Sign language students in hearing fieldwork practice: experiences from a Norwegian bachelor program in learning disability nursing

Purpose: This study explores the experiences of sign language students during fieldwork practice in learning disability nurse education within predominantly hearing clinical settings.

Methods: Semi-structured interviews were conducted with five sign language students and three fieldwork supervisors.

Results: Two overarching themes emerged: “responsibility for accommodations is placed mainly on the shoulders of the students” and “communication is more demanding for all parties.” While students reported positive aspects of their fieldwork experiences, they also described challenges such as coordinating interpreters, insufficient interpreter support during evenings and weekends, fatigue from noisy environments, and limited deaf awareness among staff. Supervisors highlighted the need for better pre-placement preparation. Communication barriers affected everyone involved and were closely linked to practical accommodations for fieldwork practice.

Discussion: The findings highlight the importance of proactive pre-placement planning, consistent use of qualified interpreters, and deaf awareness training for supervisors and staff to ensure inclusive and equitable fieldwork experiences for sign language students in professional education.

1 Introduction

Access to higher education is widely recognized as a gateway to professional opportunities and a better quality of life. Enrollment of deaf and hard-of-hearing students in universities has increased steadily over the past two decades. Yet, progression and graduation rates remain lower than those of their hearing peers (Garberoglio et al., 2021). Barnes (2017), in a UK-based doctoral study, revealed that deaf students frequently encounter obstacles accessing the whole curriculum, receive limited funding for interpreter support during work placements, and struggle with the challenges of navigating job interviews that require interpreter mediation. These factors restrict their ability to develop employability skills and frequently push them toward career paths within the Deaf community. The study underscores the need for universities to improve the transition to employment and support the development of work-related competencies to ensure deaf graduates have equal opportunities to succeed in the labor market.

Fieldwork practice is an integrated part of curriculums in some academic programs such as nursing, teacher education, and social work education. It represents an active learning process that facilitates the transformation of practical experiences into work skills and student knowledge (Lee and Fortune, 2013a). According to Lee and Fortune (2013a,b), learning activities in a social work practicum involve observing other professionals, process recording, linking theory with practice, and working independently. In Norway, 47% of bachelor programs include mandatory fieldwork components (Helseth et al., 2019). Yet, little is known of the experiences of sign language students in fieldwork practice, where learning depends heavily on predominantly spoken interactions with clients, colleagues, and supervisors. Of note, the term “sign language students” refers to both deaf and hard of hearing students who use sign language as part of their communication. Evidence shows that fieldwork and other work-experience components of university programs are often associated with accessibility challenges for deaf students (Barnes, 2019). In a UK study of deaf undergraduates, Barnes (2019) found that although students were generally able to acquire academic skills, the development of career-specific and job-seeking competencies was often limited by a lack of awareness among tutors and peers, as well as insufficient funding for interpreter support through Access to Work or the Disabled Students’ Allowance. As a result, deaf students’ opportunities to gain essential employability experience are frequently limited. These findings indicate that the transition from classroom to workplace is associated with distinctive challenges for sign language students; yet no research has examined how such issues emerge within fieldwork practice in health and social care education in Norway/Nordic countries.

In Norway, the bachelor’s program in learning disability nurse education (Norwegian: Bachelor i Vernepleie) is a 3-years applied academic program to become a health- and social worker specifically tailored to help individuals with physical, mental, and social disabilities. Fieldwork practice plays a critical role in the training of students in this program and students are required to complete 30 weeks of supervised practice focused on user needs in actual professional situations (Ministry of Education and Research, 2019). Throughout the supervised fieldwork practice, the students gain experience across the following areas: cross-professional and interdisciplinary collaboration, social education and rehabilitation, health promotion and health education, facilitation, inclusion and participation for individuals with intellectual disabilities, innovation, documentation and quality assurance. A fieldwork practice supervisor supports students in order to integrate theoretical knowledge into practice, offers feedback, tracks their progress, and makes sure that the students work toward their learning outcomes. Students can contact their university faculty for any professional, academic, or ethical questions related to the fieldwork practice.

