The dyslexia disadvantage in nursing

Introduction

Dyslexia appears to be poorly considered or understood in the New Zealand nursing profession, as evidenced by the lack of research, literature and resources from a New Zealand perspective.

International literature appears to focus heavily on student nurses’ experiences during their academic studies and clinical placements, rather than that of qualified nurses navigating their way through clinical practice and employment.

New Zealand academic bodies, such as polytechnics, are beginning to consider and invest in research to understand and best support the needs of their neurodiverse learners. However, it is still unclear what support is accessible at an employment level, especially when nursing students become qualified new graduates.

The idea of exploring the subject of “nurses with dyslexia” was born after a summer of brainstorming to come up with a research topic I felt passionate about, to pursue in my third year of study.

Applying the PECOT framework,4 I narrowed in on a research question: “What are the barriers for nurses with dyslexia in clinical practice?” I explored literature from national and international contexts, but soon discovered that most of it was either outdated, under review, or purely focused on student nurses. Unfortunately, New Zealand-based literature on the topic was scarce or non-existent.

From what literature there was, I managed to identify three prominent barriers for nurses with dyslexia — individual barriers, employer barriers and resource barriers.

Why is this important?

Dyslexia is stigmatised, misunderstood and often perceived as a personal deficit, rather than a gift or an advantage. I, like many others, have historically labelled myself as “stupid”, which has self-limited my opportunities, making me wonder whether I had what it takes to become a qualified nurse.

I have chosen to explore this topic to highlight to the New Zealand nursing profession the barriers that nurses with dyslexia experience, as well showcasing the strengths of nurses with dyslexia. I hope to bring a new lease of life to the issue and advocate for those whose voices are not already projecting loudly enough.

I am optimistic that my efforts will pique the interest of employers, educators, researchers, and prospective nurses, to consider how the traits of dyslexia also align with the attributes of a top-shelf nurse (see Table 1 below).

What is dyslexia?

The word dyslexia breaks down into “dys = difficulty with” and “lexia = words”.5 Dyslexia is defined as an adaptable learning disability; it is also considered an alternative way of thinking, characterised by unexpected difficulties in numeracy and literacy.6 It is also described as a neurological difference that disrupts the efficiency of learning processes and performance in everyday life, education and work.

Dyslexia can negatively affect a person’s ability to plan, organise and adapt to change. It can also interfere with verbal and written communication.3 It is estimated that between 10 and 20 per cent of the New Zealand population experience some of the characteristics of dyslexia, which matches the international prevalence.7,8 A calculation based on that statistic suggests that anywhere between 5000 and 10,000 of the present 58,206 nurses in New Zealand might have some degree of dyslexia.9

In the 1990s, neuroscientists discovered that the left hemisphere of the dyslexic brain appeared to be underdeveloped.10 The left side of the brain is associated with language and word processing, which is why reading, writing, and language are challenging zones for people with dyslexia.10

In contrast, the right “visual” side of the dyslexic brain gifts people with dyslexia a “sea of strengths” in areas such as critical thinking, problem-solving, reasoning, vocabulary, general knowledge, empathy, comprehension and concept formation.3

Nurses with dyslexia could use their creative problem-solving skills to show ‘an exceptional understanding of patients’ individual needs and the wider nursing issues involved in nursing care’.

People with a dyslexic brain can be better at seeing the big picture than focusing on the finer details. They tend to excel at interconnected reasoning, having the ability to see things from multiple perspectives, or see connections others haven’t seen before. They tend to use “narrative reasoning” . . . “to remember facts as experiences, examples or stories, rather than abstractions”, with a strong ability to learn and reflect from experiences.11 Additionally, people with dyslexia have the ability to reason well in dynamic settings when the facts are incomplete or changing.11

In this light of these qualities, having dyslexia could afford a nurse some advantages. British nurse Jacqueline Wiles, writing in the Nursing Standard in 2001, argues that being dyslexic enhances a nurse’s ability to use “a multidimensional approach to patient care” and to “visualise a patient as an integrated whole. They can connect with a patient in ways that integrate the art and science of nursing”.12

She said nurses with dyslexia could use their creative problem-solving skills to show “an exceptional understanding of patients’ individual needs and the wider nursing issues involved in nursing care”.12

The individual barrier

The first theme arising from the literature is the individual barriers that originate from one’s own awareness, attitudes and perceptions of dyslexia. Self-labelling and society-labelling can cause detrimental effects on an individual’s confidence, restricting aspirations for future success.13

Society’s perceptions of dyslexia stem from the historical deficit ideology, that people with dyslexia are “stupid” or slow, an idea which remains in circulation today.

