A STUDY OF THE KNOWLEDGE, SKILLS, AND DISPOSITIONS OF NURSE

EDUCATORS RELATED TO LEARNERS WITH ADHD

By

Eileen T. Yost

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BONITA WILCOX, Ph.D., Faculty Mentor and Chair

D. PAXSON BARKER, Ph.D., Committee Member

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JERRY HALVERSON, Ph.D., Committee Member
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James A. Wold, Ed.D., Interim Dean, School of Education
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A Dissertation Presented in Partial Fulfillment

Of the Requirements for the Degree

Doctor of Philosophy

Capella University

July 2015
 ProQuest Number: 3718030

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© Eileen T. Yost, 2015
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 Abstract

Colleges and universities have experienced a greater prevalence of students diagnosed

with attention-deficit hyperactivity order (ADHD) including nursing education programs.

With the predicted increase in demand for nurses over the next decade, nursing faculty

need to develop strategies to educate all types of learners, including those students with

cognitive deficits associated with ADHD. The purpose of this study was to discover a

deeper understanding of the knowledge, skills, and dispositions of nurse educators who

teach students with ADHD. This research was designed as a basic qualitative study using

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a purposeful convenience sample of baccalaureate degree program nurse educators from

three universities in the State of Connecticut. The nine participants completed a semi-
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structured interview: eight one-to-one interviews and one Skype interview. Data was

collected using Merriam’s constant-comparative data analysis method. The responses

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revealed seven codes separated into four themes. The themes that emerged from the

interviews were a lack of faculty knowledge about ADHD; the ambiguity of federal laws
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and disability services responsibilities; the uncertainty of which effective teaching skills

promote student success; and faculty dispositions. Implications from this study revealed

the need for universities to provide knowledge enhancement opportunities for nurse

educators to improve their understanding about ADHD, to learn evidence-based teaching

strategies that can lead to improved student outcomes, and to identify student learning

strategies to compensate for cognitive deficits associated with ADHD. In addition, the

participants expressed an interest in further education related to nursing students with

ADHD. Such knowledge acquisition can be accomplished through the help of the

disability services office and the adult learning tool of self-directed learning.
 Dedication

This doctoral dissertation is dedicated to my husband, Steve. I know that I would

not be where I am today if not for the journey we began together at Pace University, in

what seems a life-time ago. Thank you for encouraging me to value lifelong learning in

the never-ending journey to become the best nurse that I can be. Over the last thirty-plus

years you have given me your total devotion, strength, confidence, kindness,

understanding, and unending love. Truly, there is nothing more I could have asked of

you. You are my role model, my inspiration, my love, and my rock! I love you more

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than words can say!

To my wonderful loving, bright, warm, patient, understanding children: Erin,

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Matthew, and Colleen. I hope I have instilled in you a love of learning and the courage

and integrity to pursue your dreams. I know I gave each of you wings to fly high and
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confidence to believe in yourself. I am so proud of the adults you have all become. The

greatest honor, achievement, and happiness in my life is being your mom!

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Finally, this dissertation is dedicated to all educators who work with students with

learning disabilities, especially those students with Attention-Deficit-Hyperactivity

Disorder in nursing education.

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 Acknowledgments

First, I would like to send a sincere thank you to the members of my dissertation

committee, Dr. Paxson Barker and Dr. Jerry Halverson, for your interest and participation

in my study. A most special thank you to Dr. Bonita Wilcox, my dissertation mentor and

committee chair. Your guidance, support, encouragement, and expertise have been

invaluable. I could not have done this without you.

I would like to thank the nurse educators who took the time to participate in this

study.

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To my editor, Mary Skowronski. Thank you for your time, expertise, patience,

dedication, and perseverance. You are a saint!

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To Kelly Melore for your unending efforts in reading this dissertation and

providing me with much needed feedback, advice, and revision ideas, and to Matt, for
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sitting by my side during the summer when I needed it the most. Each of you helped me

get through the most difficult parts of this journey.

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To my family; and especially my father, John Healey. Thank you for your love

and support over my lifetime and for always believing in me. You have helped make this

dream come true. And to my mother, Marilyn Healey. I know you are watching from

above, and I hope this accomplishment makes you proud. To my sisters, Cathy Henry

and Mary Alas, and my brother-in-law, Manny Alas. Thank you for supporting this

arduous journey. I could not have done it without your love, support, help, and

understanding. You are the best!