In professional training programs, barriers to full participation arise not only from physical obstacles but also from prevailing societal attitudes. The concept of ableism is central to understanding these barriers, referring to structures, norms, and practices that privilege able-bodied norms and disadvantage people with disabilities (Hehir, 2002; Lid, 2022). This perspective is particularly relevant for sign language students in predominantly hearing fieldwork environments, where spoken communication norms and limited deaf awareness may reinforce systemic inequity. Related to ableism, we also draw on the concept of audism (Bauman, 2004) to highlight how hearing-centric norms and the privileging of spoken language can marginalize deaf and hard-of-hearing individuals. Audism refers to the belief that hearing and speech are inherently superior, shaping institutional practices and evaluations in ways that disadvantage sign-language users (Bauman, 2004). McGuire (2023) further argues that audism and phonocentrism (ideologies that treat sound and speech as the standard and most valued forms of communication) shape how deaf individuals are situated within “hearing spaces,” influencing their opportunities for participation and feelings of belonging. In clinical education, these hearing-normative expectations become especially salient, as spoken-language communication practices make participation more challenging for deaf and hard-of-hearing students.

Although access via sign language interpreters is critical in health care, research shows that such access alone does not guarantee participation (De Meulder and Haualand, 2021). In many healthcare interactions, deaf people still face significant communication challenges, even when an interpreter is present. Health professionals often lack awareness of deaf patients’ communicative needs and may assume that interpreter provision resolves all barriers, resulting in what Napier and Sabolcec (2014) describe as a “translated life,” where interaction is mediated rather than direct. In Norwegian postnatal and pediatric consultations, recent observational studies by Løkken (2024, 2025) revealed that even with interpreters, deaf parents do not always have full access to interaction: differences in gaze direction, turn-taking dynamics, and interactional footing often privilege spoken-language norms and position sign-language users at a disadvantage. Interpreter-based solutions may therefore create an illusion of inclusion, masking unequal language status and ongoing structural barriers in hearing-normative environments (De Meulder and Haualand, 2021). These dynamics are particularly relevant in clinical training contexts, where interaction with patients and supervisors is central to learning and where sign language students risk becoming peripheral participants despite having formal access.

Communication in hearing-dominated environments can also impose substantial physiological and cognitive demands. For hard-of-hearing students who used hearing devices, concentrating on lip-reading, speech perception, and environmental cues in noisy or dynamic settings may increase listening effort, sensory overload, and fatigue (e.g., Holman et al., 2019; Santana et al., 2025). Such fatigue can reduce participation throughout the fieldwork day, especially in busy and communication-intensive clinical environments.

In parallel with these challenges, scholars highlight that deaf individuals also bring unique communication assets to professional environments. The concept of Deaf Gain emphasizes the value of visual attention, non-verbal sensitivity, and diverse communicative strategies that can enhance interpersonal engagement and care practices (Bauman and Murray, 2013; McKee et al., 2013). In health and social care contexts, such competencies may facilitate meaningful interactions with care recipients who rely on visual communication or have limited spoken language. Recognizing Deaf Gain shifts the discourse from deficit to asset, framing sign-language students not as needing accommodation but as contributing valuable strengths in practice-based learning environments.

Research on inclusive education highlights the need to address barriers that arise from the learning environment rather than from individual learners. According to the social model of disability, obstacles such as unclear communication channels, limited accessibility, or ableist attitudes restrict participation for students with disabilities (Wilson, 2017). Universal Design for Learning (UDL) has been proposed as an approach to proactively reduce such barriers by designing curricula that anticipate and eliminate potential obstacles before instruction begins (Cumming and Gilanyi, 2023; Ok et al., 2017). Consistent with the social model of disability, UDL focuses on adapting the learning environment, rather than expecting the individual to adjust, in order to create equitable learning environments for students with special needs. This student-centered framework rejects the expectation that students must adapt cognitively or physically to a “hegemonic normal” curriculum shaped around able-bodied or neurotypical norms (Wilson, 2017). It also seeks to prevent exclusion by ensuring that all students, including sign language users, can participate fully in both academic and practice-based learning settings.

Guided by the concepts of ableism, audism, phonocentrism, and universal design, the present study aims to explore the experiences of sign language students during fieldwork practice in learning disability nurse education, particularly within hearing clinical settings. In this article, we use the term “inclusive fieldwork practice” to refer to fieldwork arrangements that are planned and implemented to enable all students, irrespective of functional limitations, to participate on equal terms. By examining the experiences of both students and fieldwork supervisors, we seek to identify factors that shape students’ learning and sense of belonging in clinical health fieldwork sites. Understanding these experiences is important for developing more inclusive fieldwork practice in higher education, both for students with disabilities in general and for sign language students in particular. As such, this study addresses the following research question: What factors, as reported by sign language students and fieldwork supervisors, influence sign language students’ experiences of fieldwork practice in learning disability nursing education?

