1-SUMMARY of the information you found in that specific source. The summary section gives your reader an overview of
the important information from that source. Remember that you are focusing on a source's method and results, not
paraphrasing the article's argument or evidence. The questions below can help you produce an appropriate, scholarly
summary:
● What is the topic of the source?
● What actions did the author perform within the study and why?
● What were the methods of the author?
● What was the theoretical basis for the study?
● What were the conclusions of the study?
Remember, a summary should be similar to an abstract of a source and written in past tense (e.g. "The authors found
that…" or "The studies showed…"), but it should not be the abstract, written in your own words.
2-CRITIQUE/ analysis of each source. In this section, you will want to focus on the strengths of the article or the study
(the things that would make your reader want to read this source), but do not be afraid to address any deficiencies or areas
that need improvement. The idea of a critique is that you act as a critic—addressing both the good and the bad.
In your critique/analysis, you will want to answer some or all of the following questions
●
●
●
●
●
●
●
●
●
●
●
●
●
●
Was the research question well framed and significant?
How well did the authors relate the research question to the existing body of knowledge?
Did the article make an original contribution to the existing body of knowledge?
Was the theoretical framework for the study adequate and appropriate?
Has the researcher communicated clearly and fully?
Was the research method appropriate?
Is there a better way to find answers to the research question?
Was the sample size sufficient?
Were there adequate controls for researcher bias?
Is the research replicable?
What were the limitations in this study?
How generalizable are the findings?
Are the conclusions justified by the results?
Did the writer take into account differing social and cultural contexts?
3-APPLICATION-justify the source's use and address how the source might fit into your own research. Consider a few
questions:
● How is this source different than others in the same field or on the same topic?
● How does this source inform your future research?
● Does this article fill a gap in the literature?
● How would you be able to apply this method to your area of focus or project?
● Is the article universal?
Remember, annotated bibliographies do not use personal pronouns, so be sure to avoid using I, you, me, my, our, we, and
us.
99
International Journal of Learning, Teaching and Educational Research
Vol. 15, No. 11, pp. 99-110, October 2016
A Qualitative Study of the Perceptions of Special
Education Personnel about Inclusive Practices of
Students with Disabilities
Jeanine Birdwell, EdD, Lori Kupczynski, EdD (corresponding author), MarieAnne Mundy, EdD and Steve Bain, DMin
Texas A & M University-Kingsville
Center for Student Success
700 University Blvd.
Kingsville, TX 78363
Abstract. Students with disabilities in the State of Texas are now
required to participate in state wide academic assessments with passing
rates tied to federal funding. This qualitative research studied the
perceptions of district personnel regarding instructional practices for
students with disabilities utilizing open-ended, semi-structured
interviews of a principal, special education director, diagnostician, and
special education teacher from each of two districts. District 1
exclusively used the inclusion model while District 2 used a
combination of inclusive and pull-out programs to provide special
education services. The interviews were analyzed utilizing coding which
generated the following themes: the importance of positive relationships
between general and special education educators and between students
and teachers, individualization of the needs of each student, and the
importance of the availability of resources such as appropriate staff and
dedicated time on the successful implementation of inclusion.
Keywords: Texas education; student disabilities; inclusion; educational
resources
Introduction
Ensuring that every student has access to general education curriculum
rather than equitable curriculum through placement in general education
classrooms is considered an issue of social justice (Turnball, 2012). Increased
focus on state wide assessments and accountability for every individual student
has caused districts to reconsider best practices for instruction and placement of
students with disabilities. In addition, there is no clear guideline to demonstrate
successful implementation of such services. Districts with special education
populations demonstrating low performance levels benefit from implementation
of alternate service models and inclusion style services in the general education
classroom. Students with disabilities who receive academic support and services
© 2016 The authors and IJLTER.ORG. All rights reserved.
100
to ensure their academic success are impacted by this problem. Contributing to
this problem are many possible issues including support services dedicated to
inclusion implementation and educational placement. This study contributes to
the research knowledge base necessary to address this issue by gathering
qualitative data to reveal successful and unsuccessful inclusive practices in high
schools in South Texas districts 4A and larger as expressed by school principals
and lead special education personnel. The University Interscholastic League
(2016) assigns school districts in Texas a classification ranging from 1A-6A based
on student enrollment.
Review of Literature
No Child Left Behind (NCLB) state level accountability standards and
systems for mathematics and reading were developed and implemented with
the intention that every student would have and maintain proficiency in both
math and reading by the 2013-14 school year. Administrators are also required
to examine the annual progress of student subgroups, including those with
disabilities. NCLB was an active force in convincing administrators to assess the
importance and necessity of access to general education curriculum in the
general education setting for all students. Students with disabilities, if they are to
be expected to meet statewide assessment standards, need access to regular
education curriculum (Ross-Hill, 2009). The Individuals with Disabilities
Education Act (IDEA) and NCLB push the need for inclusive instruction. The
triumph of both laws hinges on the expertise and mindset teachers portray in the
classroom (Ross-Hill, 2009). Few educators would disagree with federal law, but
instructional practices may not reflect that ideology. While general education
teachers may be supportive of inclusion in theory, most of them do not feel that,
in practice, they can integrate students with disabilities successfully into their
classrooms (Santoli, Sachs, Romey & McClurg, 2008).
Least Restrictive Environment
The principle of least restrictive environment (LRE) is a critical
component of the Individuals with Disabilities Education Act. LRE necessitates
that children with disabilities be educated alongside students who do not have
disabilities as much as possible. Aron and Loprest (2012), found that 95% of
students with disabilities are in public schools, but they are outside the general
education classroom. As a student reaches high school, he or she is more likely
to be removed from the general education (Aron & Lomprest, 2012). Inclusion
becomes increasingly difficult at the high school level due to course content and
curriculum complexity, instruction models, achievement gaps, high stakes
testing, and accountability to outside agencies like colleges (Rice, 2006; Keefe &
Moore, 2004; Dieker, 2001; Mastropieri & Scruggs, 2001).
Inclusion
The principle of inclusion requires that all students have the opportunity
to participate in society, or in the case of education, the general education
setting. Critics of this notion argue that the strengths and weaknesses of the
child must be considered along with the environment. Each student has a
different level of capacity (Lindsay, 2003). Inclusive education refers to the
dedication to educate students with disabilities, to the appropriate maximum
extent, in the general education classroom he or she would traditionally attend.
Inclusion involves providing needed instructional and/or related services to the
© 2016 The authors and IJLTER.ORG. All rights reserved.
101
child and involves only that the child advances from being in the class (Yell,
2006). In accordance with the principle of least restrictive environment, inclusion
suggests that students with disabilities are placed in the general education
classroom with needed supplementary aids and services. Students are only
removed from that setting if necessary services cannot be provided in the
general education setting. There are many benefits to inclusion for all students,
but without proper implementation and support it can be a frustrating process
for all stakeholders (Hammel & Hourigan, n.d.).
In the general education
setting, special education students are often held to higher educational
standards and develop better social skills (Ripley, 1997).
Special Education Service Models
Models for special education services are best described as being a
continuum of services and placements. A commonly misunderstood principle is
that the least restrictive environment for all students is the general education
classroom. While the regular education classroom may be the least restrictive
environment within the special education continuum, it may not be the best
environment for every student with a disability. In many individual cases, in
order to meet a student’s needs a variety of potential placements and services
may be required (Farris, 2011; Lindsay, 2003). Variations on placements and
services include: a student with a disability may be placed in the general
education classroom with the general education teacher meeting all needs; or a
special education teacher may serve a consultant style role within the general
education classroom or may be more extensively involved in the delivery of
services. This model is known as co-teaching or the collaborative teaching
model. In this particular model, services are delivered in the general education
setting with seldom removal of the student from that environment for service
participation. In the resource model, a dedicated special education class is
attended as needed while a significant portion of the day is spent in the general
education setting. The self-contained model requires students to spend minimal
time within the general education setting with the majority of services being
delivered in a dedicated special education setting or classroom. This model is
typically reserved for students for which inclusion has proved unsuccessful and
leverages the advantages of small group instruction and increased attention
from educators.
Research from 2000-present
The attitude of the general education teacher towards inclusive practices
is a key factor in implementation of inclusion (Daane, Beirne-Smith & Latham,
2000; Henning & Mitchell, 2002). Henning and Mitchell (2002) noted that,
“teacher perceptions about exceptional students may be the factor with the
greatest effect on student success” (p.19). In 2000, Daane, Beirne-Smith, and
Latham looked at the perceptions of both administration and teachers regarding
the collaboration process of inclusion in elementary grade levels. All parties
participating in the study agree that students with disabilities have the right to
education in the general education setting. Conversely, all parties also agreed
that instruction for students with disabilities in the general education setting
was not effective due to concerns with preparedness of the general education
teacher, discipline concerns, and workload for the general education teacher.
© 2016 The authors and IJLTER.ORG. All rights reserved.