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 To some very special people in my life; Angie Bellantoni and Melina

Przyborowski. Without your friendship, patience, encouragement, love, humor, and

understanding, this dissertation would never have come to fruition, nor would I be where

I am today. Much thanks to you for always believing in me. Your never ending support

helped me to believe in me! You are cherished beyond measure!

To my colleagues at Sacred Heart University for your patience, understanding,

and support during this challenging journey. Special thanks to my colleague, friend, and

travelling companion, Shery Watson. I would not have wanted to experience this journey

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with anyone but you. Thank you for the laughter, tears, love, and support! We both

know this dissertation would still be on my “the do list” without your encouragement and

faith in me. Thank you, my friend!

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Finally, to my wonderful husband, Steve, my children Erin, Matt, Colleen, and
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my son-in-law, Brett. Thank you for your patience, understanding, and constant

encouragement. Your faith, love, and support gave me the courage to take this journey,
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the wings to fly, and the strength to finish.

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 Table of Contents

Acknowledgments iv

List of Tables ix

CHAPTER 1. INTRODUCTION 1

Introduction to the Problem 1

Background, Context, and Theoretical Framework 3

Statement of the Problem 10

Purpose of the Study 11

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Research Questions 12

Rationale, Relevance, and Significance of the Study 12

Nature of the Study

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Assumptions, Limitations, and Delimitations 18

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Definition of Terms 20

Organization of the Remainder of the Study 22

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CHAPTER 2. LITERATURE REVIEW 23

Introduction to the Literature Review 23

Theoretical Framework 25

Review of Research and Methodological Literature 30

Chapter 2 Summary 57

CHAPTER 3. METHODOLOGY 58

Introduction to the Methodology of the Study 58

Research Design 59

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 Target Population, Sampling Method, and Related Procedures 60

Field Test 64

Data Collection 65

Data Analysis Procedures 67

Credibility 68

Transferability 70

Expected Findings 70

Ethical Considerations 72

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Chapter 3 Summary 74

CHAPTER 4. RESULTS 75

Introduction
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Description of the Sample 76

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Research Methodology 77

Data Analysis 79
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Summary of the Findings 95

Chapter 4 Summary 114

CHAPTER 5. CONCLUSIONS AND DISCUSSION 117

Introduction 117

Summary of the Findings 117

Discussion of the Findings 122

Discussion of the Findings in Relation to the Literature 132

Limitations 140

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 Recommendations for Further Research 141

Implication of the Results for Practice 142

REFERENCES 144

APPENDIX A. STATEMENT OF ORIGINAL WORK 153

APPENDIX B. INTERVIEW GUIDE 154

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 List of Tables

Table 1. Faculty Definition of ADHD 81

Table 2. Faculty Description of ADHD Characteristics 82

Table 3. Institution and Class Accommodations 83

Table 4. Accommodations and Learning Outcomes 84

Table 5. Faculty Classroom Pedagogies 85

Table 6. Faculty Challenges with ADHD Students 86

Table 7. Faculty Course Preparation 87

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Table 8. Faculty Notification of Disability 88

Table 9. Faculty Responses to Perceptions 91

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Table 10. Faculty Recommendations to Enhance Learning 92

Table 11. Faculty Perceptions of Barriers in the Profession 96

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Table 12. Overarching Themes 116
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 CHAPTER 1. INTRODUCTION

Introduction to the Problem

According to Buchanan (2011), more students with learning disabilities are

entering universities and colleges. Educating students within these different populations

requires educators to identify teaching methodologies that will benefit all types of

learners. One population of student that warrants increased attention is students with

learning disabilities (LD), specifically attention-deficit hyperactivity disorder (ADHD).

ADHD is just one of several disorders listed under the umbrella of learning disabilities

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and is reported to be the number one learning disorder in postsecondary education

(Learning Disabilities of America, [LDA] Position Statement, 2012, para 1). ADHD is
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defined as a “behavioral disorder with a strong hereditary component,” most likely a

result of neurological dysfunction” (Guthrie, 2003). The Diagnostic and Statistical

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Manual of Mental Disorder (DSM-5; American Psychiatric Association [APA], (2013)

proposed two diagnostic categories of ADHD: (1) ADHD, predominantly inattentive type
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and (2) ADHD, predominantly hyperactive-impulsive type.