2 Materials and methods

2.1 Fieldwork practice in this study

The data for this study were collected from one Norwegian bachelor’s program in learning disability nurse education. During the second year of the program, students undertook a 10-weeks fieldwork practice in healthcare settings such as municipal nursing homes and home nursing. During this period, students engaged directly with patients under the supervision of an experienced professional. The student and fieldwork supervisor sign a formal learning agreement that specifies the expected learning outcomes and responsibilities for the fieldwork practice period. Students perform various tasks related to daily care, guidance, rehabilitation, and support for independence. They also carry out nursing procedures and administer medications. Additionally, they learn to work in a team with other health workers, and to communicate effectively with patients, relatives, and other members of the interdisciplinary team. They also develop skills in assessing patients’ needs, creating and implementing care plans, and assessing the effectiveness of their care. Furthermore, they become familiar with laws, rules, and ethical guidelines relevant to health work, and how these are applied in practice. Finally, they reflect on their own practice, learning, and development, with support from a fieldwork practice supervisor.

It’s worth noting that during the first year of their education, the students underwent two periods of fieldwork practice. The first one took place over a period of 2 weeks in the first semester where students observed how trained health personnel communicated with their patients and coordinated medical and social services with clients. The second fieldwork practice occurred over 8 weeks in the second semester. This period of fieldwork allowed students to actively collaborate with their supervisors, enabling them to develop skills to prepare for the variety of services provided to clients. Importantly, during the first year, the majority of sign language students conducted their fieldwork practice in a Norwegian non-profit governmental foundation. This foundation provides services to deaf, deafblind, and hard-of-hearing individuals who may also have additional impairments such as mental, physical, or cognitive impairments. Most of the staff at this foundation can use sign language for communication, making it a sign language friendly environment.

2.2 Participants

A total of eight individuals participated in this study, comprising five sign language students in a Norwegian bachelor program in learning disability nursing and three fieldwork practice supervisors. The student group included three deaf students who used signed communication and two hard-of-hearing students who used both spoken language and sign language for communication.

2.3 Sign language students in learning disability nurse education

The five students were in their second year of the bachelor’s program and were interviewed individually at the end of their 10-weeks fieldwork practice during their fourth semester. The interviews explored their experiences, opinions, and perceptions of communication, supervision, and participation in fieldwork practice, including both barriers and facilitators to inclusion. As noted, two of the participants were hard of hearing and primarily used spoken language during fieldwork. One of these students used sign language interpreters only during professional lectures at the practice site, but neither required interpreter support in the fieldwork site nor during the interviews. The remaining three students were deaf and used sign language interpreters both during fieldwork practice and during the interviews for this study.

Two authors of the present study conducted the interviews; one of whom is a hearing fluent signer. Although one of the interviewers is a hearing fluent signer, all interviews with deaf participants were conducted with a sign language interpreter to ensure accuracy in communication, maintain consistency across interviews, and reflect the communication conditions the students experienced in their fieldwork practice. The interviews were carried out in a quiet room either at the university or at the fieldwork practice site and were video recorded to ensure accurate transcription. To guarantee the quality of the transcripts, a separate co-author, who is a native signer, reviewed and checked the transcriptions. Each interview took between 45 min and 1 h.

2.4 Fieldwork practice supervisors

Three fieldwork practice supervisors from three different fieldwork sites were invited for interviews upon completion of the fieldwork practice period. The interviewers met two fieldwork practice supervisors at the fieldwork sites during visits to interview students. In addition, we used Microsoft Teams to conduct an interview with another supervisor, as the practice site was located far from the interviewer’s workplace. The goal was to gather information from fieldwork supervisors about their experiences, opinions, and perceptions concerning fieldwork practice for sign language students. The interviews were audio-recorded for subsequent transcription. Each interview took approximately 30 min.

2.5 Procedure

The current research employed a qualitative approach, namely descriptive phenomenology, to explore the experiences of sign language students in fieldwork practice. We conducted semi-structured interviews using open-ended and follow up questions to understand the experiences of sign language students, as well as the perceptions of fieldwork practice supervisors in relation to the fieldwork practice in healthcare for sign language students.

For the sign language students, the interview focused on describing a typical day during the fieldwork practice, any unique experiences, challenges, or surprises encountered, noteworthy learning situations, and the supervision process. In addition, they were asked about the preparation for this fieldwork practice, including expectations, sign language interpreters, and communication. They were also asked to compare this fieldwork practice period with previous ones, and to provide advice for future sign language students interested in a similar fieldwork practice.

