Nurse Education in Practice 14 (2014) 674e679

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Nurse Education in Practice journal homepage: www.elsevier.com/nepr

Nursing students with special educational needs in Japan* Yuko Ikematsu a, *, Masako Mizutani 1, Hiroaki Tozaka a, 2, Sachiko Mori 3, Koji Egawa b, 4, Midori Endo c, 5, Mitsuko Yokouchi a, 6 a

Department of Nursing, Nagoya University Graduate School of Medicine, Japan Kobe City College of Nursing, Japan c Yamanashi Prefectural University School of Nursing, Japan b

a r t i c l e i n f o

a b s t r a c t

Article history: Accepted 29 August 2014

Aim: To reveal the prevalence of nursing students with special educational needs in Japan. Method: A mail survey of 833 nursing programs was conducted. Nurse educators were asked to report on their program's profiles and the number of extremely difficult students who belonged to the March 2011 class of graduates. They were also asked to fill a modified questionnaire developed by the Ministry of Education, Culture, Sports, Science and Technology about each extremely difficult student. Results: Among the 14,325 students enrolled the class of 2011, 146 students (1.02%) were identified as having one or more special educational needs for “listening,” “speaking,” “reading,” “writing,” “math,” “reasoning,” “inattentiveness,” “hyperactivity/impulsivity,” or “social interaction/restricted interests.” The most prevalent need was “social interaction/restricted interests,” followed by “listening” and “inattentiveness.” These students had the most difficulty participating in “nursing care for patients during clinical practicum.” Conclusion: The proportion of nursing students with special educational needs is small but may have a large impact on the clinical practicum. Evaluation and support systems at multiple levels, including entrance examinations, course placement, and special educational programs, are warranted. © 2014 Elsevier Ltd. All rights reserved.

Keywords: Nursing students Special educational needs Developmental disorders Japan

Background Developmental disorders, including learning disabilities (LDs), attention deficit/hyperactive disorder (ADHD, and high-functioning autistic spectrum disorder (HFAD) or Asperger's syndrome, have been widely recognized in adolescents and young adults in recent years (Adreon and Durocher, 2007; Graetz and Spampinato, 2008; * All authors listed on the title page participated in the full process of the designing, planning, and conducting the study. * Corresponding author. Department of Nursing, Nagoya University Graduate School of Medicine, 1-1-20 Daiko-minami, Higashi-ku, Nagoya 461-8673, Japan. Tel./fax: þ81 52 719 1567. E-mail addresses: [email protected] (Y. Ikematsu), [email protected]. ne.jp (M. Mizutani), [email protected] (H. Tozaka), [email protected]. ac.jp (S. Mori), [email protected] (K. Egawa), [email protected] (M. Endo), [email protected] (M. Yokouchi). 1 Tel.: þ81 52 794 3833. 2 Tel.: þ81 52 719 1576. 3 The author used to be a faculty of the Department of Nursing, Nagoya University Graduate School of Medicine, Japan. 4 Tel.: þ81 78 794 8092. 5 Tel.: þ81 55 253 8745. 6 Tel.: þ81 52 719 1572.

http://dx.doi.org/10.1016/j.nepr.2014.08.007 1471-5953/© 2014 Elsevier Ltd. All rights reserved.

VanBergeijk et al., 2008). In Japan, the Act on Support for Persons with Developmental Disabilities was enacted in 2004, and the responsibilities of higher educational institutions to accommodate the needs of students with developmental disorders were clearly stated. Japan Student Service Organization conducts surveys on students with disabilities in higher education every year. According to the survey, 41 students with clearly diagnosed developmental disorders were identified in all allied health science schools of universities and junior colleges in Japan in 2013 (Japan Student Services Organization, 2014). However, the survey reports the prevalence of only those students with definite diagnoses. There may be numerous students with undiagnosed developmental disorders or relevant special needs. The Organization also publishes a guidebook for faculty and staff to support those students (Sato et al., 2012). However, the guidebook does not provide sufficient information to assist nursing faculties who teach students in unpredictable clinical sites. Although the existence of nursing students with developmental disorders is recognized (Bradshaw and Salzer, 2003; Evans, 2013; Ijiri and Kudzma, 2000), the distribution of those students remains unknown. The present study was inspired by an author's