102
Research conducted by Ramirez (2006) and Smith (2011) also supports
the findings that the majority of administrators believe that special education
students have the right to be educated in the general education environment at
the cost of academic benefits. A series of qualitative interviews conducted by
Daane, Bierne-Smith and Latham (2000) and Mulholland & O’Connor (2016)
revealed that teachers believe more collaboration is necessary between general
education and special education teachers regarding student individualized
education plans (IEPs) and instructional planning for the inclusion process to be
more effective. Collaboration is critical for successful implementation of
inclusion and should include all stakeholders: administration, general education
teacher, special education teacher, counselor, social worker, related service
providers, paraprofessionals, and family (Salend, 2005). Collaboration is an
ongoing process and all parties must be open minded participants for the
development of a comprehensive plan (Daane et al, 2000).
General educators need more guidance on curriculum differentiation,
and the implementation of accommodations and modifications. However,
scheduling conflicts, lack of knowledge, and lack of time often impede
collaboration time (Daane et al, 2000) (Worrell, 2008). Muholland and O,Connor
(2016) found that their teachers endorsed time restraints as a limitation to
collaboration. According to Rice (2006), teachers are also concerned with the
legal, ethical, pedagogical, and procedural aspects of IEP implementation.
Legally, general education teachers become responsible for ensuring the service
times specified in the IEP are being met. A solid foundation in special education
laws, issues and terms, is critical for the general education teacher to
successfully implement an IEP (Liston, 2004; Worrell, 2008). Principals need
understanding of legal regulations, legislation, and practices regarding students
with disabilities, as well (Lasky & Karge, 2006).
Lack of training on effective implementation of accommodations and
modifications is a frequently reported issue (Galano, 2012; Rice, 2006). Galano
(2012) noted that teachers’ attitudes towards inclusion are significantly
correlated to the level of training. Shoulders and Krei (2016) found that the more
hours general education teachers spent in professional development and coteaching the higher the efficacy in student engagement. Similarly, limited
training in special education also resulted in principals having negative views of
inclusion (Galano, 2012). Santoli et al. (2008) found a group of Southeastern
middle school teachers who felt confident in their teaching strategies and
collaborative strategies in working with special education students, increasing
the likelihood of successful implementation of inclusive practices.
Without a positive attitude towards academic outcomes, teachers are just
going through the motions. There is a significant relationship between teacher
expectations and student success (Henning & Mitchell, 2002; Santoli et al., 2008).
Monsen and Frederickson (2004) also identified that special education students’
performance on standardized test scores is directly correlated to the attitude of
their general education teachers and their teachers’ view on inclusion.
The effectiveness of educational inclusion services can be influenced by
the campus administrator (Praisner, 2003). In her research with elementary
school principals, Praisner found that implementation of inclusive practices
occurred more frequently when the principal had positive views of inclusion.
© 2016 The authors and IJLTER.ORG. All rights reserved.
103
Galano (2012), Ramirez (2006), and Smith (2011) also found a correlation
between the promotion of inclusive placements and principal’s attitude.
Role of the Campus Administrator in Inclusion Implementation
With the growing implementation of inclusion services, the role of the
principal is widened to include more paperwork, an increase in the number of
personnel needed, and therefore more duties (Praisner, 2003). Administrators
can lead in a way that maintains status quo, or lead in a way that promotes
social change. Strong leaders build relationships in the community and build
capacity of a campus team. These relationships allow for the implementation of
practices that foster a culture that supports diverse learners (Riehl, 2000).
Principals promote inclusion in their actions, words, interests, activities, and
organization of staff and resources. Villa, Thousand, Nevin & Liston (2005)
described that the degree of administrative support for inclusive practices was
the strongest predictor of the attitude of the general education teacher towards
inclusion. Support can be provided in the form of school climate (Cook, Semmel,
& Gerber, 1999), opportunity for collaboration (Barnett & Monda-Amaya, 1998),
or professional development (Shade & Stweart, 2001).
Dieker (2001) described successful inclusion implementation has hinging
on six co-teaching practices. First was a positive climate between students and
teachers supporting an attitude of acceptance through cooperative learning.
Secondly, inclusion is only accepted primarily through the staff’s positive
perception. Additionally, active student centered learning is necessary to help
create an environment with engaged students while allowing for peer tutoring
opportunities. Further, accommodation integration can be achieved through
activity based instruction. High academic and behavioral expectations for every
student are necessary as well. Mutual planning time between co-teachers must
also be used effectively to plan lessons. Finally, multiple evaluation methods
such as written assessments, presentations and projects in addition to
performance tasks should be used to gauge student learning.
DiPaola and Walther-Thomas (2003) identified skill areas critical for
principals in ensuring growth of student with special needs. Principals must
have knowledge of each disability along with the learning, behavioral or medical
challenges of each. In addition, they must possess thorough knowledge of laws
and educational rights of special needs students so that they may communicate
with families. Equally important, principals lead the implementation of research
based teaching practices on campus. Lastly, principals need a clear
understanding of the supports necessary to make inclusion successful (DiPaola
& Walther-Thomas, 2003). They are responsible for securing support services,
supplies and necessary resources (Frederico, Herrold, & Venn, 1999).
Methodology
Two high school principals from a 4A or larger district in the South Texas
region and six lead special education personnel from each of those districts were
interviewed. The qualitative data was coded for themes to determine successful
instructional practices in regards to students with specific learning disabilities.
Population and Sample
The researcher began interviews by selecting two high school principals
from 4A or larger high schools in the South Texas region. Next, interviews were
© 2016 The authors and IJLTER.ORG. All rights reserved.
104
conducted with six lead special education personnel recommended by the
principal from the district. Principals and lead special education personnel were
selected through purposive sampling. The purposive sampling in this study is
informational in nature in order to capitalize on the strengths and weaknesses of
inclusion programs in Texas high schools 4A and larger in the South Texas
Region. Principals and lead special education personnel were selected based on
their involvement with special education students on the high school campus.
The purpose of interviewing the principals and lead special education personnel
from each district was to identify their perceptions of successful instructional
practices for students identified with specific learning disabilities. Each district
has autonomy in developing service models for special education services,
allowing for differences in instruction and therefore achievement.
Instrumentation
The study involved the gathering of data through open-ended, semistructured interviews with purposefully selected participants. This
questionnaire was composed of twelve open-ended questions. The purpose of
the questionnaire was for participants to express their experiences with inclusive
practices with students with disabilities and to share their opinions about
practices that contribute to successful implementation of instruction for students
with disabilities.
Interview Protocol:
1. What is your position with the district and how many years of experience
do you have?
2. Are you familiar with the terms inclusion, resource, and co-teaching?
3. If so, how would you describe each one?
4. What instructional service models are used in this district?
5. What is your role in the implementation of services for students with
learning disabilities?
6. How does the district implement inclusive instructional support?
7. What have been your experiences with inclusion and resource
instruction?
8. What do you think are the factors that contribute to successful
implementation of inclusion services?
9. What do you think are the biggest obstacles in implementation of
inclusion?
10. Do you believe that instructional setting affects academic success of
students with specific learning disabilities? Why or why not?
11. What is your ideal vision of instructional services for students with
specific learning disabilities?
12. Are there any comments you would like to add?
Procedures and Data Analysis
Data was gathered by conducting one-on-one interviews with selected
participants. The participants were asked to provide their personal experiences
in response to the interview questions. A digital audio recorder was used to
record the entire interview in order to ensure accuracy. The digital recording for
each interview was saved in an audio computer file and transcribed. The data
was analyzed through descriptive coding.
© 2016 The authors and IJLTER.ORG. All rights reserved.
105
Results
District Profiles
District 1 is a large district in the South Texas region. Based on the 2014
State of Texas Assessment of Academic Readiness End Of Course (STAAR EOC)
data, the special education population is 9% of the district population and 77%
of the students are economically disadvantaged. This district is predominately
Hispanic (94%). Figure 1 summarizes the ethnic breakdown of the student
population.
District 1
[CATEGORIENAAM
]
5%
Other
1%
Hispanic
White
Other
[CATEGORIENAAM
]
94%
Figure1: Ethnic Groups of District 1
District 1 used the inclusion model to provide services to students with
learning disabilities. Interviews revealed that inclusion services were provided
by either a special education certified teacher or a paraprofessional and that
most students were served in English and/or Math for twenty to thirty minutes
three days per week.
District 2 is also a large district in the South Texas region. Based on the
2014 STAAR data, 10% of the district population receives special education
services and 41% of the district is economically disadvantaged. District 2 is
predominately Hispanic (56%). Figure 2 illustrates this information.
© 2016 The authors and IJLTER.ORG. All rights reserved.