For fieldwork practice supervisors, the interviews focused on their experiences with sign language students during the fieldwork practice, a description of a typical day in the practice field, and any notable learning situations. They were also asked about any unexpected events during the practice, the supervision process, their actions to support students during the practice, comparison of this practice period with sign language students to previous supervision experiences with hearing students. Lastly, they were asked about any suggestions they might have for improving future practice for sign language students.

2.6 Ethical considerations

Ethical approval for this study was obtained from the Norwegian Agency for Shared Services in Education and Research (323933). All participants received written information regarding the study, including details about their right to withdraw from participation at any time. All participants gave written informed consent for participation in the study.

2.7 Data analysis

All interviews were audio-recorded, transcribed verbatim, and anonymized before being imported into NVivo 14 for analysis. The authors analyzed the data using Systematic Text Condensation (STC), an inductive and descriptive thematic cross-case analysis approach (Malterud, 2012). STC is well-suited for small qualitative interview datasets where the aim is to explore participants’ experiences and identify patterns across cases in a systematic and transparent way. STC consists of four key steps: (a) gaining an overall impression (from chaos to themes), (b) identifying and sorting meaning units (from themes to codes), (c) condensation (from code to meaning), and (d) synthesizing (from condensation to descriptive concepts). The analysis was conducted inductively and with an open mind, and no predefined codes or themes were applied prior to data examination.

NVivo 14 was used to support the organization and management of the data throughout the analytical process. To develop a general understanding of the material, five authors independently read the transcripts multiple times. Four of the authors then collaboratively discussed and negotiated the data, resulting in five preliminary code groups: (1) preparation before fieldwork practice, (2) supervision during fieldwork, (3) accommodations related to fieldwork sites and students, (4) collaboration with colleagues and workplace culture, and (5) collaboration with patients.

During step 3 of Malterud’s method of STC (condensation), the same four authors gathered and agreed to reframe the codes into six themes: (a) preparation before fieldwork, (b) supervision, (c) fatigue and sensory overload, (d) use of sign language interpreters, (e) relationships with colleagues, and (f) relationships with patients. In this step, the meaning units were grouped and transformed into first-person narratives representing the collective voice of participants. Illustrative quotations were selected to accompany the condensed texts.

In the two final team sessions related to step 4 of Malterud’s method (synthesis), the six themes were reorganized into two overarching thematic categories, “responsibility for accommodations is placed mainly on the shoulders of the students” and “communication is more demanding for all parties.” These categories were developed to better capture the central findings and address the research question: What factors, as reported by sign language students and fieldwork supervisors, influence sign language students’ experiences of fieldwork practice in learning disability nursing education? Of note, these categories are discussed in light of previous research and theoretical perspectives on ableism, as well as other relevant theoretical frameworks.

3 Results

The analysis resulted in two overarching thematic categories: (1) “responsibility for accommodations is placed mainly on the shoulders of the students” and (2) “communication is more demanding for all parties (sign language students, fieldwork supervisors, patients and employees at the fieldwork unit).” These categories are not mutually exclusive but represent interconnected aspects of the students’ fieldwork experiences. The first theme focuses on the practical aspects of accommodating sign language students in fieldwork and initial prejudice. The second addresses the social, interpersonal, and relational dimensions of communication.

1. Responsibility for accommodations is placed mainly on the shoulders of the students

Students frequently described needing to take initiative and take charge of making accommodations work. This included preparing for fieldwork practice, managing fatigue, arranging interpretation, and showing competencies in advocating for themselves.

1.1 Pre-placement preparation

Proactive and early communication between the university, the fieldwork site, and the student was identified as a key factor in facilitating a smooth start to the fieldwork practice. Students who experienced such coordination reported feeling welcomed and better integrated from the beginning. Conversely, a lack of preparation often led to confusion and frustration, negatively affecting the sense of inclusion. As one student described: “When I arrived on the first day with two interpreters, my supervisor was completely unprepared… I ended up going home, wondering how I was supposed to handle this. I got a bad impression; I felt rejected in a way on that first day.” Supervisors also noted the importance of being informed and involved in planning prior to the student’s arrival. One supervisor noted:

I think the most important information I could have received in advance was how to relate to a deaf or hard-of-hearing student. How different our language is, how I position myself so that the person can hear me or catch what I am saying, and how much facial expressions matter.

In addition, students emphasized that the responsibility for coordinating interpreters was placed mainly on their shoulders. Students had to coordinate interpreters and often guide them in new settings. Organizing interpreter support could be especially difficult for evening and weekend shifts when interpreters were not always available. As one student noted: “When I had long shifts on weekends, I didn’t get an interpreter.”