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experience with a student who had difficultly behaving appropriately in clinical practicum. Students with developmental disorders may have special needs that require additional support to implement a nursing career. Knowing the prevalence of such students may facilitate understanding of their needs and may subsequently help develop support programs for the students. Therefore, this study aimed to reveal the prevalence of nursing students who had special educational needs with specific traits relevant to developmental disorders. Literature review Learning disabilities (LDs) are characterized by unsatisfactory academic achievement because of difficulties with one or more learning skills, such as reading, writing, and mathematics (Sadock and Sadock, 2009). Dyslexia, a difficulty with language, is a wellknown example of a learning disability. People with dyslexia experience difficulties in organizing lines and dots written on a paper and sounds spoken by other people. One student with dyslexia described his perception of written language as being similar to “dispersed black sesame seeds on a white canvas” (National Institute of Special Needs Education, 2005). Students with a learning disability may face a variety of difficulties with higher education. Ijiri and Kudzma listed possible difficulties experienced by college students with learning disabilities (Ijiri and Kudzma, 2000). Some or all of the difficulties, such as issues with reception and expression of oral language, reading, and computation, can be obstacles for students to study nursing. Nursing students with dyslexia have been studied in Western countries. The experiences of these students have been explored in Europe. Two qualitative studies explored the experiences of nursing students with dyslexia. Morris and Turnbull interviewed 18 nursing students with dyslexia in the UK and identified five themes that the students faced (Morris and Turnbull, 2006). The study found that the students were concerned with whether they should disclose their dyslexia and that they developed self-managing strategies, needed more time to complete their assignment, had emotional responses, and were thoughtful about their choice of future work settings. Although the study provides useful information to nursing faculty who support students with dyslexia, the authors suggested more research studies to establish evidence for the effectiveness of such support. Child and Langford, also in the UK, conducted a phenomenological study to explore the learning experiences of nursing students with dyslexia (Child and Langford, 2011). They interviewed nursing students with and without dyslexia to clarify the experience that is specific to dyslexia. In addition to common themes found in both groups, dyslexic students expressed difficulty in short-term memory, spelling and writing, reading, and pronunciation. Their need for more time and clinical mentors' understanding of dyslexia were revealed. In that study, the importance of clinical mentors' support and schools' advocacy role was emphasized. The identities of nursing students with dyslexia have been studied in Ireland. The discourse analysis revealed that there were students who embraced, passively engaged, or resisted their handicaps (Evans, 2013). Although some students positively coped with their disabilities, other students resisted admitting dyslexia as an identity. Most students did not use language related to the medical diagnosis of dyslexia, and they complained about a lack of understanding of dyslexia among clinical staff, as well as academic nurse educators. ADHD is characterized by a failure of sustained attentiveness and control of impulsiveness (Sadock and Sadock, 2009). Although the symptoms of ADHD are most problematic in school-aged children, the symptoms persist in adolescents and adults in