Self-labelling can sometimes be considered positively, as a way of empowering the individual so they can identify, acknowledge and reflect on the strengths, challenges and opportunities of dyslexia.14 Early identification, a formal diagnosis and tailored strategies can all promote positivity and positive results, such as achieving goals and feeling successful in education and at work.15

Some personal ownership and responsibility for their learning difficulty can help them manage the obstacles and challenges life may throw their way.16

The bespoke strategies used by people with dyslexia become concrete as they learn to grow and navigate through their world. In a nursing context, strategies include writing lists, double/triple-checking drug calculations, breaking down complex tasks into smaller parts, and using reflective practice to increase self-awareness.17

Dyslexia can also have negative implications for nursing practice — issues can include poor time management, writing notes beyond the clock-off time, or frequently making mistakes in practice.18 These examples show the need for further investigation to design strategies which enable individual nurses to practise safely and sustainably.

There is no evidence to suggest that people with dyslexia cannot cope with academic study to become qualified nurses.18 In fact, many successful dyslexic nurses are seen working in higher positions, such as Ruth May, the Chief Nursing Officer of England, who has only recently been diagnosed with dyslexia.19

 . . . strategies include writing lists, double/triple-checking drug calculations, breaking down complex tasks into smaller parts, and using reflective practice to increase self-awareness.

Lastly, the barrier of non-disclosure is a significant issue in the nursing profession. The literature suggests that the true statistics of nurses with dyslexia remain murky and under-reported. A significant contributor to non-disclosure is the individual’s fear of ramifications, such as discrimination and stigmatisation from their employer and colleagues.13, 39

Nurses’ failure to disclose their dyslexia can be a direct result of fears which have grown out of past negative experiences in education and employment.14 Dyslexic nurses, again, fear the stigma of being labelled as “stupid,” “slow,” or “high risk” by their colleagues, employer and the wider public.20

According to one research team, there is little evidence suggesting that nurses with disabilities compromise the care and safety of their patients,21 while another adds that dyslexic nurses are hypervigilant in practice, with evidence that they are more likely to double and triple-check drug calculations to prevent errors.22 This demonstrates the increased self-awareness and the safeguarding measures that nurses with dyslexia adopt to maintain safe and professional practice.

The employer barrier

The second theme from the literature is the relationship between the employer and the employee with dyslexia. Barriers such as negative historical experiences in the workplace, lack of employer awareness, and poor understanding of dyslexia inhibit opportunities for an individual to be transparent about their dyslexia.

Key findings from the employers’ perspective show a considerable lack of knowledge about dyslexia. A disheartening 55 per cent of workplaces feel that their understanding of dyslexia is poor or non-existent.23

The fact that an unknown number of nurses do not disclose their dyslexia at work impedes the employer-employee relationship, preventing honest communication and cutting the nurse off from potential support.

In New Zealand, under the Employment Relations Act 2000, health-care workers have rights that include freedom from discrimination, the right to employment relationships built on good faith, and the right to be treated with respect and dignity.24

Employees are responsible for communicating their needs to their employers under the Health and Safety Act 2020. At the same time, New Zealand employers have a responsibility under the Human Rights Act 1993 to initiate “reasonable accommodations” to meet the needs of their employees with disabilities.

Suggested examples of “reasonable accommodations” include modifying tasks, changing environmental ergonomics, normalising disabilities and supporting diversity in the workplace.25 Employers should consider multisensory education and training to meet the learning styles of their employees.18

 . . . dyslexic nurses are hypervigilant in practice, with evidence that they are more likely to double and triple-check drug calculations to prevent errors.

The development of workplace cultures that promote calm, supportive and open environments will lead to employees trusting they will not experience discrimination, which increases the likelihood of them disclosing their dyslexia.26

Lastly, employers need to recognise the value of the dyslexia advantage in the workplace. People with dyslexia possess talents in visual thinking and problem-solving and tend to have the ability to see the bigger picture and strong verbal communication skills.

Other traits include reading body language, collaborating as a team player, a curious imagination and a drive to succeed.27 These dyslexic traits have the potential to add immense value to the organisation.

Table 1: Dyslexia qualities vs nursing qualities

DYSLEXIA QUALITIES	NURSING QUALITIES
Reasoning skills	Communication skills
Critical thinking	Critical thinking
Problem solving	Problem solving
General knowledge	Humour
Comprehension	Time management
Concept formation	Vocabulary
Visual 3D thinking	Attention to detail
Seeing the bigger picture	Creativity/imagination
Think outside the box	Advocacy
Emotional intelligence	Empathy
Ambitious	Compassionate
Cooperative and collaborative	Open, accountable and committed
Easily grasps new concepts	Willingness to learn

The resource barrier

The third barrier identified in the literature involves opportunities and access to resources, such as best practice guidelines and adaptive technology. It is disappointing to report that there are no New Zealand-designed resources tailored for dyslexic nurses. International tool kits are over a decade old and are currently under review. Perhaps this is an opportunity for a New Zealand-designed resource to be developed for the nursing profession.

The Royal College of Nursing’s (RCN) Dyslexia, dyspraxia, and dyscalculia: a guide for managers and practitioners,28 although currently under review, includes critical points about employers’ legal, moral, and professional responsibilities; how to recognise and support staff with dyslexia; future recommendations; and other resources for information and support.