1.2 Prejudice

Although not always expressed directly, some students encountered prejudice or misconceptions about their abilities. As one student explained, staff showed uncertainty about using sign language in the ward:

I felt that staff were uncertain about what we can do. One day my supervisor told me not to use more sign language in one ward because someone said the patients did not want it. That stayed with me, because many patients were ill and confused, but the ones who could communicate were always happy to see me and wanted to talk. In the end, I realized it was not the patients, but a staff member. And then we automatically withdrew from that ward and were there less after that comment. That was a bit unfortunate.

Some students described that colleagues were hesitant or unsure about how to interact with them, particularly at the beginning of the fieldwork placement. This hesitation appeared to stem from limited experience with deaf individuals and the need to communicate through an interpreter: as one student reflected: “Maybe they were shy. They had never met a deaf person before. Because everything had to go through an interpreter. They tended to speak very quietly. They seemed shy.”

One student described that colleagues needed time to overcome uncertainty about communicating with a deaf student. This initial hesitation meant students had to take active responsibility for building trust with colleagues:

At first, I felt that colleagues were a bit afraid or unsure. That changed over time, but in the beginning I had to figure out how to connect with each person. On my previous placement, there were both hearing and deaf employees and we used sign language, but I still did not feel very connected to anyone. Here, I have had to break the code — how do I get in contact with this person and that person? How do I make my supervisor feel confident with me, so that we can build a good relationship?

Supervisors also noted that colleagues needed time to adjust their attitudes. One supervisor mentioned that some staff members were initially hesitant, but gradually developed more inclusive attitudes through direct interaction with deaf students. As one fieldwork supervisor reflected: “I have the impression that there is a bit of prejudice. I do feel it, unfortunately. But only from some people, not everyone.”

1.3 Fatigue and exhaustion

Both hard-of-hearing students and their supervisors noted the sensory overload and exhaustion from following conversations in noisy environments that were not acoustically adapted to their needs. Both students and supervisors noted that rooms in the buildings often had poor acoustics, which amplified background noise and resulted in listening fatigue for hard-of-hearing students. As one student noted “Plus, there is a lot of noise at the placement site, which makes me very tired.” As a consequence, frequent or extended breaks were often necessary, and students noted that even rest periods in the staff room did not provide adequate recovery. A fieldwork supervisor shared how facilitations were made to better support a student:

That’s why we had to set up a separate break room for student during the first weeks. The student was so exhausted, and I could see it, the student was completely “out of it,” so we tried to find other places where the student could take breaks, because the student couldn’t be with us in the regular break room.

Some students described how the continuous listening effort required in busy clinical environments led to significant cognitive fatigue. One student explained that the exhaustion accumulated throughout the week, leaving little energy for recovery or social life: “It means that after a week of practice — Monday, Tuesday, Wednesday, Thursday — you almost have to sleep all Friday, Saturday, and Sunday just to have enough energy for Monday.”

2 Communication is more demanding for all parties

Fieldwork practice in predominantly hearing environments presented unique communication demands for everyone involved (sign language students, fieldwork supervisors, patients and other employees at the fieldwork site). Several students described the effort required to initiate and maintain effective communication in dynamic clinical contexts.

2.1 Formal communication settings

Students found handover meetings particularly challenging due to rapid speech, multiple speakers, and lack of visual access. This led to exclusion from social conversations. One student reported that communication became particularly challenging during fast-paced meetings involving multiple professionals, which led to feelings of exclusion from essential learning situations:

At some meetings where many professions were gathered in the same room, I could only catch a few individual words, not full sentences. In those situations, I felt more like an object in the room than an active participant. Fortunately, I had supervisors who understood this and allowed me to wait outside the meeting and then gave me the information afterward.

Some students shared that working through an interpreter could make it more difficult to establish direct relationships with patients. In cramped rooms or emotionally sensitive settings, the presence or placement of an interpreter could unintentionally disrupt the interaction. As one student described: “Sometimes the room is small, or the interpreter is placed too far from me or the patient, and the communication becomes awkward. Some patients even look at the interpreter instead of me, and that makes me feel invisible.”

One fieldwork supervisor elaborated on this point, noting: “In situations where you need to act quickly (like when a patient resists care), it’s not easy to sign. You can’t just let go of the patient in the middle of it. Those situations are hard.” Supervisors also noted challenges in communication, especially when the student could not see the patient’s face during care tasks. This sometimes led to missed verbal cues.