106
District 2
[CATEGORIENAAM
[CATEGORIENAAM
]
]
1% [CATEGORIENAAM
.3%
]
2%
Hispanic
[CATEGORIENAAM
]
40%
White
[CATEGORIENAAM
]
56%
African American
Asian
Native American
Figure 2: Ethnic Groups of District 2
Participants from District 2 reported using a combination of coteaching, other inclusive practices, and resource support to provide services for
students with learning disabilities. Co-teaching was done by two certified
teachers five days per week for the entire class period. Inclusion support was
provided by a certified teacher or a paraprofessional. Frequency and duration
ranged, and depended on the needs of the student. Resource services were
provided in a location other than the general education classroom. The class was
taught by a teacher who is certified both in the content area and in special
education.
Seven female and one male participated in the semi-structured
interviews. Ages ranged from 34-63. Two of the female participants were
Hispanic, and the other participants were Caucasian. Table 1 presents the
pseudonym, position and district for each participant.
Table 1: Research Participants
Interview #
Participant
1
2
3
4
Dan
Sue
Jan
Cindy
5
6
7
8
Amy
Mary
Elizabeth
Ann
Position
District
High School Principal
Special Education Director
Educational Diagnostician
Lead Special Education
Teacher
High School Principal
Special Education Director
Educational Diagnostician
Lead Special Education
Teacher
1
1
1
1
2
2
2
2
Both principals defined the terms inclusion and co-teaching in similar
ways. Inclusion was seen as a classroom composed of both general education
students and special education students of varying instructional levels. Primary
© 2016 The authors and IJLTER.ORG. All rights reserved.
107
delivery of instruction is performed by the general education teacher with a
special education teacher or paraprofessional as a support system. In coteaching, “both teachers deliver the primary lesson” and students have the
opportunity to “learn in two different ways”. It was explained that teachers in
this model have “the same conference time to plan together” in order for both
teachers to be “on the same page”. Personnel in special education agree that coteaching and inclusion both involve the education of special education students
in the general education setting with some instruction provided by a special
education teacher or paraprofessional.
The recurring idea shared by the six special education professionals is
that theirs is a role of support. Directors support services by providing training
opportunities and sending staff to workshops. Diagnosticians and special
education teachers support general education teachers in a variety of ways.
Special education teachers support all students in the classroom by “re-teaching,
redirecting, and varying instructional strategies”.
The theme of relationships emerged as the primary factor affecting
successful inclusive practices. Both principals reported that the relationship
between the general education teacher and the special education teacher is the
leading predictor of whether inclusion will be successful. Special education
personnel agree. Successful inclusive practices depend on the “attitude of the
general education teacher.” “The teachers have to be willing to learn new
instructional strategies and willing to accommodate for our students.” The
special education teachers also stressed the importance of building relationships
with the special education students in the classroom.
All personnel interviewed spoke frequently of the importance of
individualization when it comes to the education of special education students.
Both principals agreed that individualized supports should be in place for each
student, and that some students require a smaller setting to find their “comfort
zone” and address their “learning style.”
The most important limiting factor in the implementation of inclusion
identified by all respondents was time. All participants stressed that it is crucial
for inclusion and general education teachers to have a common planning time
for inclusion to be a success, but that scheduling and the master schedule were
obstacles.
The participants also spoke of needing more staff to implement services.
According to one participant, “some of our teachers are supporting three
different teachers. It is hard to plan and have any ownership of that many
classrooms.”
Money and time also affect the ability of the districts to provide training
to their teachers. All respondents voiced a need for increased training.
Respondents noted that training for general education teachers is needed to
ensure understanding of the inclusion models and disability education.
Conclusions
Several themes emerged from the semi-structured interviews. All
participants discussed the importance of relationships in successful inclusive
practices. Relationships must be developed between general education and
special education teachers, as well as between teachers and the students. The
© 2016 The authors and IJLTER.ORG. All rights reserved.
108
second theme was the need for individualization in making decisions regarding
educational settings for students with learning disabilities. Participants agreed
that the needs of each student must be considered individually, on a case-bycase basis. Participants also agreed that the availability of resources limits the
successful implementation of inclusion. Specifically, time and staff were named.
Time is necessary to develop collaborative relationships between teachers and
between teachers and students, and to plan for instruction. Lastly, respondents
voiced a need for training for both general education and special education
teachers. Topics included the implementation of accommodations and
modifications and the nature of disabilities for general education teachers, and
content area curriculum for special education teachers.
The findings of this study suggest that there is no one size fits all model
for all students with learning disabilities. Participants in this study expressed the
idea that a continuum of services be available to meet the needs of each student.
The results of this study provide information to be used by lead special
education personnel, Administrators, and Admission, Review, and Dismissal
committees as they seek to meet the needs of every student including students
with disabilities. This research suggests that instructional arrangements, or the
placement of a student with a disability in general education or resource
classrooms, may not be a significant factor contributing to academic
achievement for students with disabilities. This study limited qualitative data to
interviews with administrators and lead special education personnel in each
district. Future research could include perspectives from other stakeholders such
as general education teachers, parents, and students.
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www.uiltexas.org/about.
Villa, R., Thousand, J., Nevin, A., & Liston, A. (2005). Successful inclusive practices in
middle and secondary schools. American Secondary Education, 33(3), 33-50.
Worrell, J. (2008). How secondary schools can avoid the seven deadly "sins" of inclusion.
American Secondary Education, 36(2), 43-56.
Yell, M. (2006). The law and special education (2nd ed.). Upper Saddle River, NJ: Merrill.
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Available online at www.sciencedirect.com
ScienceDirect
Procedia - Social and Behavioral Sciences 204 (2015) 81 – 87
4th World Congress on Technical and Vocational Education and Training (WoCTVET), 5th–6th
November 2014, Malaysia
Implementation of Inclusive Education For Special Needs Learners
with Learning Disabilities
Maizatul Azmah Ab.Latiff a, Wan Azlinda Wan Mohamedb, Mohd Azrani Asranc*
a,b
University Tun Hussein Onn Malaysia, Batu Pahat, 86400, Malaysia
Sekolah Kebangsaan Putrajaya18(1), Putrajaya, 64150, Malaysia
c
Abstract
Conducting interviews is a very important qualitative research technique that helps researchers obtains answers from respondents
by exploring their perspectives on a particular idea, program, or situation. In this study, the researchers would like to explore the
implementation of inclusive education in Special Education Program Integration with Learning Disabilities in primary school.
Specifically, this study aims to identify the form of implementation of the program, the form of collaboration and adaptation
performed by the subject teacher and resource teacher. To achieve the purpose of the study, the researcher designed structured
interview questions for the principal, senior assistant special education teachers, subject teachers and resource teacher. Interview
questions were then pilot tested in a primary school in the state of Malacca. Two administrators and two teachers who were
involved in the Inclusive Education Program have been selected to be interviewed in this pilot test. Structured interview data
were analyzed. Based on the interview, 68 units of themes have been established. These analyzed data were given to three experts
to evaluate. Cohen's Kappa index for the validity and reliability of the interview questions were used and Cohen's Kappa
coefficient of agreement at 0.7 was obtained. Thus, the set of interview questions is found to be suitable for this study. In addition
to this structured interview, the study will also be supported through other findings such as observations and document analysis.
©
Published byby
Elsevier
Ltd.Ltd.
This is an open access article under the CC BY-NC-ND license
© 2015
2015The
TheAuthors.
Authors.Published
Elsevier
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer-review
under
responsibility
of
Faculty
of
Technical
and Vocational
Education,
University
of TunOnn
Hussein
Onn Malaysia.
Peer-review under responsibility of Faculty of Technical
and Vocational
Education,
University
of Tun Hussein
Malaysia.
Keywords:Qualitalive research, Structured Intervie, Inclusive Education Program, Cohen’s Kappa Index
* Corresponding author. Tel.:+06-016-9294129; fax:+06-03-88886659
E-mail address:maizatulazmah@yahoo.co.uk
1877-0428 © 2015 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).
Peer-review under responsibility of Faculty of Technical and Vocational Education, University of Tun Hussein Onn Malaysia.
doi:10.1016/j.sbspro.2015.08.115
82
Maizatul Azmah Ab.Latiff et al. / Procedia - Social and Behavioral Sciences 204 (2015) 81 – 87
1. Introduction
Inclusive Education Program in Malaysia began in 1962, 1988 and 1999. These differences in years are based on
the type of target students with special needs. In 1962, the Inclusive Education Program was implemented for
visually impaired students (Tambi, 1997). In 1988, the program was implemented in Special Education Integration
Program with Learning Disabilities (Bosi, 2004). This program is the largest contributor to increase enrollment in
Inclusive Education Program now. In 1999, Inclusive Education Programs was implemented in technical schools
(Shaari, 2005). In Malaysia, the Inclusive Education Program is an education program for students with special
needs who are educated in a regular class at government schools or non-government schools for nearly all of the
day, or at least for more than half of the day (Malaysia, 2013).
