group (DDIG)

Collaborative group originally set up by stafffrom Loughborough University, CoventryUniversity and De Montfort University toprovide advice and support in relation tomathematical problems associated withdyscalculia or dyslexia.


Appendix 1

Examples of good practice

University of Nottingham School ofNursing, Midwifery and Physiotherapy

Has created a resource known as ReusableLearning Objects (RLO) which covers a rangeof topics and provides a multi sensoryapproach to learning which often benefitsthose with a SpLD. There are also two RLOon the topic of dyslexia.www.nottingham.ac.uk

University of Southampton DyslexiaServices

Created a booklet Supporting students withdyslexia in practice placements (on whichthis toolkit was modelled) and which isavailable for download. The service has alsoproduced a useful booklet Dyslexia in theworkplacewhich from the website:www.southampton.ac.uk

University of Worcester Institute ofHealth and Society

Offers a booklet, written by a former studentnurse, which provides advice for otherstudents about managing their dyslexiawhilst on placement. Access is via the linkon the nursing course pages (Dip HS or BScor Graduate Diploma) at the followingaddress: www.worcester.ac.uk

West Middlesex University HospitalsNHS Trust

Runs a support group for students withdyslexia, where individuals can sharestrategies they have found useful andgenerally offer peer support. The groupusually self facilitates but is supportedby Tina Jones, a Clinical Practice Educatorbased at Isleworth.See www.west-middelesex-hospital.nhs.uk

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www.west-middelesex-hospital.nhs.uk

www.worcester.ac.uk






The following personal stories weregenerously provided by membersfollowing a request on the RCN website.A large number of stories were receivedand it has therefore not been possible toinclude them all, but in some cases adecision was taken not to include a storyas the events described were so specificthat the individual might be identified. Forthe remainder all identifying features(whether personal or employer) wereremoved to protect the individualsconcerned. Finally, as some stories werevery detailed, only certain excerpts havebeen included to illustrate what it is reallylike to live and work with one of theseconditions. The accounts have not beenedited in any way in terms of spelling orgrammar – merely shortened wherenecessary.

“I started my Nurse Training at age 21 anddid not have any particular problems untilchildren’s ward. of course it is necessary tocalculate the correct drug dosages for eachchild and as a student nurse this was one ofthe objectives to be achieved in order tocomplete the placement. I struggled to dothe maths and the staff would deliberatelyavoid doing any drug calculations with me. Iwas capable of doing the calculations but Ineeded more time to complete them, whichthey did not seem prepared to give. Somestaff were overtly rude and I remember oneSenior Staff Nurse refusing to even do drugswith me”.

“The principle gripe I have at the moment isthat I have very little access to computers.Word processors (as they were then) helpedme through school and university. The ‘spellchecker’ is an invaluable tool for me and notone I have ready access to at work. I have tofight with elbows to get near to computersto write letters and there is no computer in

my department at all!!!! I have not thoughtabout making my case for a computer on thebasis of my “disability” because I do not likedrawing attention to it. I do not believe thatdyslexia is a classic “disability” because it isa difference in the brain make up and thatdifference makes me the way I am and Ithink that my brain is okay and that it makesme a good nurse”.

“On placement I informed my mentors of mydyslexia but not everyone knows what thismeans or they have the wrong idea of whatit is. Every mentor I have had has beenexcellent they have corrected the oddsentence so it flows better as I have missedout a word or if I miss spelt a word pointed itout so I can sort it. I used a little booklet formy placements that was designed fordyslexic students I could write things in, itwas colour coded for different subjects, itwas given to me by the disabilitiesdepartment. Which was really helpful. Atfirst when I was diagnosed, I felt anger withmy school, for labeling me as lazy and notidentifying my dyslexia 20 odd years ago. Ialso felt anger towards my parents as wellfor not trying to understand why I struggledwith English, writing and speaking. Myfather’s reaction summed it up when I toldhim, he simply said “since when”, like I hadjust caught dyslexia rather than sufferingwith it all my life”.

“I had my test done in the march of my firstyear but did not hear back till April with theresult. At the time I was writing my firstessay since school which was 17 years agoat the time.When I read the report I was athome on my own I was in tears, it was likethe my world had come to an end, Iwondered what was the point of doing thecourse I had wanted to do since school. Itmade sense why I never got the grades atschool and through my two years pre

Appendix 2

Personal stories

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nursing course I did too. I didn’t give in tothe idea of stopping because of being told Iwas dyslexic, I gave myself a kick anddecided I wasn’t going to give up what I hadwaited so long to do. I contacted thedisabilities department to inform them ithad been confirmed I am dyslexic, this iswhere I received more help I was aloud oneto one meetings to go through strategies oflearning, revision, essay writing and notetaking in class. They would also readthrough my essays to point out areas that Ihave repeated, show sentences that weretoo long and any spelling errors. I met with**** who was the tutor of the group andwho also had dyslexia and dyspraxia whichwas a great help as it was someone whounderstood where you were coming from allthe time. I also received a laptop withspecial programmes on to help learn in away that suits me. I found a programmecalled inspirations fantastic it helped withformulating my essay plans to revision forexams. A Dictaphone to record lecture so Idon’t miss anything and the PowerPoint’s ofmost lessons prior to the lecture so I couldprint them out and write next to thecorresponding slide any extra informationwhich I found really useful”.

“When I first started my training it was veryhard because I was the first to come to theuniversity and be dyslexic. When I first as atutor were I was able to find the support Ineeded and was told I would find it verydifficult and that I might not pass thecourse. I did of course and I have beenqualified since 2005. During my placementsas a student I would informmymentors sothat they were aware. Each mentor was verysupportive”.

“I did not know about dyscalculia aboutabout three years ago when I heardsomeone speaking about their problemsand realised that this was exactly what I wasexperiencing. I have never been formallydiagnosed. Nowadays I still struggle withcombinations of numbers such as telephone

numbers. My main problem is that all officesin the NHS have number coded access tothe doors. I am forever getting the numberswrong and therefore getting stuck,sometimes between floors. My way ofdealing with this is keep the number codesin a secret place so that I have access inemergency. I carry my mobile on me when Iam in the building so that I can call someoneif necessary otherwise I rely on kindpassers-by to rescue me if I get stuck.Another way of dealing with this is to get toknow alternative routes (usually a very longway round) that avoid using number codes. Idon’t think any one here knows my problem,they just think I am a bit forgetful or‘dappy’”.

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The RCN represents nurses and nursing,promotes excellence in practice andshapes health policies

August 2010

RCN Onlinewww.rcn.org.uk

RCN Direct www.rcn.org.uk/direct0345 772 6100

Published by the Royal College of Nursing 20 Cavendish SquareLondon W1G 0RN

020 7409 6100

Publication code 003 833

ISBN 978-1-906633-48-3

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