At the same time, both students and fieldwork supervisors highlighted that the non-verbal communication played a crucial role in building relationships, especially with patients. Students described how attention to facial expressions and gestures enhanced their ability to respond to patients’ needs. As one student reflected:

My supervisor said that I work in a completely different way, as I read the patient. For example, when a patient had incontinence, I could see from small movements, like their legs shaking, that they needed the toilet. The supervisor said this was something they had not noticed. For me it feels natural; I use visual skills like body language and facial expressions, which supervisors also commented on during practice.

Supervisors also observed that students’ sensitivity to non-verbal cues benefited patient care, particularly with older individuals or those with cognitive impairments. One supervisor remarked: “I think the student has even more value for older patients because they read body language much more clearly than many others. Sometimes it’s like the student already knows what the patient is about to say, just by watching them.”

2.2 Interpretation quality and interpreter-student dynamics

Students highlighted that the quality of interpreting and the interpreter’s familiarity with the clinical setting greatly influenced communication and learning. Inconsistent or inexperienced interpreters presented challenges, as noted by one student: “I got a newly educated interpreter. A nice person, but it really wasn’t right to put an inexperienced interpreter on a dementia ward – you probably need a bit of experience to interpret in those situations.” One student also noted:

It is also challenging when interpreters are replaced often, or when there is no interpreter available on weekends. Then I either have to manage without an interpreter and use written communication, or work alone. I am the one who must make sure that the interpretation works, and it becomes exhausting to always have to oversee and lead the interaction.

Supervisors also recognized that the consistency of interpreters affected the overall quality of communication and the engagement of students in fieldwork practice. Some noted that when the same interpreter was used throughout the fieldwork practice, communication became more fluid and efficient.

2.3 Supervision and mutual adaptation

Students emphasized the importance of supervisors who were open, attentive, and willing to adapt their communication style. Supervisors who faced students while speaking, used gestures, or repeated instructions were especially appreciated. One student noted: “My supervisor understood that I am a deaf student. They told me that if there was anything I needed, I should just let them know.” Some participants highlighted situations where supervisors actively adapted their communication to ensure inclusion, with one student describing how supervisor adjusted speaking style and remained confident in interacting even when hearing technology was unavailable:

Whenever I didn’t hear something, she used clear mouth movements so I could understand. Sometimes I had taken off my hearing aid, or the battery was low, and she was still able to communicate with me using only her mouth — full sentences. She was not afraid to communicate with me. That made me feel truly included, even when the battery was empty.

Some supervisors were initially unfamiliar with working with deaf or hard-of-hearing students, but learned through the process. As one supervisor reflected: “But I notice that I really have to work on myself to speak clearly when I explain things; I have to make an extra effort, because I know I can speak fast.”

4 Discussion

This study set out to explore what factors, as reported by sign language students and fieldwork supervisors, influence sign language students’ experiences of fieldwork practice in learning disability nursing education. The findings provide new insights into how these students experience fieldwork practice in predominantly hearing environments. Two overarching themes emerged: “responsibility for accommodations is placed mainly on the shoulders of the students,” and “communication is more demanding for all parties (sign language students, fieldwork supervisors, patients and employees at the fieldwork unit).” Students experienced communication breakdowns during fieldwork, insufficient interpreter support (particularly during evening and weekend shifts), as well as inconsistency in interpreter assignments. Some interpreters lacked experience or familiarity with healthcare settings, and accommodations often depended on the students themselves to manage in the moment. Inaccessible physical environments and limited deaf awareness among staff further contributed to fatigue, social isolation, and increased stress among students.

Despite these challenges, the fieldwork practice offered significant opportunities for learning. The students especially demonstrated meaningful interactions with patients through non-auditory communication (using touch, body language, lip-reading, and sign language) which enabled them to build connection. Supervisors were generally positive but expressed uncertainty about how best to support students, especially when it came to communication in time-sensitive care situations. Overall, the findings point to a need for coordinated inclusion practices between universities and healthcare practice sites to promote inclusive fieldwork practice for all students.

Our findings are consistent with earlier studies that emphasize the gap between formal inclusion and actual participation for sign-language students in higher education (e.g., Batista and García, 2023; Hendry et al., 2021; Kermit and Holiman, 2018; Listman et al., 2024; Thoutenhoofd et al., 2025). Even when sign language students are officially admitted and provided accommodations, they often remain on the margins of full participation because of social and communication barriers. As noted earlier, UDL emphasizes the proactive removal of environmental barriers so that participation does not depend on individual adaptation. This indicates a need for UDL-informed planning of supervision, communication routines, and expectations in clinical training. Integrating UDL principles may therefore strengthen equal access and reduce the risk of sign-language students becoming peripheral participants during fieldwork practice.