Studies related to the Inclusive Education Program in Malaysia are not new. Several researchers in previous
studies have conducted it with a different focus. Some of the studies include, “The Perceptions of Inclusive Practices
in Malaysia” (Jelas, 2000); “Malaysian Preschool Children with ADHD in Inclusive Setting” (Saad, 2003); “Pilot
Study Implementation of Inclusive Education in Malaysia (Bosi, 2004); “Pilot Study on the Commitment and The
Role of Teachers in The Implementation of the Approach to Inclusive Education in Malaysia (Saad, 2005); “The
Management of Inclusive Education Program in Technical and Secondary Day School” (Shaari, 2005); and “A case
Study on Inclusive Education Program Implementation for Autistic Pupils at a Primary School” (Muhammad &
Mahmud., 2010).
In 2013, a guideline was issued by the Ministry of Education. This guideline briefly describes the procedure for
placing pupils in inclusive classes, the age of pupils involved, the typical ratio of pupils and students with learning
disabilities in the inclusive classroom, and the responsibilities of relevant parties (in school) in the implementation
of Inclusive Education Program. This study will use this guideline to explore the implementation of Inclusive
Education Program in Malaysia. This study will only focus on Special Education Integration Program with Learning
Disabilities in primary schools. Since most of the research on Inclusive Education program uses quantitative
research and/ or mixed methods research, the researchers felt the need to conduct a full qualitative research. This is
because in qualitative research, there are various forms of interview design that can be developed to obtain thick,
rich data utilizing a qualitative investigational perspective (Creswell, 2007).
In this study, the researchers will design a set of interview questions to obtain information from the respondents.
Through the interviews, the researchers will have in-depth information relating to the experiences and views
respondents by exploring their perspectives on the implementation of inclusive education in Special Education
Program Integration with Learning Disabilities in the primary school. The interview was conducted as a pilot study
to test the validity of a set of questions developed by the researchers. The pilot study was conducted at School A,
Merlimau, Malacca.
The interviews became a key instrument in the study of the implementation of Inclusive Education in Special
Education Integration Program with Learning Disabilities. Thus, the set of questions must be valid and reliable in
order to answer the research objectives effectively. Other than testing the validity of the questions by verifying them
through the agreements of experts, themes from the findings in interviews were also established.
2. Purpose and objectives
The purpose and the objectives of the study is as follows.
2.1 Purpose of study
The purpose of this study is to design a set of interview questions for qualitative research. The set of
questionnaires will be validated in a pilot study. This validated interview questions will be used in the study to
explore the implementation of Inclusive Education Program in Malaysia. Among the questions posed in this study
are:
i)
ii)
How do teachers implement the Inclusive Education Program?
What forms of collaboration can occur in the implementation of the Inclusive Education Program?
Maizatul Azmah Ab.Latiff et al. / Procedia - Social and Behavioral Sciences 204 (2015) 81 – 87
iii) What are the adaptations made by subjects’ teacher and resource teacher to the implementation of Inclusive
Education Program?
2.2 Objectives of the study
The objective of this study is to:
i) Test the validity of the set of interview questions set by the researcher
ii) Establish the themes of study from the findings of the interviews
iii) Obtain the agreement of experts in order to validate the set of interview questions
3.
Research design
Qualitative research design can be complicated depending on the level of experience the researcher may have
and with particular type of methodology. As researchers, efforts to develop and expand knowledge and experience
in the form of qualitative research is very necessary in order to better utilize a variety of research paradigms for
further investigations (Tuner, 2010).
In qualitative research design, an interview protocol is one area of interest to researchers. Interviews help
researchers collect in-depth information on respondents’ views and experiences on a particular idea, program, or
situation. In fact, in order to strengthen the findings from interviews, researchers usually makes additional data
collection such as through observation and document analysis.
Pilot tests should also be carried out to help researchers determine whether there is a weakness, limitation, or
other flaws in the set of interview questions. Through the pilot test, the researchers can check and improve the set of
questions before performing the actual study (Kvale, 2007). The pilot test will also help researchers refine research
questions.
The place of study chosen should be simple and not complex (Yussof, 2001). This allows researchers to make
more frequent visits, observations and interviews at the school and save time. Respondents should be carefully
selected for an interview (Creswell, 2007Ϳ. Researchers should also conduct a pilot study on respondents who are
prepared in an open and honest sharing of information or "their story" (p. 133). This is because the interview is
easier done in a comfortable environment in which respondents can share the information.
3.1 Research Instruments
Research instrument is a device used to measure the variables studied (Konting, 2009). With this instrument, the
study is more systematic, organized, focused and have high reliability (Merriam, 2001). In this study, the main
instrument is the researchers. This is because the study was carried out based on the thinking of researchers
(Yussof, 2001). According to Miles and Huberman (1994), researchers should get a better understanding of making
data interpretation because of the dynamic interaction between researchers and informants.
3.1.1 Interview
In this study, the researchers choose the structured interview technique because it is suitable for this research. In
addition, the structured interview gives more space for the respondents to express their opinion on the scope
required. Structured interviews are given consistently to several respondents. Thus, the answer given by the
respondents is consistent in the scope of the question. The questions' construction is relatively easy to build. The
researchers use protocol questions as proposed by Hill, Knox, Thompson, Williams, Hess and Ladany ( 2005),
Protocol questions are a list of questions prepared by the researchers to find answers to the research questions.
Protocol questions are arranged according to:
a) Introduction questions
b) Transition questions
c) The key question
83
84
Maizatul Azmah Ab.Latiff et al. / Procedia - Social and Behavioral Sciences 204 (2015) 81 – 87
d) Closing questions
However, the researchers will also provide additional follow-up questions for the respondents when more
information is needed (probing questions). According to Berg (1995), additional questions will provide additional
reliability to respond to repeated topics and responses that have been given. This interview was also conducted with
flexibility to respondents and is not subject to the order of questions in the interview protocol (Merriam, 2001Ϳ͘The
questions used were "open-ended" questions. This is because the research questions should be effective and have the
five elements: the words should be open; the question must be as neutral as possible; the question must be asked one
by one; the question must be clear; and be cautious when asking the "why" questions (McNamara, 2009).
In this pilot study, interviews were carried out to the principal, senior assistant special education teacher, subject
teachers and resource teacher. All interviews were then analysed using NVivo8 software.
3.2 Data Collection
School A, Merlimau Malacca has been selected as the pilot school to test the validity of the interview questions.
Interviews were carried out with the principal, senior assistant special education teacher, subject teacher and
resource teacher. Each interview takes approximately 45 minutes to 2 hours. All interviews are recorded using a tape
recorder and video recording.
3.3 Data Analysis
Data analysis is the process of making sense of the data collected (Merriam, 2009). If the data is not analysed,
the data collected will not bring any meaning. Researchers also need to analyse the data each time the data is
collected (Miles & Huberman, 1994). This shows that the process of data analysis is an on-going process.
In this study after the data is collected, the data is analysed. Data in the form of speech and actions of
respondents are collected were then transcribed into word (verbatim). Researchers will conduct data screening
(select, focus, simplify, abstract, changing the meaning of the data easy to handle and count) (Miles & Huberman,
1994)
In this study, researchers compared the data obtained from respondents, as proposed by Mohammed (2012). The
researcher then obtains themes and categories using NVivo8 software. The six steps proposed by Malakolunthu
(2001) are namely:
a)
b)
c)
d)
e)
f)
Data cleaning
The encoding of data
Updating the data
Analysis of documents
Understand of documents; and
Analytical categories
There are two types of validity: internal validity and external validity. In order to ensure internal validity, there
are five strategies (McCall & Simmons, 1969) that can be used in qualitative research which is as follows:
a)
b)
c)
d)
e)
The method of triangulation;
Inspection and peer review as well as supervisors to ensure the validity of the interview instrument;
The review by the informants in this research by allowing them to read, view and verify the interpretation done;
Involve respondents in all phases of the research study; and
Explain the hypothesis, subjectivity and theoretical orientation of the researchers at the beginning of the study.
External validity is ensured through the use of a lot of information, various themes and the maximum variation
data until the data reached saturation. To preserve the validity of the content of the study, the researcher obtains
information from teachers and administrators to use a different set of questions to get feedback on.
In this study, researchers have obtained the consent of the Index Cohen Kappa coefficient (Cohen, 1960). Based
Maizatul Azmah Ab.Latiff et al. / Procedia - Social and Behavioral Sciences 204 (2015) 81 – 87
on Cohen's Kappa analysis, the researcher has sought the cooperation of three qualitative experts who knows how to
evaluate the calculation of Cohen's Kappa coefficient level or consent of the themes of the interviews. The theme is
chosen based on the domain of the transcription of the interview.
There are several opinions about the Cohen’s Kappa index analysis to determine the degree of agreement among
experts in qualitative research. According to Steven (1958), an agreement among the experts is important to
determine the reliability in illustrating the themes. In 1977, Landis and Kosh have suggested ways to calculate
Cohen's Kappa agreement using the scale (Landis & Kosh, 1977). Table 1 shows the Cohen’s Kappa scale of
agreement.