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approximately half of all cases (Sadock and Sadock, 2009). Inattentiveness, distractedness, impulsiveness, and other symptoms of ADHD affect executive functions that are essential behaviors for successful achievement in college (Bradshaw, 2006; Bradshaw and Salzer, 2003). Nursing students with ADHD may experience difficulties, particularly in clinical settings where time-management and prioritization are crucial. An anecdotal episode of inappropriate behavior of a nursing student with ADHD was illustrated in the literature (Bradshaw and Salzer, 2003). The student in the report loudly verbalized her astonishment when she saw her patient's perineal appearance because of a medical condition. One of the authors of the report later published a review article on nursing students with ADHD (Bradshaw, 2006). Recommendations to accommodate ADHD students in nursing education are described in the article, but a solution for interpersonal problems is not definitive. HFAD, or Asperger's syndrome, is a pervasive developmental disorder. HFAD shares common clinical features with autistic disorder, except for language delay. People with HFAD exhibit difficulties in communication, especially in nonverbal communication, impaired socialization, and restricted interests and behaviors (Sadock and Sadock, 2009). The need to support college students with HFAD is well recognized (Graetz and Spampinato, 2008; VanBergeijk et al., 2008). The difficulties associated with HFAD may also impede nursing practice. For example, the failure to understand nonverbal cues may affect the establishment of rapport with patients, and being unable to collaborate with nursing and other health care staff may hinder a nurse in providing comprehensive health care. However, our literature search revealed there are no current articles on nursing students or nurses with HFAD. The inclusion of disabled students in nursing education has been debated after the 1990 Americans with Disabilities Act in the United States, the 1995 Disability Discrimination Act and the 2010 Equality Act in the United Kingdom, and the 1992 Disability Discrimination Act in Australia. A balance between students' right to study and patient safety was the most important issue regarding including disabled students in nursing education (Chih Hoong and Fong, 2008; Davidson, 1994). In Japan, Disqualification Conditions for health care professions became “relative” instead of “absolute” in 2001. Prior to the amendment, physical, mental, and sensory impairments were disqualifying conditions in health care professions, including nursing. After the amendment, nursing schools were not able to reject students based on their disabilities, and the selection of prospective students remains each school's decision. Issues related to the acceptance of disabled students in nursing education have been discussed in the literature (Kurihara and Hirota, 2012). However, the discussion has focused mostly on physical and sensory disabilities, and the possibilities for students with developmental disorders were not widely recognized. Developmental disorders were not well known in Japan until recently, although autism was well known. Currently, Asperger's syndrome is the most widely known disorder, and ADHD is the second most recognized disorder. Learning disabilities are much less known. Asperger's syndrome became publicly known in relation to crime; therefore, a negative image of Asperger's syndrome is predominant in Japan. ADHD also has a negative connotation. It was publicized in conjunction with restless children who disrupted classroom teaching. Adults with developmental disorders are now widely recognized, and many books on the topic have been published within the past few years in Japan. In 2002, the Ministry of Education, Culture, Sports, Science, and Technology (MEXT) of Japan conducted a national survey of elementary and junior high school students (6e15 years old) to detect those with special educational needs (Ministry of Education

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Culture Sports Science and Technology (2003)). A sample of 41,579 students in mainstream classes (i.e., not in special support classes) was evaluated by school teachers using a questionnaire that was specifically developed for the survey. The survey revealed that 6.3% of the students had special learning and/or behavioral needs relevant to developmental disorders. It is highly suspected that those students are among current nursing students. Accordingly, a national survey on nursing students with special educational needs was conducted in Japan. It must be noted that this survey did not aim to “diagnose” the disorders. Rather, it aimed to identify students with special educational needs who have similar difficulties as people with developmental disorders. The term “special educational needs” was used in the MEXT study described above. Although nurse educators who completed the questionnaire were not trained to diagnose developmental disorders, they were able to assess abilities because they were specialized in education and were able to assess the students from an educational perspective that is consistent with the aim of this study. Methods Survey questionnaires were sent to all registered nurse (RN) nursing programs for which mailing addresses were available in Japan. There was a total of 833 programs, including four-year baccalaureate programs, three-year associate degree programs, four-year diploma programs (high school to RN and public health nurse), three-year diploma nursing programs (high school to RN), and two-year nursing programs (assistant nurse to RN). There are four possible licensures for Japanese nurses (RN, public health nurse, nurse midwifery, and assistant nurse). Japanese RN education is twofold. One path is three-year diploma school, three-year junior college, or four years of college or university after 12 years of general education. The other path is two years (or three years for part-time programs) of education after being licensed as an assistant nurse. An assistant nurse is trained for two years. Nine years of general education is the minimum requirement to apply to assistant nurse programs, but most current applicants have 12 years of general education. Public nurses and nurse midwives are required to train for an additional year after finishing the RN program. Some four-year diploma schools and a majority of four-year colleges or universities employ integrated programs for RN and public health nurse education. The survey consisted of two questionnaires. One of the questionnaires (Questionnaire 1) attempted to elucidate the program's overall features regarding students with special needs. The questionnaire included questions about the entrance examination of the program, student support system, number of enrolled students in the classes to be graduated in March 2011 (i.e., admitted in April 2007, 2008, or 2009 depending on the length of the program), number of extremely difficult students among the enrolled students, and the participants' perceptions about extremely difficult students. An extremely difficult student was defined as a student with problems such as being unable to perform an ordinal task, being unaware of their circumstances, being unable to detect implications, behaving with extremely bad manners, being unable to connect known things, misunderstanding common daily things, being extremely clumsy, repeatedly mistaking easy Chinese characters (Japanese written language consists of three characters, i.e. Hiragana, Katakana, and Chinese characters) and/or simple calculation, having no interest in other people, being unable to understand other people's viewpoints, being unable to cope with sudden changes, being unable to perform simple tasks after repeated training, and being unsuccessful despite re-practicum and/or individualized instruction. This definition was used to form a population of students with developmental disorders or special