Our findings are consistent with Kermit and Holiman (2018), who reported that even when deaf students had access to interpreters and academic accommodations, many still felt excluded from informal learning and social interactions. This reflects a similar broader pattern identified by Powell et al. (2014) among university students; although accommodations like interpreters and visual communication aids are essential for full participation, they are not often sufficiently provided. There were several instances in our study where support was either lacking or not sufficient, reinforcing the argument made by Powell et al. (2014) for greater institutional awareness and improved resources to meet the needs of sign language students in fieldwork practice.

Importantly, our findings extend the existing literature by incorporating the perspectives of fieldwork supervisors, a viewpoint that has seldom received attention in prior research. Recent research in Norway by Langørgen et al. (2020) found that academic staff and fieldwork supervisors often expressed ambivalence toward students with disabilities, stemming from role ambiguity, limited training, time pressures, and a lack of structural support. Similarly, supervisors in our study struggled to balance their responsibilities as both mentors of professional competence and facilitators of inclusive learning environments. One supervisor expressed concerns about how to ensure patient safety in situations requiring rapid auditory communication, such as emergency situations. These concerns reflect the “conflicting roles and values” identified by Langørgen et al. (2020).

In addition, our findings are in line with Langørgen and Magnus (2020) which in a Norwegian study of students with disabilities in professional education, found that structural barriers and insufficient planning often placed students at risk of being unable to cope with the demands of fieldwork practice or to demonstrate their professional competence. We reason that, similar to our study, insufficient planning when placing students in fieldwork sites reduced their opportunities to demonstrate competence and to cope with the demands of practice, particularly in relation to interactions with colleagues in the units and with patients.

Our findings also revealed that supervisors’ attempts to learn basic sign language had a positive impact on students. One supervisor described how they and their colleagues tried to use simple signs such as “yes” and “understand” during interactions with the deaf student. The student responded positively, and we suggest that this fostered not only a sense of belonging but also a sense of recognition of student’s Deaf identity and culture. These small but intentional efforts contributed to a more inclusive learning environment in fieldwork sites. This is in line with previous research by Kermit and Holiman (2018), who emphasized that educators’ familiarity with sign-language communication and Deaf cultural competence is essential for meaningful inclusion.

A prominent barrier identified in our research and existing literature is limited understanding of deaf awareness and cultural norms and ongoing ableism within healthcare education environments. Supervisors and staff, often unfamiliar with deafness, may hold implicit biases about sign language students’ capabilities or view accommodations as burdensome. In a recent study of deaf students in Scotland, Hendry et al. (2021) noted that university staff and peers often lacked deaf awareness, leaving students feeling isolated and unsupported. Our participants highlighted this, describing how some colleagues would speak to them without facing them or neglected to adjust their communication, behaviors that reflect a lack of deaf awareness. Such instances may be interpreted as manifestations of structural ableism embedded in the norms of clinical health training settings.

In addition, we interpret the results within audism theory, which describes how hearing-centric assumptions operate at both individual and institutional levels to disadvantage sign language students in fieldwork practice systematically (Bauman, 2004). In our study, manifestations of audism were evident in situations that implicitly valued oral/aural participation, such as a preference for direct speech rather than mediated communication through interpreters, throughout fieldwork practice. These forms of bias are in line with ableism (Hehir, 2002; Lid, 2022). Research in nursing education has found that ableist assumptions are often reflected in evaluations of students with disabilities (for instance, presumptions that a deaf student might be a safety risk or unable to handle certain tasks) (Epstein et al., 2024). In our study, some supervisors initially expressed concern about patient safety in urgent situations that required rapid verbal communication when working with a sign language student. These concerns often focused on the student’s limitations rather than on identifying adaptive strategies. This is in line with Epstein et al. (2024)’s observation that ableism biases perceptions of disabled students’ competence for clinical practice.

As introduced earlier, the concept of Deaf Gain highlights that deaf and hard-of-hearing individuals contribute valuable strengths in interaction and communication (Bauman and Murray, 2013). For example, one supervisor observed that how the unit team began to learn basic signs after working with a deaf student. These reciprocal learning moments not only enhanced the student’s sense of belonging but also improved the team’s awareness of diverse communication methods. We reason that gaining transferable skills (such as speaking more clearly and slowly, and also consistently ensuring mutual understanding) are useful in interactions with patients with diverse communication needs. Similar benefits have been documented in medical education, where sign language trainees enhance the learning experience of hearing colleagues and faculty (McKee et al., 2013).