As the numbers of students with LD and ADHD enter higher education, faculty

must engage in the development of teaching-learning pedagogies and build understanding

of self-biases regarding students with cognitive learning impairment. Few research

studies have investigated either nursing students with ADHD or educators’ understanding

of the disorder. Findings have suggested that nursing faculty have mixed feelings about

students with learning disabilities in nursing education. The limited amount of

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information related to success or lack of success for nursing students may well be related

to the lack of faculty knowledge and preparation.

Over the last one hundred years, attention-deficit hyperactivity disorder also has

been referred to as attention-deficit disorder [ADD] (CHADD, 2015). ADHD is the

current label used to recognize this previous disorder (CHADD, 2015). For the purpose

of this study, ADHD will be the term used to delineate this disorder. The American

Psychological Association (2014) defined ADHD as a “behavioral condition that makes

focusing on everyday requests and routines challenging” (ADHD, para 1). In the DSM-5,

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ADHD is organized into two core deficits: a) inattention and b) impulsivity-hyperactivity

(APA, 2013; Barkley, 2006; Nigg, 2001). Individuals with ADHD are diagnosed as one
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of the two subtypes related to their presenting symptoms (CHADD, n.d.).

The etiology of ADHD is still under investigation. Numerous studies conducted

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by genetic researchers and leading ADHD experts have described the significant role of

behavioral inhibition and the executive functioning of the brain as a segue into
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understanding ADHD. Barkley (2007), a renowned expert in ADHD, concluded

behavioral inhibition is the central cause of ADHD. Further, he explained that genetic

researchers have uncovered structural and biochemical defects in the brain; providing

further credence to theories associated with genetic markers as risk factors associated

with the disorder. In total, there remain several working hypotheses as to the causes of

ADHD. The theories include behavioral inhibition, executive skills dysfunction, the

influence of prenatal insult, congenital brain defects, or deficits in working memory

(Anderson, Watt, Noble, & Shanley, 2012; Barkley, 2002; Buchanan, 2011).

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 According to Ramsay and Rostain (2008), clinical research has shown that

comorbidities and adult ADHD go hand in hand as the rule rather than the exception.

These comorbidities include anxiety, depression, substance abuse, and learning

difficulties (Ramsay & Rostain, 2008). The heightened awareness of the long-term

impairments of ADHD in adults continues to spur research as scientists build on existing

empirical evidence to understand the disorder and appropriate treatment modalities

(Ramsay & Rostain, 2008). However, despite empirical evidence about ADHD, the

discussion surrounding this disorder remains controversial in the eyes of health care

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providers, parents, and the public.

To date, few studies have focused on nursing education and faculty perceptions of
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students with ADHD. This study targeted nursing faculty’s knowledge regarding ADHD,

effective education of nursing students with ADHD, and faculty dispositions surrounding
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this disorder in nursing. One goal of this study was to empower nurse educators to

pursue life-long learning opportunities to develop evidence-based, innovative, effective

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instructional practices that could promote learning for students with ADHD in nursing

education.

Background, Context, and Theoretical Framework

The nursing profession is experiencing a shortage of nurses and the American

Association of Colleges of Nursing (AACN) (2014b) projects a shortfall of over one

million nurses by the year 2022. This is a staggering 36% shortfall between the supply

and demand for nurses (Allen, 2008). In light of this impending shortfall and subsequent

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crisis, alleviating the shortage of nurses is a priority in the profession. Leading nursing

experts have considered several strategies for further discussion.

One initiative suggested to ease this crisis was to provide innovative strategies to

recruit and retain students in nursing. According to Allen (2008), increased focus on

recruitment strategies that included examining new student populations and those barriers

that prevent admission to nursing programs should be a strong focal point of ongoing

research. Pragmatically, one of the key measures to alleviate the nursing shortage was to

retain students who have met the admission criteria and are attending nursing school. A

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second crucial factor was the evidence that supported the need for nurse educators to

have the skills to meet the educational needs of all learners with diverse backgrounds
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regardless of race, age, ethnicity, or educational history. The paucity of research into the

nursing student with learning disabilities, specifically ADHD, warrants increased

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attention.
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Disability Law

The United States has three laws that correspond to individuals with disabilities:

Section 504, Individuals with Disabilities Education Act (IDEA), and the Americans with

Disabilities Act (ADA) of 1990. Section 504 of the Rehabilitation Act of 1973 and the

Americans with Disabilities Act of 1990 are federally mandated acts designed to protect

the civil rights of disabled individuals (Hardcastle & Zirkle, 2012; Smith, 2001). Section

504 applies to those organizations who receive federal funding and the ADA applies to

all agencies including private schools who do not receive federal funds (Hardcastle &

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Zirkle, 2012). Section 504 was designed to “level the playing field” (Maheady, 1999, p.