Table 1. Cohen's Kappa scale of agreement
Cohen's Kappa agreement using the scale.
Below 0.00
Scale of agreement
Very poor
0.00 – 0.20
Poor
0.21 – 0.40
Moderate
0.41 – 0.60
Moderate good
0.61 – 0.80
Good
0.81 – 1.00
Very good
This analyzed questionnaire was given to three experts to evaluate. After that, researchers will sit together to
calculate the value of Cohen’s Kappa agreement. Every agreement of the unit is noted. The coefficient of agreement
for each expert is separately recorded and then aggregated to obtain a coefficient of agreement for the entire process.
Then, the researchers calculate Cohen's Kappa formula as follows:
K = fa – fc
N - fc
Which is:
K - the coefficient of agreement
fa - unit of agreement
fc - units likely set at 50 percent expected agreement
N - number of units (themes) that tested the agreement
4. Results and discussion
4.1 Cohen’s Kappa analysis
Table 2 shows the scale of agreement from the 3 experts who were given to evaluate the analyzed interview
questionnaire
Table 2. Scale of agreement
Scale of agreement
fa-fc/N-fc
Expert 1
64/68
64-34
68-34
30//34
0.88
Sum of coefficient of agreement
Average
Coefficient of agreement
0.88+0.82+0.5/3
0.7
fa-fc
Expert 2
62/68
62/68
68-34
28/34
0.82
Expert 3
51/68
51/68
68-34
17/34
0.5
85
86
Maizatul Azmah Ab.Latiff et al. / Procedia - Social and Behavioral Sciences 204 (2015) 81 – 87
Overall, there are 68 units of themes established. The operational definition of each theme was given to the
experts to evaluate. According to Cohen (1960), 40 units are sufficient to find the consent of each theme (unit).
Through the pilot study, the Cohen’s Kappa coefficient of agreement at the level of 0.7 was obtained as well. Not
many comments and suggestions given in writing as experts had verbal discussions with researchers. Improvements
were made based on oral and written opinion given by the three appointed experts.
4.2 The results of the interview
Findings from the interviews conducted reveals that respondents can understand the interview questions set.
This is because, when the researcher described the purpose of the interview questions, the respondents agreed that a
set of questions developed can achieve the objectives of the research. Prior to going to the selected school to conduct
the interview, the researchers have contacted the school, special education teachers and senior assistant to explain to
them about the study so that respondents can respond truthfully and share their ideas and viewpoints about inclusive
education freely as suggested by Creswell (2007).
The findings were analyses using NVivo8 software and researchers acquired 68 units of themes. This shows that
the set of interview questionnaire reaches the standard theme in which Cohen suggested that the minimal is 40 units
(1960).
Through the evaluation and suggestions made by experts, the researchers will also propose to conduct
interviews to the mainstream teachers who are not conducting the teaching and learning of Inclusive Education
Program. In addition, questions related to the theme of the special pedagogical needs will also be provided. Subject
teachers should also know the methods and approaches that should be used appropriately when teaching in an
inclusive classroom.
5. Conclusion
This study is only a pilot study on the implementation of the Inclusive Education Program conducted in the
Special Education Program Integration at a primary school in Malacca. This study is an initial step taken by the
researchers to test the validity of the interview questions that will be used in an interview before the actual study. It
is also not intended to prove any theory or model of the implementation of Inclusive Education. However, it opens
up space for discussions and improvements to make the study more rigorous and systematic. Thus, the set of
interview questions must be validated to ensure that the data obtained may help researchers answer the research
questions more accurately. In addition to this structured interview, other forms of data collection will be used in
order to provide the researcher with a well-rounded collection of information for analyses.
Acknowledgment
The researchers would like to thank the principle and teachers at School A, Merlimau Melaka for their cooperation
during the pilot study.
References
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Jossey-Bass.
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Saad, S. (2003). Malaysian preschool children with attention deficit hyperactivity disorder (ADHD) in inclusive setting. PhD Thesis. University
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87
Original Research
Students With Chronic Conditions:
Experiences and Challenges of Regular
Education Teachers
The Journal of School Nursing
2017, Vol. 33(4) 307-315
ª The Author(s) 2016
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1059840516674053
journals.sagepub.com/home/jsn
Janice Selekman, DNSc, RN, NCSN, FNASN1
Abstract
School nurses have observed the increasing prevalence of children with chronic conditions in the school setting; however,
little is known about teacher experiences with these children in their regular classrooms. The purpose of this mixed-method
study was to describe the experiences and challenges of regular education teachers when they have students with chronic
conditions in their classroom and implications for the school nurse. The national sample consisted of regular education
teachers. The methodologies consisted of focus groups and an online survey. Seven themes emerged: Teachers want to be
informed about their students with chronic conditions, teachers lack information about the conditions, there is a lack of
preparation in preteacher education programs about students with chronic conditions, teachers feel frustration and stress in
working effectively with these students, teachers shared concerns about their students, teachers are asked to perform healthrelated tasks for students, and teachers made recommendations of what they need from the school nurse.
Keywords
chronic diseases, elementary, high school, middle/junior/high school, special education/disabilities
The prevalence of children with chronic conditions in the
schools has increased significantly since 1994 when 12.8%
of students were considered to have a chronic condition.
That number more than doubled by 2006 to 26.6% (Van
Cleave, Gortmaker, & Perrin, 2010). The U.S. Department
of Health and Human Services, Office of Adolescent Health
reported that in 2016, approximately 31% of adolescents
‘‘suffer from at least one moderate or severe chronic condition’’ (2016, para. 1). These increases were initially due to
improved health care leading to a longer life span, increased
awareness that children in the classroom have chronic conditions, increased inclusion in the classroom, and decreased
numbers of children placed in special schools. However, the
increasing prevalence continues in conditions such as
asthma, obesity, diabetes, food allergies, mental health
conditions, and neurodevelopmental disorders (Perrin,
Anderson, & Van Cleave, 2014). Federal laws mandate a
free and appropriate education to all children in the least
restrictive environment with reasonable accommodations
made in order for them to take full advantage of the educational experience.
Chronic conditions are those that last at least 1 year and
require ongoing medical attention and/or limit learning or
other activities of daily living (USDHHS, 2010). Because
children spend half of their waking hours in the school setting and a significant number have a chronic health condition, health care becomes an issue in the schools. According
to the National Association of School Nurses (NASN, 2007),
41.3% of public schools had a full-time registered nurse,
25.3% had no nurse at all, and the rest had a nurse for part
of each week. When school nurses are not present, health
care for children with chronic conditions often becomes the
responsibility of secretaries and teachers. The purpose of
this study was to describe the experiences and challenges
of regular education teachers when they have students with
chronic conditions in their classroom.
Review of the Literature
The literature on this topic is sparse, but the themes over two
decades have been similar related to children with chronic
conditions in regular education classrooms. They indicate
teacher concerns, including how to respond to medical emergencies, lack of teacher preparation for this population of
students, and the extra time needed to provide health care in
the classroom resulting in a decrease in teaching time.
1
University of Delaware, Wilmington, DE, USA
Corresponding Author:
Janice Selekman, University of Delaware, 324 Waycross Road, Wilmington,
DE 19803, USA.
Email: selekman@udel.edu
308
A dated small study by McCarthy, Williams, and Eidahl
(1996) explored teacher experiences with children with
chronic conditions in the school, as well as their concerns
in educating these students. Teacher concerns included how
to respond in medical emergencies, student absences, student fatigue, student behavior problems, parents, and the
students’ peers. Teachers also reported that concern about
medical emergencies was greatly reduced if a school nurse
was present in the school. Clay, Cortina, Harper, Cocco, and
Drotar (2004) queried educators in one state and found that
59% reported no academic training in working with children
with a chronic illness and 64% reported no on-the-job training in dealing with these children. They concluded that
schoolteachers were not prepared to deal with issues presented by students with chronic illness.
Hill and Hollis (2012) surveyed elementary teachers in
one state on the amount of time they spent on health issues.
They found that time ranged from 36 to 73 min per day,
including calling parents. They also found that when a
school nurse was present, more than 80% of teachers felt
there was increased communication with the school nurse
related to students’ health-care needs, less teacher time spent
on health issues, more time spent teaching, and increased
confidence that students with chronic illnesses are safer. In a
study by Baisch, Lundeen, and Murphy (2011), teachers
from all grades spent an average of more than 26 min on
health-care issues per day without a school nurse and just
over 6 min per day when a school nurse was present.
Shippen et al. (2011) explored the strategies teachers
implemented in general classes to accommodate students
with disabilities compared to special education teachers.
General education teachers reported an absence of coursework in their preservice education programs regarding
accommodations needed for students with disabilities,
which resulted in their lack of comfort with these students.
The researchers recommended both content and experiences
for teachers to foster confidence and positive attitudes
toward those with chronic conditions.