educational needs. Because evaluation of all graduates was not possible, it was assumed that students with developmental disorders or special educational needs might have been included in the extremely difficult students defined above. Administrators of the participating programs were asked to complete Questionnaire 1. More detailed information about extremely difficult students was sought through another questionnaire completed by the nurse educators who were well acquainted with the students. The other questionnaire (Questionnaire 2) consisted of a modified battery to assess special educational needs and contained supplemental questions on frequently observed behaviors, difficult learning situations, outcomes, and space for free comments about the students. The battery was originally developed and used by MEXT Japan for the elementary and junior high school student survey noted above. This article reports on the prevalence of students with special educational needs determined by the MEXT battery, difficult learning situations of the students, and the student outcomes. The battery consisted of learning difficulty content (six items for “listening,” “speaking,” “reading,” “writing,” “mathematics,” and “reasoning”), nine items for each “inattentiveness” and “hyperactivity/impulsivity”, and 27 items for “social interaction/restricted interests.” The learning difficulty questions used a four-point Likert scale ranging from 0 points (not at all) to 3 points (often). Questions for “inattentiveness” and “hyperactivity/impulsivity” also used a four-point Likert scale ranging from 0 points (not at all or very rare) to 3 points (very often). The “social interaction/restricted interests” questions used a three-point Likert scale ranging from 0 points (not applicable) to 2 points (applicable). Items irrelevant to nursing students were adjusted to nursing students. Examples of adjustments include changing “plays alone” to “isolated” and “runs and climbs around” to “moves around.” “Difficulty with answering verbal math quiz in grade-equivalent reading level” was modified to “unable to understand assignment written in words.” This item was originally included in the “mathematics” category but was changed to the “reasoning” category because of the nature of the modified item. “Difficulty with comparing amounts and/or difficulty with understanding units expressing an amount as gradeequivalent level (i.e., the fact that 15 cm equals to 150 mm)” was modified to “difficulty with comparing amount and/or difficulty with understanding units expressing amount (i.e., the fact that 15 cm equals to 150 mm).” This item was originally included in the “reasoning” category but was changed to the “mathematics” category because it assesses mathematical ability. The Cronbach's alpha values of the nine categories of the modified questionnaire were between 0.82 and 0.90. The presence or absence of special needs, or suspected developmental disorder, was determined according to the scoring method provided by the MEXT. Learning difficulty was determined by adding the item points for each category (i.e. “listening,” “speaking,” “reading,” “writing,” “mathematics,” and “reasoning”). For “inattentiveness” and “hyperactivity/impulsivity,” 0 and 1 point were converted to 1 point, and 2 and 3 point were converted to 1 point. Then, the points for “inattentiveness” and “hyperactivity/ impulsivity” were generated by total points of each category. The “social interaction/restricted interests” was determined by adding the points of all 27 items. The cut-off points were as follows:12 points or above of one or more categories of “listening,” “speaking,” “reading,” “writing,” “mathematics,” and “reasoning” for special learning needs; six points or above in either or both categories of “inattentiveness” and “hyperactivity/impulsivity”; and 22 points or above for “social interaction/restricted interests.” To determine difficult situations for the students with special educational needs, the participating nurse educators were asked to