162) for individuals with disabilities including life activities within and beyond learning

(Smith, 2001). The purpose of Section 504 was to ensure that individuals with

disabilities had the same access to education that individuals without disabilities had

(Hardcastle & Zirkle, 2012). Section 504 accomplished this by eliminating barriers that

excluded individuals with disabilities from participating in protected activities, including

a free and appropriate public education. As an educational benefit law, IDEA offers

additional services and protections for those with disabilities (Buchanan, St. Charles,

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Rigler, & Hart, 2010; Hardcastle & Zirkle, 2012; Smith, 2001). These laws are

characterized by different eligibility requirements and the benefits provided under each
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law. The definition of a disability is much broader under Section 504 than it is under

IDEA. IDEA students are covered by Section 504, whereas not all Section 504 students
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are protected under IDEA. An Individual Education Plan (IEP) is provided to students

covered by IDEA; the plan is tailored to the learner’s unique needs and must result in
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educational benefit. However, a Section 504 Plan provides accommodations based on the

student’s disability and resulting needs, but does not require academic improvement.

Finally, there is the ADA of 1990. This federal law protects students with disabilities

from discrimination and affords each learner an equal opportunity to education

(Buchanan et al., 2010). The guidelines supported by the ADA (1990) refer to all

students, regardless of age, including adult learners with ADHD.

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Historical Overview of ADHD

Initially, ADHD was thought to be a childhood disorder. However, exhaustive

research has shown that 40-80% of children diagnosed in elementary and secondary

schools will have manifestations of ADHD that persist into adulthood (Barkley, 2007;

Volkow & Swanson, 2013). Furthermore, research conducted on adults with ADHD has

revealed that these individuals struggle socially, psychologically, economically, and

academically (Buchanan, 2011; Marchetta, Hurks, Krabbendam, & Jolles, 2008). Over

the last decade, research into the adult with ADHD has branched out to include the

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college-age student. Findings have reported that young adults with ADHD suffer from

symptoms that include inattentiveness, poor memory retrieval, forgetfulness, poor social
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skills, lower collegiate grade point average (GPA), increased risk of academic probation,

higher dropout rates, and negative effects of self-control (Alderson, Kasper, Hudec, &
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Patros, 2013; Fleming & McMahon, 2012; Ramsay & Rostain, 2008). Although

researchers and scientists have made great strides in understanding the college student
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with ADHD, a gap in the research existed in understanding how to address these gaps.

Studies have estimated that the prevalence of ADHD in college students to be

anywhere between 2% and 8% although these statistics vary (Barkley, 1997; Buchanan,

2011; Fleming & McMahon, 2012; Weyandt & DuPaul, 2008). Cleveland and Crowe

(2013) reported that ADHD ranked second to all disabilities, physical and psychological,

registered in higher education. The impact of these statistics in college classrooms

influences the dynamics of the classroom and indicate an increasing need for effective

teaching strategies that foster success in students with ADHD.

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 Multiple studies have documented that the transition into college is a difficult one;

but experts agree that the transition is more problematic for individuals with ADHD

(Barkley, 2007; Buchanan, 2011). Norwalk, Norvilitis, and MacLean (2009) found that

students with ADHD experienced more challenges in dealing with this transition than

students without ADHD. The difficulty, as examined by Norwalk et al., stemmed from

the increased demands for self-organization, self-regulation, and independent thinking of

the individual with ADHD.