Some of the studies on this topic focus exclusively on one
condition. For example, Bishop and Boag (2006) measured
teachers’ knowledge about and attitudes toward epilepsy.
Their findings indicated teachers lacked knowledge about
epilepsy and its impact on the classroom and affected students’ academic performance. Teachers felt unprepared to
recognize and respond appropriately to seizures. Responding teachers wanted to know how to discuss epilepsy with
the other students in the class and suggested that increased
exposure to information on this condition and its management be included in teacher preparation courses.
While approximately 1 in 4 students has a chronic health
condition, only 12.9% of the total student body receives the
services of special education (U.S. Department of Education, 2016). The Individuals with Disabilities Education
Improvement Act (IDEA) covers 13 categories of conditions
including learning disability, autism spectrum disorder,
The Journal of School Nursing 33(4)
emotional disturbance, speech/language impairment, visual
impairment, hearing impairment, deaf-blindness, orthopedic
impairment, intellectual disability, traumatic brain injury,
multiple disabilities, and ‘‘other health impaired’’ (OHI).
OHI is defined as ‘‘having limited strength, vitality, or alertness, including a heightened alertness to environmental stimuli that results in limited alertness with respect to the
educational environment’’ and can include conditions ranging from attention deficit hyperactivity disorder (ADHD)
and cardiac conditions to diabetes (U.S. Department of Education, 2004, para. 1). In addition to those requiring special
education are students with other chronic conditions that
require accommodations without special education, such
as those with life-threatening allergies, cystic fibrosis, and
inflammatory bowel disease.
The significance of this study is that it is the first national
study exploring teacher experiences and challenges from
both qualitative and quantitative perspectives. Teaching
children with chronic health needs can result in stressors
on teachers, requiring a change in teaching strategies, a
change in the amount of teaching time teachers have to cover
content to the class, and asking teachers to perform actions
that are within the realm of the practice of nursing rather
than within the role of educator. By increasing school nurse
awareness of the needs and stressors of teachers regarding
this population of students, school nurses can become more
proactive in their planning and interventions. This study also
can provide data to enhance advocacy for the need for school
nurses in those schools that do not have full-time school
nursing services.
Method
Design
This two-phase study used a mixed-method design using
both qualitative and quantitative data. The qualitative component of the study (Phase 1) was completed first. Phase 1
consisted of focus groups and Phase 2 was an electronic
survey. The study was approved by the institutional review
board of the University of Delaware.
Phase 1: Focus groups
Phase 1: Sample/setting. Participants in the focus groups
included practicing public school regular education classroom teachers (Grades 1–12) with at least 1 year of experience who were attending a biennial national teachers’
conference sponsored by the American Federation of Teachers (AFT) in July 2013. Those participants who registered
for the AFT conference were sent a description of the study
by the AFT and asked to participate if they were a public
schoolteacher in Grades 1–12. This stipulation limited the
number of eligible participants. Consent to participate and
be audio-recorded was obtained prior to beginning the focus
Selekman
group. Each session was 60–90 min. Six focus groups were
convened with 2–4 participants per group.
While the room was difficult to find, 17 of the 27 who
registered for a session participated. They represented five
states (New York, New Jersey, Georgia, Minnesota, and
Rhode Island) and included one occupational therapist and
two paraprofessionals; these nonteachers were allowed to
stay in the groups, but their feedback was removed from the
analysis. Therefore, there were 14 teachers in Phase 1.
Focus group procedure. The researcher moderated each
focus group with either a school nurse researcher or the
assistant director of the AFT Nurses and Health Professionals division. All sessions were audio-recorded; notes were
also taken by one of the two facilitators present during the
sessions.
The discussions allowed teachers to share their experiences and preparation/knowledge when having children with
chronic conditions in their regular education classrooms.
The semi-structured questions that guided the discussion
were gleaned from the professional literature and included
the following:
1.
2.
3.
4.
5.
6.
In the past 3 years, what chronic conditions have
your students had?
Tell us about an experience you have had teaching a
child with a chronic condition. Include the challenges that were present, how you had to adapt your
teaching, the concerns you had, and what helped.
What information do you wish you knew before having these children in your class?
What preservice training and professional development was provided to you regarding children with
chronic conditions in the classroom?
What resources (school staff, school nurses, written
materials, professional development, individualized
education programs [IEPs], or 504 plans) were most
helpful?
What medical treatments, if any, are you asked/mandated to do?
The tapes were transcribed by a paid service and then all
transcriptions were checked against the original tapes by the
primary researcher. Concepts related to the topic of the study
were placed on index cards and sorted multiple times by four
research assistants until consistent themes emerged. Validation of the themes was confirmed by the three focus group
facilitators.
Phase 1: Results. The sample of 14 teachers was evenly
distributed among those who taught elementary, middle, and
high school. The mean years taught was 16, with a range
from 2 to 35. The teachers reported that they taught an
average of 23 students with known chronic conditions in the
past 3 years; the total number of students they taught per
year ranged from 24 to 120.
309
Table 1. In the Past 3 Years, I Have Taught Students With the
Following Conditions.
Focus Groups (N ¼ 14)
Online Survey (N ¼ 1,280)
Asthma
Attention deficit hyperactivity
disorder (93.2%)
Asthma (88.5%)
Learning disabilities (78.9%)
Allergies (especially to foods)
Attention deficit hyperactivity
disorder
Learning disabilities
Autism spectrum disorder
Diabetes
Mobility conditions (cerebral
palsy, walker or wheelchair
use, muscular dystrophy,
muscle problems)
Seizures
Sensory disorders (vision/
hearing)
Sickle cell disease
Others (mentioned by one or
two): emotional disturbance,
Down/intellectual disability,
HIVþ, speech and language,
depression/anxiety, Tourette
syndrome, cystic fibrosis,
kidney problem, substance
abuse, stroke due to a brain
tumor, ‘‘tubes coming out of
their bodies,’’ and ‘‘a kid who
was very violent’’
Allergy other than food (76.2%)
Food allergy (70.6%)
Autism spectrum disorder
(65.2%)
Anxiety disorder (58.3%)
Speech impairments (56.5%)
Depression (49.9%)
Diabetes (48%)
Vision disability (42.1%)
Bipolar disorder (41.4%)
Significant obesity (35.7%)
Deaf/hearing deficits (34.5%)
Seizure disorders (34.3%)
Other: (obsessive-compulsive
disorder, intellectual
disability, heart conditions,
sickle cell disease, skin
disorders, addictions, color
blindness, eating disorders,
and cancer)
Analysis of the focus groups resulted in seven themes:
decreased communication, a lack of information about the
chronic conditions, a lack of preparation in preteacher education programs, increased frustration and stress, concerns
teachers had for students with chronic conditions, healthrelated tasks teachers were asked to perform for students,
and recommendations of what would be most helpful to
regular education teachers now.
When asked to identify the chronic conditions they saw
most frequently in their students, asthma, allergies, and
ADHD were the top three (Table 1). The most prevalent
theme that emerged from the focus groups was the need for
communication.
Theme 1: Lack of communication. Teachers expressed frustration and disappointment that it often took weeks or
months until someone shared with them that a student in
their classroom had a chronic condition that required their
attention. Teachers shared how they found out about a student’s condition once they expressed concern about a behavior or performance problem. One stated, ‘‘In November
when I complained to the nurse about a student, she said,
‘‘Well, didn’t you know she was a diabetic?’’’’ Some had a
310
formalized way of finding out which students had health
conditions, but these were not always legal. Comments
included, ‘‘The school nurse brings a sheet of who has
asthma, allergies, diabetes, or anything we need to know
about the child’’ and ‘‘The principal and the nurse gave us
a list of all students in the building and what they had and
what medications they were taking.’’
Theme 2: Lack of information about the conditions. The second strong theme was a lack of and a desire for information
about the conditions their students have, especially what
they should look for that indicated the child was in trouble
and what they should do while they are waiting for help to
arrive. Teachers in the focus groups described how they
accessed information about the conditions, with personal
family experiences and WebMD the most frequently noted.
The impact of this lack of information was evident when one
teacher stated, ‘‘I didn’t understand his ADHD. I never dealt
with anyone who had it. I wasn’t very patient. I thought the
kid was being disrespectful.’’ When asked if the school
nurse was helpful in providing information, a teacher stated,
‘‘I don’t have time to talk to the nurse about the condition
because we share her [with another school] and by the time I
am done teaching, she is gone.’’
Theme 3: Frustration and stress. Teachers expressed frustration and stress from a number of perspectives. Students
with chronic conditions may require more teacher time
(‘‘Some of the other students didn’t benefit from my help
because he was monopolizing my time in a way’’). A number of teachers felt they were blamed for the students’ poor
performance on state tests. Comments such as the following
demonstrate this point. ‘‘Teachers have to be aware that
they’re going to get the blame even though there’s really
no blame to take.’’ ‘‘Everything is still placed on the teacher.