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select five of eight predetermined situations and rate them 1 to 5, with 1 indicating the situation was the most difficult to teach the student. The predetermined situations were as follows: classroom lecture, group work, paper and pencil test, skill lab, communication with patients and families at clinical practicum, relationship with teachers and/or clinical instructors at clinical practicum, providing nursing care to the patients, and research. During final scoring, the score was inverted (i.e., 5 points was assigned to the most difficult situation). The sum of the scores of all students with special educational needs indicated the degree of difficulties of the situations for the students. Ethical considerations A cover letter explaining autonomous participation and anonymity was enclosed with the questionnaires. Completing and returning the questionnaires were considered to represent the participants' willingness to participate in the study. An identification number was printed on the self-addressed return envelope only and not on the questionnaires. The envelopes were opened every 10 or more responses, and the envelopes and the questionnaires were stored separately. This procedure made it impossible to relate the questionnaires and identification number with the name of a particular school. Inability to withdraw from the study after returning questionnaires was explained to the potential participants on the cover letter. To maximize the confidentiality of the students, age, gender, and other demographic data were not collected. Returned questionnaires were stored in a locked cabinet in the principal investigator's office, and only the principal investigator was able to unlock the cabinet. This study was approved by the Institutional Review Board of the Nagoya University Graduate School of Medicine. Informed consent by the students was waived because most of the students had already left the programs and could not be contacted by the participating schools. Results Three hundred and ninety-three programs (47.5%) responded. Answers from 341 programs (41.2% of target programs) were eligible for analysis. The remaining questionnaires were returned blank. The analyzed programs consisted of 46 baccalaureate programs, 7 associate degree programs, 4 four-year diploma programs, 194 three-year diploma programs, and 73 two-year diploma programs. Seventeen programs did not identify their program types. Most programs (N ¼ 286, 83.9%) interviewed all applicants, and 46 programs (13.5%) interviewed some of the applicants as a part of their entrance exams. Only eight programs (2.3%) did not interview at all. School counselors and/or other services to support difficult students were available in 45 programs (13.2%). Three hundred and thirty students were reported as extremely difficult students among the 14,325 students who entered the class of 2011, for a total prevalence of 2.3% (95% Confidence interval: CI 2.298e2.302%). Among these students, 244 students were described using Questionnaire 2 by the participants. One hundred forty-six students [1.02% (95%CI 1.019e1.021%)] were determined to have one or more special educational need in the areas of “listening,” “speaking,” “reading,” “writing,” “mathematics,” “reasoning,” “inattentiveness,” “hyperactivity/impulsivity,” or “social interaction/ restricted interests.” The most prevalent need was “social interaction/restricted interests” [0.64% (95% CI 0.639e0.641%)], followed by “listening” [0.55% (95% CI 0.549e0.551%)] and “inattentiveness” [0.42% (95% CI 0.419e0.421%)]. The prevalence of each need is shown in Table 1.

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Table 1 Prevalence of special needs n ¼ 14,325. Special need

Number of the students

Listening Speaking Reading Writing Mathematics Reasoning Inattentiveness Hyperactivity/impulsivity Social interaction/restricted interests Any of above

%

95% Confidence interval

79 54 25 21 11 37 60 15 92

0.55 0.38 0.17 0.15 0.08 0.26 0.42 0.10 0.64

0.549e0.551 0.379e0.381 0.168e0.172 0.149e0.151 0.080e0.080 0.259e0.261 0.419e0.421 0.100e0.100 0.639e0.641

146

1.02

1.019e1.021

Forty-eight students had one special need, 31 students had two needs, 23 students had three needs, and 22 students had four needs. All students with “hyperactivity/impulsivity” were also reported to have “inattentiveness.” The most difficult situation in teaching students with special educational needs was “patient care at clinical practicum” followed by “interaction with teachers and/or clinical instructors,” “communication with patient and family at clinical practicum,” and “group work” (Table 2). The trends were mostly similar among the students with each need, but students with “hyperactivity/impulsivity” presented a slightly different trend. Those students had the most difficulty in the “interaction with teachers and/or clinical instructors” followed by “group work.” Thirty-four of 146 students with special educational needs [23.4% (95% CI 22.8e24.0%)] graduated within a regular study term, 46 students [31.7% (95% CI 31.1e32.2%)] withdrew, and 52 students [35.9% (95% CI 35.3e36.5%)] were still in the programs, having extended their study terms (Table 3). Discussion This current survey revealed that 2% of nursing students have extreme difficulties in studying nursing, and half of these students have special educational needs. This proportion is less than the prevalence noted among the elementary and junior high school students surveyed by MEXT Japan. This difference may be explained by the students’ maturation. Traits such as “hyperactivity/impulsivity” and disabilities in “mathematics” may affect success in high school education and entrance exams, although students retain general intelligence. As a result, fewer students are able to enter higher education, including nursing programs. However, in contrast to the MEXT study that evaluated currently enrolled students, the present survey included many students who had already left school due to either graduation or dropping out.