Over the past decade, many adults have been diagnosed with ADHD with an even

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higher percentage of individuals who present with characteristic symptoms but have

remained undiagnosed (Barkley, Murphy, & Fisher, 2008; Kane, Walker, & Schmidt,
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2011; Selekman, 2002; Vance & Weyandt, 2008). Because adults with ADHD

experience a wide range of symptoms with varied degrees of intensity, it is difficult for
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postsecondary educators to recognize ADHD in students undiagnosed or students who

have not disclosed their disability to faculty. Moreover, without an accurate diagnosis,
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adults affected with this disorder have continued to struggle in their daily lives with

limited resources and strategies (Barkley et al., 2008; Kessler et al., 2006). According to

a study conducted by Valente and Kennedy (2012), the number of undiagnosed adults

with ADHD is reported to be as high as 85%. A study conducted by Kessler et al. (2006)

determined that adult misdiagnoses were due, in part, to the lack of reliable tools to

measure adult symptoms. Kessler and colleagues concluded that additional research

should be conducted to establish dependable tools to measure the adult population in

order to detect those individuals undiagnosed with ADHD. Patel (2011) confirmed these

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findings in a similar study. These tools, once developed, will enable health care

practitioners to diagnose adults with ADHD. New insight into ADHD, using newly

developed adult diagnostic tools, could also provide educators with a basic knowledge

needed to identify symptoms of individuals previously undiagnosed.

Professional nurses who leave clinical nursing to pursue their master degree in

nursing are prepared to teach nursing theory, nursing concepts, and advanced skills. Few

nurse educators are instructed on teaching pedagogies to enhance learning in the

classroom. This is even more so when teaching students with learning disabilities

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(Bradshaw, 2006). For this reason, nurse educators need to be aware of the symptoms of

ADHD. The success of students with ADHD has the potential to improve with the
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appropriate accommodations and the use of effective teaching strategies for adult learners

with ADHD. Faculty knowledge specific to the young adult and college-age learner
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presenting with symptoms of ADHD is an important step to improving the academic

experience of these diverse students. Further, early identification of the disorder

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followed by essential individualized instruction in learning strategies may aid these

students in accomplishing their set goals.

The literature review for this study revealed few research articles that address

ADHD in nursing education. The number of nursing students with ADHD is unknown.

The field of nursing education lacks published information about nursing faculty’s

experiences working with students with ADHD, understanding student limitations and

challenges, and the lack of best practice teaching strategies lent credence to this research

study. To understand the best approach to educating students with ADHD, researchers

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must begin by looking through the eyes of the nurse educator. Understanding the needs

of nursing students with ADHD begins with faculty knowledge, understanding of the

disorder, evidence-based teaching strategies, and the identification of personal bias and

attitudes.

Theoretical Implications

The pursuit of lifelong learning and the acquisition of new knowledge are

consistent with the beliefs and values of educators in all disciplines and specifically in

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nursing education (Bradshaw, 2006). The Robert Woods Johnson Foundation (RWJF)

and the Institute of Medicine (IOM) (2010) established eight recommendations for the
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future of nursing practice. One resounding theme was the transformation of nursing

education. According the RWJF (2010) nursing institutions of education need to

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recognize the importance of lifelong learning and consider it a non-negotiable in nursing

practice. Following the RWJF publication, educator competencies were soon developed
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by the American Association of Colleges of Nursing (AACN), the Quality for Safety in

Nursing (QSEN), and the National League of Nurses (NLN) organizations.

Specifically, the RWJF (2010) argued that academic institutions must foster an

environment that encourages lifelong learning of nursing faculty. Nursing education

should require “all faculty to participate in continuing professional development and to

perform with cutting-edge competence in practice, teaching, and research” (RWJF, 2010,

para 3). Nurse educators must remain in the forefront of evidence-based practices to

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remain competent in nursing education. The educational competencies established by the

AACN foster lifelong learning.

The theoretical framework that supported this study was self-directed learning

(SDL). In addition, SDL supports the AACN Educator Competency framework. The

educator competencies developed by AACN provide an educational standard for nurse

educators. This SDL framework meets the needs of learners by addressing their desire

for further learning, professional responsibility, and a desire to become their best self.

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Statement of the Problem

Recent research showed an increase in the prevalence of students with ADHD

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entering colleges and universities including nursing education (Barkley, 1997; Buchanan,

2011; Davidson, 2008; Weyandt & DuPaul, 2008). Extensive research focused on
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children with ADHD and recent attention focused on the college-level learner. Evidence

supported that not all students chose to disclose their disability while others remained
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undiagnosed entering postsecondary education (Selekman, 2002; Shinn & Ofiesh, 2012).