What is the teacher NOT doing right so this child is not
moving along? They aren’t looking at the child’s IEP (Individualized Education Program). They aren’t looking at the
child’s chronic condition.’’ ‘‘Even when I gave him all that
help, it almost felt useless. It was really frustrating.’’
Teachers also expressed frustration with parents, especially those who do not advocate for their own children and
those who refuse the development of IEPs. One teacher said,
‘‘It’s really sad. I have kids who we identify as needing
services, maybe first grade, but the parent will say ‘no, I
don’t want them to have special education.’ And then they
will wait until fourth grade and the child is still not reading
and then they will say, ‘OK, give them services,’ and then
I’ve got 3 years to make up.’’
Theme 4: Teacher concerns. The teachers expressed concerns about the high absenteeism rates of children with some
chronic conditions. This raised concerns as to how to help
the student make up class work and keep up with peers.
Additional concerns expressed included the following: (a)
‘‘How do I know if they are using their disability as a crutch
The Journal of School Nursing 33(4)
or an excuse to get out of work?’’ (b) ‘‘What do I do when a
diabetic is bringing in the wrong foods from home?’’ (c)
‘‘There is an attitude of ‘the student knows how to deal with
it.’ But what if he doesn’t?’’ (d) ‘‘I don’t know if it is legal
for me to ask them anything about their condition?’’ and (e)
‘‘How do I discuss the child’s health-care needs when the
parents are not English speakers and/or not legally in the
U.S.?’’
Theme 5: Deficient information provided in their preteacher
education. Teachers in the focus groups were overwhelmingly critical of the lack of content and experiences provided in their preteacher education programs. Almost half of
the teachers had not received any information on children
with chronic conditions and how these might impact on their
teaching modalities. Three had an undergraduate course
about the conditions that are included in IDEA, but nothing
medical was included, and another had only one lecture on
this topic. As new teachers, they indicated they felt unprepared to understand and deal with the health-care needs of
their students.
Theme 6: Teachers were required to provide nursing care.
With one exception where a school nurse was present fulltime, teachers indicated they had the responsibility to provide ‘‘nursing care’’ to their students. One teacher stated she
was told by the office, ‘‘If it is not bleeding, broken, or a
breathing issue, don’t send them to the office. You take care
of it.’’ The degree of preparation for these skills and medication administration varied. A teacher in the focus groups
indicated she was given a handout on how to administer
rectal Diastat for seizures and was to keep the medication
in her desk drawer. Another watched a video on EpiPen use
but did not have a practice session and reported she did not
feel comfortable or confident in the skill.
Theme 7: What teachers want from the school nurse?
Because teachers are apparently not receiving information
in most of their preteacher education programs regarding
children with chronic conditions in their classrooms,
teachers in the focus groups expressed an emphatic need for
professional development, especially on the conditions they
see most frequently.
Phase 2: Electronic survey
Phase 2: Sample. A convenience sample was used for the
electronic survey 6 months after Phase 1 focus groups. A
subset of the AFT membership received an e-mail via SurveyMonkey1 that included a cover letter indicating eligibility; consent was implied with survey completion. The
number of questionnaires distributed is unknown, as AFT
does not have mailing lists specific for regular education
teachers in 1st through 12th grades. Of the 1,575 who completed the survey, 245 indicated they were considered to be
special education teachers and were eliminated from the
analysis. Another 50 questionnaires were eliminated when
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responses on the questions indicated that they did not
qualify, for example, being a substitute teacher, being
retired, and having roles that were not in the classroom. The
total sample of participant responses included in the analysis
was N ¼ 1,280.
Survey. The survey utilized for this study was developed
prior to Phase 1 of the study by a selected team that included
a special education professor and a school psychologist who
teach in their respective fields at a large research-intensive
university, a national school nurse researcher, and a school
nurse educator. Based on concerns respondents expressed
during the focus groups about their lack of knowledge, it
was determined that two questions should be added regarding the content teachers received during their preteacher
education about children with chronic conditions.
The final survey consisted of 48 questions: 24 were multiple choice or one-word fill-in (e.g., number of students
taught per year), 19 were questions using a Likert-type scale,
2 asked for lists (e.g., the student medications they keep in
their desks), 1 asked participants to rank order their student
concerns, 1 asked for suggested content to be included in
prelicensure programs, and 1 asked what would be most helpful to them now with these students. There was a space after
most questions for the participants to write comments. The
survey was initially piloted using a convenience sample of
elementary and middle school teachers in the South Atlantic
and mid-Atlantic region. Three reviewers familiar with survey methodology and the needs of children with chronic
conditions in the classroom were queried regarding content
validity. They included a middle school principal who had
initially been a first-grade teacher, a middle school honors
teacher, and a statistician. There was 100% agreement
regarding the content, with formatting recommendations
from the statistician; these were incorporated into the final
version of the tool. Reliability checks were not conducted.
Phase 2: Results. Results were downloaded in a deidentified format into Excel and no answers could link back to
participants in any way. Surveys were analyzed with SPSS
221. The participants in Phase 2 represented at least 23
states, with 62.4% teaching in urban schools, 23.8% in suburban schools, and 13.8% in rural schools. Participants had
taught for an average of 17.5 years with a range of 1–48. The
majority of participants had a master’s degree (72.3%), with
21.7% having a bachelor’s degree. Distribution of the participants revealed 30.6% representing grades 1–2, 30% representing grades 3–5, 28% representing grades 6–8, and 32.9%
representing grades 9–12 (with some teaching in multiple
levels). On average, teachers taught 15 students with chronic
conditions in the past year (2013–2014; range: 0–350).
Of the top 10 conditions seen by teachers in their classrooms, 70% were the same between the focus group findings
and the online survey (Table 1). Over 75% of teachers had
students with ADHD, asthma, learning disabilities, and
allergies. It is also essential to acknowledge that half of the
311
Table 2. The Needs of Each Child With a Chronic Condition in My
Classes Have Been Clearly Communicated to Me.
Percentage indicating rarely or never on a 5-point
Likert-type scale (N ¼ 1,280)
Grades
Grades
Grades
Grades
1–2
3–5
6–8
9–12
48.3
44.4
40.5
52.7
Table 3. The School Nurse Provides Guidance About Children
With Chronic Conditions in My Class.
Percentage indicating rarely or never on a Likert-type
scale (N ¼ 1,280)
Grades
Grades
Grades
Grades
1–2
3–5
6–8
9–12
32.8
33.1
28.6
41.5
top 10 conditions identified by survey participants are considered to be mental health conditions.
In questions related to being informed about students in
their classroom, 45.3% of the online sample (N ¼ 1,280)
indicated they did not receive any early warning at the start
of the school year that they were to have a child with a
chronic condition in their classroom. For those who were
informed, 37.7% were informed by the school nurse,
30.2% by the parent, 28% by the school counselor/psychologist, 27.4% by another teacher, 16.9% by the student, and
15.7% by the principal. Using Pearson w2, there was statistical significance of having a school nurse in the building 5
days per week and routinely being informed at the start of
the school year that they would have a student with a chronic
condition (p ¼ .002).
When asked if the needs of each child with a chronic
condition were clearly communicated to them, 47.6% of the
survey participants indicated never or rarely on a 5-point
Likert-type scale (always, often, sometimes, rarely, and
never; Table 2). When asked if the school nurse provided
guidance about the children with chronic conditions in their
class, 28.6–41.5% of the survey participants indicated never
or rarely on the same scale (Table 3). When asked who was
most helpful in helping them feel confident in working with
children with chronic conditions, 37% gave credit to special
education teachers, 29% gave credit to the school nurse, and
25.6% gave credit to the parent.
Using a Likert-type scale of never, rarely, sometimes,
often, and always, 15% of the survey participants indicated
that they often or always feel overwhelmed having children
with chronic conditions in their classroom; 31.7% felt overwhelmed sometimes. Using the same scale, 29.1% indicated
they experience more stress having a child with a chronic
312
The Journal of School Nursing 33(4)
Table 4. Ranking of Factors That Most Concern You About Your
Students With Chronic Conditions.
Concern/Grade
Table 5. Number of Extra Minutes per Day in Direct and Indirect
Health Care Provided by Teachers in the Classroom.
1–2 3–5 6–8 9–12
Grade
High absenteeism rate
Student with a chronic condition is
underperforming in school
Behavior issues
Poor concentration
Student fatigue/low energy
Failure to complete daily assignments
Rejection by peers/bullying
1
3
2
1
1
2
1
2
2
4
5
6
7
3
4
5
6/7
6/7
3
4
5
6
7
3
5
4
6
7
Note. N ¼ 1,280.
condition in their classroom than when they do not have a
child with a chronic condition in their classroom; another
21.6% experience this stress sometimes. One teacher commented on the survey, ‘‘I don’t understand why this profession expects so much of the teacher. She already wears many
hats and now it becomes her responsibility to handle medical
affairs.’’