Table 2 Difficult learning situations of the students with special needs n ¼ 146. Rank

Learning situation

Summed scorea

1 2

Patient care at clinical practicum Interaction with teachers and/or clinical instructors Communication with patient and family at clinical practicum Group work Skill lab Paper and pencil test Classroom lecture Research

419 399

3 4 5 6 7 8

370 323 286 91 72 33

a Summation of the most difficult (5 points) to fifth most difficult (1 point) of each student.

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Table 3 Outcome of students with special educational needs n ¼ 146. Graduated

Withdrawn

Extended term

Unknown

34 (23.4%)

46 (31.7%)

52 (35.9%)

13 (8.7%)

The evaluation depended on the memory of the nurse educators. Therefore, these results may be underestimated. A prospective study is needed for a more accurate estimation of the prevalence. One percent of enrolled nursing students were reported as having special educational needs. Although one percent initially appears to be a small number, this result indicates that there is one student with special educational needs every year for programs with 100-student classes and one student every other year for the programs with 50-student classes. One student may not be a substantial problem for classroom lectures, but one student may have a large impact in a clinical practicum in which students work in small groups. In this situation, one or more teachers/instructors need to focus on the student, which may severely affect the teaching of other students. The most prevalent special educational need was “social interaction/restricted interests.” This need is relevant to HFAD. Unlike LD and ADHD, there are no existing literature reports on nursing students with HFAD. “Social interaction/restricted interests” or HFAD in nursing students needs to be addressed more. Whereas the prevalence of other special educational needs was obviously lower than among the elementary and junior high school students, the prevalence of the students with this need (0.64%) was close to the prevalence reported in the MEXT study (0.8%). A study of college students in the United States found a 0.7e1.9% prevalence of HFAD (White et al., 2011). The traits of HFAD can impair studying nursing. People with HFAD are unable to recognize nonverbal cues in communication. Insensitivity to facial expressions and/or voice tones (Ingersoll, 2010) may hinder awareness of patient emotions and may cause issues with patients and their families. Problems in the areas of “listening,” “inattentiveness,” and “speaking” may also be obstacles in the clinical practicum. Students who fail to understand what was explained to them by school teachers and clinical instructors may perform incorrect actions. Students who are not able to set up equipment and do not follow the steps of care may not be able to provide appropriate nursing care to the patients. Students who cannot efficiently express themselves may not be able to communicate with nurses in busy clinical circumstances. Difficult learning situations, such as “patient care at clinical practicum” and “interaction with teachers and/or clinical instructors,” that were found in this study may reflect these obstacles. All except eight nursing programs employed interviews as part of their entrance exams. Despite the interviews, there still were students with communication and other behavioral problems. This fact may indicate that it is difficult to identify these problems during the short timeframe of the interviews. The effectiveness of interviews needs to be examined, although it may be difficult to follow applicants who are rejected. The improvement of entrance exams should ideally be evidence-based. However, strong knowledge of the essential characteristics upon entry into nursing education is currently lacking. Therefore, a longitudinal prospective study is warranted. In addition to improving the selection of students, particular educational approaches may be necessary for enrolled students with special educational needs. For example, whereas many students acquire social skills, such as appropriate verbal expression in a particular circumstance through school or daily life, students with