A review of the literature revealed a paucity of research on nursing students with ADHD.

Davidson (2008) reported that nursing programs have experienced an increased

enrollment of students with learning disabilities. Most nursing faculty has been educated

to teach nursing concepts, theory, and psychomotor skills of the traditional learner;

however, few have been instructed on how to meet the needs of students with cognitive

learning deficits (Bradshaw, 2006). In fact, research showed that educators often lack

foundational knowledge about ADHD (Anderson et al., 2012). Bradshaw (2006) noted

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that some students enter the program without knowledge of their disabilities and then

struggle with the rigor of the nursing curriculum. Resulting course failures and program

dismissals decreased self-esteem and motivation, increased anxiety, escalated attrition

rates from nursing programs, and affected graduation rates (Bradshaw, 2006). According

to Anderson et al. (2012), educators who lack knowledge about ADHD could overlook

characteristic behaviors associated with the disorder. Those educators, who were

unaware of the classic signs and symptoms of ADHD, may have misconstrued the

behaviors as a lack of motivation or student laziness. Unfortunately, educators in post-

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secondary education often lack the knowledge to identify these undiagnosed students and

lose the opportunity to provide appropriate learning strategies (Anderson et al., 2012). In
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contrast, awareness by nursing faculty can guide students to appropriate resources to

prevent course failure and decreased self-confidence (Bradshaw & Schurr Salzer, 2003).
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This study examined the personal experiences of nursing educators who teach college

students with ADHD, their knowledge, teaching skills, and dispositions, in relation to
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educating students diagnosed of ADHD. This study sought to explore the basic core

knowledge about ADHD that will assist these educators to be alert for early signs of this

disorder in order to combat such negative outcomes.

Purpose of the Study

The purpose of this basic qualitative study was to explore nurse educator’s

general knowledge, skills, and dispositions regarding student nurse learners with ADHD.

The findings of this research broadened faculty awareness regarding common

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characteristics associated with ADHD and extrapolated teaching-learning strategies used

by the educators to decrease learning obstacles and improve student success.

Research Question(s)

What knowledge, skills, and dispositions do nurse educators currently possess

related to learners in their college classes with attention-deficit hyperactivity disorder?

1. How do nurse educators describe their knowledge relating to teaching ADHD

nursing students?

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2. How do nurse educators determine best practice strategies to accommodate and

support the ADHD nursing student?

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3. What pedagogical strategies do nurse educators use in the classroom to promote

the academic success of students with ADHD?

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4. How do nurse educators describe their dispositions towards ADHD nursing

students?
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Rationale, Relevance, and Significance of the Study

The interest for this study stemmed from the personal experiences of this

researcher. After twenty-five years of clinical and management experiences, the

completion of a master degree in nursing (MSN), and the natural life changes that came

from raising a family, this researcher chose to enter academia. Over the last seven years,

this researcher witnessed many students who struggled with the rigors of a nursing

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Rationale for the Study

All university faculty members are responsible to utilize various teaching

methodologies to support all types of students; educators must continue to expand their

knowledge and seek opportunities for personal growth and enlightenment. Current

research indicated that the college-age student population with ADHD remained under

investigated; with minimal research conducted in nursing education (Bradshaw, 2006).

This study was anticipated to illuminate, not only nursing faculty, but the university-wide

community about effective teaching strategies of students diagnosed with ADHD. One

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objective of this study was to encourage faculty to endorse lifelong learning in the best

interest of their nursing students with ADHD. The rationale for this proposed study was
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to explore the knowledge, teaching skills, and dispositions of nurse educators who teach
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in undergraduate postsecondary nursing education.

Relevance of the Study

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Every graduating student has an impact on the critical outcome of the nursing

shortage. This study recognized the responsibility educators have toward promoting the

success of all students, including those students with diverse learning needs (Jeffries,

2007). This increased awareness of knowledge deficiencies has the potential to develop a

closer relationship with disability services and subsequent sharing of information.

Strategies to enhance student self-confidence, self-advocacy skills, and study strategies

may improve a student’s self-perception, self-esteem, and motivation (Bradshaw, 2006).

Therefore, this study supported the development of evidence-based research to improve

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