4.1 Implications

Considering our findings, we propose several key strategies to improve inclusive fieldwork experiences for sign language students in health and social care education settings.

4.1.1 Proactive pre-placement planning and coordination

Prior to the start of fieldwork practice, the university, fieldwork site, and student should collaborate on an accommodation plan. This includes clarifying how communication will be handled in various scenarios (e.g., team meetings, emergency situations) and ensuring necessary accommodations are possible.

4.1.2 Deaf awareness and communication training for supervisors and on-site healthcare personnel

Fieldwork sites should not assume that supervisors and healthcare staff in the fieldwork sites automatically know how to communicate with a sign language student effectively. Providing orientation or training on deaf awareness can enhance awareness, reduce unconscious bias, and subsequently prevent the isolation of sign language students. Supervisors and staff need to understand how to work with interpreters, use written or visual communication when necessary, and ensure clear communication in emergency situations involving patients.

4.1.3 Providing consistent and high-quality sign language interpreters

A recurring challenge identified in our study was the inconsistency in the provision of sign language interpreters for some students. To address this gap, institutions must ensure that qualified sign language interpreters, or, where appropriate, alternative communication accommodations such as real-time speech-to-text transcription or other assistive listening technologies are available during fieldwork practice to ensure inclusive participation. Consistency is important; when support from experienced sign language interpreters is intermittent, sign language students may experience uncertainty and risk missing key information during periods without enough support.

4.2 Limitation and future directions

While this study offers valuable insights, it also has some limitations. The sample comprised five students and three supervisors from a specific academic field in Norway, which means the findings should be generalized with caution. Despite its limitations, the study offers rich information that may guide fieldwork practice in similar settings. We suggest future research consider larger numbers of sign language students across multiple institutions to identify patterns in students’ experiences in fieldwork practice of sign language students.

Another important direction is to explore the perspectives of additional groups involved in fieldwork practice for sign language students. It is also important to include university teachers and administrative staff responsible for organizing fieldwork practice, as their perspectives can offer valuable insight into how institutions can better facilitate fieldwork practice for sign language students. Further, interviewing sign language interpreters could provide insight into how best coordinate the student–interpreter–supervisor or student–interpreter–patient triads. Similarly, gathering feedback from patients in healthcare settings might highlight ethical and practical considerations in providing care via an interpreter.

5 Conclusion

This study is the first to explore how sign language students experience fieldwork practice in predominantly hearing environments within learning disability nurse education. The findings highlight both structural and interpersonal barriers to equitable participation in fieldwork practice, including communication challenges, lack of coordinated interpreter support, sensory fatigue, and limited deaf awareness among supervisors and on-site staff. Despite these obstacles, students exhibited resilience and professional development, particularly in developing patient relationships and adapting to clinical expectations. In addition, our findings highlight coordinated efforts between universities and healthcare practice sites are needed. Proactive planning, consistent interpreter availability, and deaf awareness training must be included in fieldwork practice for sign language students in order to create inclusive, accessible, and equitable fieldwork learning environments for all students.

Data availability statement

The datasets presented in this article are not readily available because they are in Norwegian language and it might be possible to identify the participants. Requests to access the datasets should be directed to c2hhaHJhbS5tb3JhZGlAdXNuLm5v.

Ethics statement

The studies involving humans were approved by Norwegian Agency for Shared Services in Education and Research (323933). The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

Author contributions

SM: Conceptualization, Software, Investigation, Writing – original draft, Writing – review & editing, Project administration, Data curation, Methodology, Validation, Formal analysis. SV: Conceptualization, Writing – review & editing, Investigation. CM-S: Methodology, Formal analysis, Writing – review & editing, Data curation. MS: Data curation, Conceptualization, Software, Formal analysis, Investigation, Writing – review & editing. LL: Writing – review & editing, Formal analysis, Investigation, Data curation, Methodology, Software. TB: Investigation, Supervision, Software, Conceptualization, Formal analysis, Project administration, Writing – review & editing, Methodology, Writing – original draft, Data curation.

Funding

The author(s) declared that financial support was not received for this work and/or its publication.

Acknowledgments

We would like to thank Sabine Gehring for her valuable support to this project.

Conflict of interest

The author(s) declared that this work was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Generative AI statement

The author(s) declared that generative AI was not used in the creation of this manuscript.

Any alternative text (alt text) provided alongside figures in this article has been generated by Frontiers with the support of artificial intelligence and reasonable efforts have been made to ensure accuracy, including review by the authors wherever possible. If you identify any issues, please contact us.

Publisher’s note

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