Teachers were asked to rank their concerns regarding
students with chronic conditions (Table 4). The top concerns
were their high absenteeism rate, the concern that students
with chronic conditions are underperforming in school, and
behavior issues.
When asked about the amount of content received in their
preteacher education program, 52.3% indicated they had
NO training on children with chronic conditions during their
basic teacher education; an additional 16.9% had only one
lecture on this topic. Teachers in the upper grades had less
basic condition-specific information than those who worked
with younger children. Only 8% indicated that their teacher
education content was helpful for this facet of their role.
Because of the longevity in the classroom of some of the
participants in the survey, an attempt was made to see
whether those graduating from a teacher education program
in the past 10 years had more content on children with
chronic conditions than those who had graduated before that
time. While more did receive the content, the association is
weak (p ¼ .08).
Survey participants indicated that 44.3% of schools had a
school nurse 5 full days per week; 11.2% had no school
nurse at any time. For those who did not have a full-time
school nurse, the question was asked who provides the
health care; the answers included the secretaries (33%), the
principal (22.7%), teachers (22.3%), health aides, and parent
volunteers.
Of the 1,280 survey participants, 110 (8.6%) were asked
to keep medications or treatments in their desks. These
included EpiPen, medications for ADHD (controlled substances), inhalers/asthma pumps/albuterol, antiseizure medications, glucose tablets, diabetes testing supplies, and
insulin. More than 86% of teachers did not believe it was
1–2
3–5
6–8
9–12
Extra Minutes of Direct Extra Minutes of Indirect
Health Care
Health Care
Total
45.7
35.9
28.9
19.2
40.6
43.2
35.8
34.8
86.3
79.1
64.7
54
their responsibility to give medications in school, but many
felt pressured to do it. One survey participant stated, ‘‘I am
not at all comfortable with providing treatment to students,
but fear my job would be in jeopardy if I did not do as I was
instructed.’’
Using Pearson w2, there was statistical significance in
having a school nurse in the building 5 days a week and
NOT being asked to keep medications in their desk or classroom (p ¼ .000). While not wanting to be responsible for
medications, only 15.9% felt that it was not their responsibility to deal with the health components of a child’s chronic
condition while in the classroom, with 68.8% believing they
should be partly responsible.
The survey asked teachers to estimate the average number of minutes each day that they spend providing direct
health-care services to students and the number of minutes
they spend providing indirect care, such as communicating
with parents about a student’s needs and writing alternative
lessons or plans based on a student’s IEP requirements. The
amount of time spent ranged from 19 to 45.7 minutes per day
in direct health care (average ¼ 33 minutes), with more time
needed for elementary school children, and 34.7 to 43.2
minutes a day in indirect health care (average ¼ 38 minutes);
the amount of time spent was less for high school students
(Table 5). Over 26% indicated that planning for a child with
a chronic condition lessens their ability to plan for their other
students often or always; another 31% indicated sometimes
to this question, on a 5-point Likert-type scale.
Teachers wanted to know what to look for, what they
should do in an emergency, and what they should know
about the condition. They asked for real scenarios that will
prepare them and they wanted more hands-on experience
with CPR (Cardiopulmonary Resuscitation) and EpiPen use.
The teachers in both Phase 1 and Phase 2 expressed a
unanimous need for professional development on the disorders they see most frequently. They want to know the impact
the disorders have on learning and what accommodations
work; they expressed a desire to know how to read an IEP
and to know which students have them; and they wanted
guidance on how to advocate for a 504 accommodation plan
and wanted to know what else could be put on it other than
extended testing time. They want information on FERPA
(Family Educational Rights and Privacy Act) and clarification of what they can share and have shared with them.
Selekman
313
Being nofied in a
mely manner
COMMUNICATION
Stress and
frustraon
Pre-teacher
educaon
With parent, school nurse,
school administraon,
healthcare provider
Being educated on
what to look for and
what to do
By the
school
nurse
Figure 1. Framework for teachers’ needs related to students with chronic conditions.
Discussion
There was a great deal of consistency between the findings
of the qualitative and quantitative components of the study,
as well as with that found in the literature. The characteristics of the sample were very similar in the percentage of
elementary, middle, and high school teachers represented,
with a fairly even distribution among groups. The average
number of years teaching was similar (16 for the focus
group and 17.5 for the survey) as was the average number
of children with chronic conditions taught in the past year
(23 vs. 15). It is also interesting that the percentage of fulltime and no school nurses present in the schools, as perceived by the teachers in the survey (44.3% and 11.2%),
closely approximates the findings from the 2007 study by
NASN (41.3% and 25.3%). Although the number of
schools with no school nurse is down to 11% in this study,
it must be kept in mind that these statistics are the impressions of the teachers and not based on any state data. However, Biag, Srivastava, Landau, and Rodriguez (2015)
found that the level of teacher satisfaction with school
nurse services correlated with the number of hours the
nurse was on site.
Of the top 10 conditions seen by teachers in their classrooms, 70% were the same between the focus group findings
and the online survey (Table 1). Some of the concerns
expressed by teachers related to having children with
chronic conditions in their class are the same as those cited
by McCarthy et al. in 1996: increased student absences and
needing to know how to respond in an emergency. The
dearth of content reportedly taught in preteacher education
programs was as much a concern in 2004, where 59%
reported no information presented in their academic program (Clay, Cortina, Harper, Cocco, & Drotar, 2014) as in
the present study; 52.3% reportedly had no content on children with chronic conditions, and another 17% having had
limited content.
The extra amount of time needed by teachers to attend to
the health needs of their students has also not improved. The
26–73 min per day documented by Hill and Hollis (2012)
and Baisch et al. (2011) is slightly less than the 19–45 min of
direct health care provided per day and the 34–43 mi of
indirect health-care interventions reported in this study. This
translates into the loss of approximately 1 hr of teaching
time per day.
In addition, Hill and Hollis (2012) determined that
teachers felt that communication and confidence increased
when a school nurse was present and Baisch et al. (2011)
calculated that the time teachers spent on health-care issues
was decreased by more than 75% when a school nurse was
present. This national study supports that when a school
nurse is in the building full time, teachers were informed
significantly more consistently at the start of the school
year that they would have a student with a chronic conditions in their classroom and were asked to provide fewer
nursing skills.
The two recommendations from teachers are clear: There
is a significant need for increased communication of information in the school setting, and preteacher education must
address the significant issues of children with chronic conditions in the classroom. There was a consistent request for
professional development for teachers in the schools related
to the health needs of children with chronic conditions.
Development of a Model
Based on the themes that developed from this study, the
following model was developed (Figure 1). The centerpiece
of the model is communication. This includes being notified
in a timely manner so that measures can be in place at the
start of the school year to assist the student; communication
with the parent, the school nurse, school administration, and
the student’s health-care provider if needed; and communication to educate teachers on what to look for and what to do.
314
Much of this education should come from the school nurse.
The presence or lack of communication directly impacts on
teacher stress and frustration levels. However, these findings
also have great relevance for university programs that prepare teachers regarding content on the common disorders
that children may have, which have an impact on the teacher’s role.
Limitations
There are four limitations identified in this study. Only 14
(52%) of the 27 teachers who had signed up to participate in
the focus groups actually participated; this may have been
due to the difficulty in finding the room. This resulted in
only five states being represented in the qualitative component of the study. As the survey was distributed by the AFT,
only 23 states may have received the questionnaire, again
limiting the anticipated national representation. The third
limitation was that the survey was not checked for reliability. Finally, correlations were not done to compare some
teacher responses to the percentage of time they indicated
a school nurse was on site.
Implications for School Nursing
The implications for school nursing are clear. Communication with teachers is essential. Having a school nurse
full time in the schools makes a positive difference for
teachers, especially related to teacher stress and time
available for teaching. School nurses must be proactive
and be aware of the increased stress put on teachers by
not knowing about their students and the actions to take
regarding student health issues. General education teachers have clearly identified the information they would
like; the school nurse has the knowledge and is in an
excellent position to provide it. School nurses must work
in conjunction with educators so that each can be an
advocate for the other.
Conclusion
On average, teachers have 15 students with chronic conditions in their classrooms each year. This study demonstrated that public schoolteachers in Grades 1–12 want
increased communication with anyone who can assist them
in understanding the health needs of the children in their
classrooms. They want this information before the children
come to their class so that they can prepare to meet their
needs; they want to know what signs to look for and what to
do until the school nurse or emergency care arrives. In
general, they did not feel well prepared by their preteacher
education programs.
While school nurses have been advocating for their inclusion in the school setting, the support from teachers has
generally not been included. Many teachers are being forced
to perform health-related skills for which they are not
The Journal of School Nursing 33(4)
prepared and do not wish to do. They are losing instructional
time and increasing their stress working with parents and
others to deal with classroom issues involving children with
chronic conditions. This study will allow their voices to be
heard, especially by school nurses. Multiple specific areas
were identified where the school nurse can intervene to
assist both teachers and students...
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