special needs of “social interaction/restricted interests” or suspected HFAD may not learn unless being instructed in a straightforward manner. Although such instruction may not be considered as part of higher education, failure of timely instruction may result in an unsuccessful career for the students. The early detection of the students and a timely individualized approach are imperative. A systematic approach called the “tripartite model” in nursing education has been proposed (Griffiths et al., 2010). In this approach, a partnership is developed by the Practice Learning Team, the Disability Service, and the Student Placement Facilitator. In this model, the Disability Service Advisor spends a day at the practice setting to understand the clinical practicum environments. This experience fosters realistic discussion among the parties. However, any form of student support service is available for only slightly more than 10% of the surveyed nursing programs in Japan. Faculty-driven support programs have been reported for nursing education in the United States. The upper-division baccalaureate nursing program at Texas Women's University e Houston Center is unable to utilize the university's student support service because the center is a satellite campus. The faculty developed a mandatory retention program that requires 5 semesters, which includes one extra semester to complete nursing education for students identified to be at risk by a Nurse Entrance Test (NET) (Symes et al., 2005). In Japan, there are extended programs including a three-year diploma program and two-year program for part-time students. These programs are one year longer than their corresponding full-time programs. However, the curricula of these programs are fixed and are not flexible for the needs of individual students. More individualized adjustment is desirable for students with various educational needs. Nearly a quarter of the students with special educational needs had graduated within regular terms. It can be challenging to fail students in a clinical setting in which there is a paucity of objective data. Furthermore, the educator's experience with the student at a clinical site can be difficult to share with other faculty members. Interviews of clinical instructors (Hrobsky and Kersberger, 2002; Jervis and Tilki, 2011) revealed that they feel anxiety and fear to fail the students, tend to attribute the students' unsatisfactory performance to their teaching skill and are not confident with their decisions. Furthermore, the instructors tend to think it is too early to make a decision at the early stage of clinical practicum and are reluctant to fail students because of pressure from mature students, particularly if the students are older than the instructors. Additionally, instructors sometimes feel pressure not to fail students from schools even if the students do not meet standards. The evaluation of attitude is very difficult because of a lack of an objective assessment tool. Nurse educators who passed the students with special educational needs in this survey might also face difficulty in failing the students. Clinical evaluation by more than one educator, frequent information sharing among faculty, and agreeable evaluation standards may be needed for more accurate judgment. Furthermore, a follow-up investigation of students who have graduated with a concern and the evaluation of the effectiveness of re-enrollment in clinical courses may be needed. The most difficult learning situations reported by the nurse educators were nursing care and communication in clinical settings. Considering the future of their students, serious medical errors are the greatest concern. It is possible that such errors are prevented by meticulous attention of clinical instructors and educators during their clinical practicum. Nurse educators are responsible for identifying students at high risk for medical errors as early as possible and are expected to provide extra training or appropriate job guidance. According to a qualitative study of interviews of 22 preceptors (Luhanga et al., 2008), the hallmarks of unsafe practice as reported by the preceptors were “inability to

Y. Ikematsu et al. / Nurse Education in Practice 14 (2014) 674e679

demonstrate basic knowledge and skill,” “attitude problem,” “unprofessional behavior,” and “poor communication skill”. Though some of these behaviors may be improved by intensive instruction, additional behaviors such as “always go to the wrong patient” may indicate special educational needs. The relationship between a medical error tendency and clinical performance during school days should be investigated. The disabilities that this study investigated are known to have positive aspects on daily life. In considering those students' potential nursing careers, it is recommended that their strengths be considered in decision making. For example, dyslexic people are excellent in pattern recognition through visual information (Sauter and McPeek, 1993). Dyslexic nurses may be excellent in recognizing subtle changes of the patients' facial expression or physical signs. People with Asperger's syndrome are known to be outstanding in remembering a specific field of interest, and some are very skillful in computer operation. Nurses with Asperger's syndrome may assist administrative departments for census or surveillance data management. Considering these strengths, nursing students with developmental disorders can be candidates for the nursing workforce. However, a question arises. Do nurses who cannot initiate prompt action for rapid changes of their patients or nurses who cannot establish rapport with their clients despite intensive training truly perform “nursing”? If nursing is defined as “protection of health through diagnosis and treatment of human response,”(American Nurses Association, 2014), nurses need to perform resuscitation if there is cardiac arrest. Likewise, if nursing is defined as “caring,” (Leininger and McFarland, 2006; Travelbee, 1971; Watson, 2008), nurses need to be interested in their patients and feel empathy. These philosophical issues may need to be debated by nurse educators in the global community. This study has several limitations. The generalizability of this study may be limited because of the low response rate. It is possible that only nursing programs that experienced extremely difficult students responded, therefore causing selection bias. Additionally, not all extremely difficult students had their special educational needs scores reported. Furthermore, the scoring depended on the nurse educators' memory, which might not be highly accurate. Although the internal consistency of the battery was adequate, it was originally developed for school-aged children and may not be appropriate for use in young adults. Additionally, the validity of the original battery was never assessed, and it was difficult to assess validity in this current survey because of the retrospective design. Despite these limitations, this study is an important step toward defining nursing students who have special educational needs with traits relevant to developmental disorders. Nurse educators who face extremely difficult students may be struggling without a definitive solution. If those students have traits relevant to a developmental disorder, particular strategies can be adopted from various sources. We hope that this study will stimulate nurse educators' and researchers' interest in nursing students with special educational needs and will facilitate further studies.

Conflicts of interest The authors declare no conflicts of interest in this work.

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