Complementary to that toolkit is the RCN peer support factsheet on nursing with dyslexia,29 with guidance on employing dictaphones, text-help, coloured papers, headphones, computer screen colour, voice recognition software, calculators, notebooks and diaries to help the nurse with dyslexia in the workplace.

Strategies such as writing shorthand, and using tick boxes, sticky notes and different coloured pens and paper are also helpful for nurses with dyslexia.22

Many successful dyslexic nurses are seen working in higher positions, such as Ruth May, the Chief Nursing Officer of England, who has only recently been diagnosed with dyslexia.

Another issue is the lack of guidelines for nurses in employment. Kingston University & St Georges University in London designed a resource that caters to the needs of nursing students and their preceptors during clinical placements.30 The information in this document could easily be transferrable to aspects of clinical practice to support both new and experiences nurses.

Lastly, the opportunity to harness technology such as adaptive equipment should be utilised, to make tasks such as reading and writing clinical notes less problematic and more empowering.

Another example of the technology barrier in nursing is the prohibition of personal smartphone use in clinical practice. The benefits of smartphone use in practice include quick access to information, a calculator, and accessible communication with other staff on duty.31

Another research study agrees that smartphones in practice should not be prohibited and should be accessible to support dyslexic students with challenges such as complex medical terminology.32

Although no hard-and-fast rules prevent nursing students in New Zealand from using smartphones on clinical placements, it is discouraged by some education providers and nursing schools.

One study found nursing students wanted to use smartphones in clinical practice to support their clinical decisions. However, nursing managers viewed the use of personal smartphones in practice as unprofessional behaviour and did not trust younger nursing students to act ethically when using this technology.33

Limited access to technologies can be due to senior staff’s lack of interest and dedication in promoting it.26 The opportunities to access this valuable technology will vary between health-care organisations, perhaps due to their policies, budget constrictions and their ignorance of the benefits.

Technology use should be embraced and promoted in practice to support and empower nurses with dyslexia. Outdated policies and procedures, such as discouraging the use of smartphones, should be challenged to break down another unnecessary barrier.

Increasing awareness

The first recurring recommendation from the literature is the need to increase awareness of dyslexia in the nursing profession. A multi-faceted approach, from individuals, employers, educators, mentors and peers, is required to create an open, trusting, supportive and inclusive environment for the diverse nursing workforce.21

Creating inclusive workplaces helps nurses feel safe and supported to disclose their dyslexia diagnosis.34 Establishing clear structures and routines, and forming small cohesive nursing teams, improves the confidence and performance of nurses with dyslexia.35 Providing education to all staff about dyslexia and other neurodiversities can increase their understanding, strengthen teamwork and communication, and reduce frustrations or stress.32

Other suggestions for designing a dyslexia-friendly workplace include: increasing the lighting, providing dyslexia-friendly signs and documents printed in different colours, and using the latest technology.35,36

Future research

There is ample literature on nursing students with dyslexia, yet there has been  minimal investigation into how qualified nurses work with dyslexia in clinical environments.17,35 Further investigation of dyslexia in the qualified nursing profession is warranted.

Looking at dyslexia among Māori and Pasifika nurses could unearth new information, such as the prevalence and impacts on these population groups.

One study considered the ethical dilemma of researching “vulnerable” dyslexic nurses, with the findings suggesting that they fear the risk of being identified, which outweighs the overall benefits of research participation.37

New Zealand has a golden opportunity to explore research pathways that are relevant and custom-designed to this country’s nursing profession. Looking at dyslexia among Māori and Pasifika nurses could unearth new information, such as the prevalence and impacts on these population groups. Investing in the interests of Māori and Pasifika populations shows commitment to te Tiriti o Waitangi and would create a model for other international research on indigenous groups with dyslexia.

Conclusion

The impending threat of a global nursing shortage of nine million nurses and midwives by 203038 means that now is the critical time to re-think and reflect on current practices, to support increasing neurodiversity in the nursing profession.

A strengthened partnership that intertwines individual nurses, educators, employers, and broader organisational structures is required to address the barriers dyslexic nurses face in clinical practice. Initiating conversations and raising the profile of dyslexic nurses will lead to opportunities that will enhance individuals’ success and improve the quality of health-care service delivery. It is an opportunity to strengthen, support and retain the current nursing workforce and promote nursing as a highly desirable and accessible profession for the prospective dyslexic nurse.

Lastly, the advantages of nurses with dyslexia, such as alternative ways of thinking, narrative reasoning and empathy, all bring new ideas and perspectives to refresh current nursing practice.

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Laura MacDonald is a third-year nursing student from Dunedin, who has just finished her final nursing placement, and is now focusing on the final hurdle, which is the state final exam.

* This article was reviewed by Marg Hughes, RN, PhD, a nursing lecturer at Ara Institute of Canterbury, who has an interest in nurses working with disabilities.

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