Analysed data were mapped onto the five stages of Duffy’s conceptual model of identify transformation37 and presented under the following headings:
Pre-entry
Participants discussed their choice to enter nursing and while half of the participants had previous exposure to intellectual disability nursing it was not their first course choice or first nursing course choice and this resulted in students changing or leaving the course. However, while it may not have been a first choice for some, participants reported adjusting to the course and growing to love it.
“I just had to go into something …. I wanted the guards (Irish Police Force) but they hadn't recruited in a few years …. so I had to go into something, but it's been great, I love it …. three went to general and one left altogether”.
For those with prior exposure this helped them choose intellectual disability nursing and settle into their programme. Experience ranged from social contact through a drama group, to exposure during school placements or work experience and employment as a carer.
“I went to a unit within the service (names removed) …. we did a show with them in the (name removed) theatre …. I did get experience and I loved it …. I was care staff for a few years”.
Some students did not have any prior experience of intellectual disability nursing prior to accepting a place on the course and this was identified as a reason why some students left the programme. Participants suggested that exposure and experience would be beneficial to assist prospective students to be informed of the course and consider intellectual disability nursing as a career choice.
“Get experience first, cos how many people did we lose in the first year …. I'd say work as care staff for a while first”.
Prior knowledge and understanding of intellectual disability nursing was seen as essential to retention of students on the course. Participants who stayed on the programme had obtained information about the programme prior to choosing the course through schools and friends.
“I found out about it in school …. one of my friends was a year above me and she did this course, so she'd give me information about it”.
However, some knew very little about the programme and articulated they were entering blind but there was a need to just choose something. Regardless for those who remained on the course they found it enjoyable.
“I knew nothing about it until I went into it …. I went into it blind …. I just had to go into something, I didn't know what I was going into, but it's been a lovely course”.
Reaffirming
Participants described ‘a sense of belonging’ developed through engagement with a variety of placements provided across intellectual disability and other nursing care settings during their programme. Such placements created a sense of settling in however, while variety was seen as positive this was finely balanced by the fact that many placements were of a short duration.
“We'd have done various placements but only a few weeks at the most in each …. you can be working in the community, in family homes, in residential care …. and we did weeks in general, paediatrics, mental health”.
The variation offered in clinical placements sites assisted students to change their views on intellectual disability nursing as a career choice.
“If I was asked that a couple of years ago, I would have said Acute setting was what I wanted but not now…. I'd rather community setting”.
A key aspect of reaffirming was the development of participants identity as an intellectual disability nurse and part of this identity formation involved reconciling misconceptions of this minority discipline of nursing.
“It is a level 8, that it is a degree, and we are nurses we do all the other things other nurses do”.
Existing nurses had a key role in forming participants identity through engagement and mentorship. However, a negative aspect in identity formation were existing staff’s sense of value and commitment to their profession and their uncertainty led to participant questioning their value rather that consolidated it.
“You walk in, and a nurse is asking you questions keeping you on your toes …. but if you're working with someone who is fed up with their own job, they're going to tell you to get out …. but the whole RNID degree is about holistic care, and you know it is a different attitude and that’s important”.
Surmounting
Most of participants placements were in residential settings and participants were aware of the landscape shift of service to the community for people with intellectual disability and were surprised there were not more community placements.
“The majority of it you could say that 80% of it has been in residential settings …. I'm surprised there isn't more placement community based …. but I've been in two community houses back-to-back, two months and two months”.
While placements were predominantly in residential setting participants developed through learning on the job. However, a need for a greater focus on clinical skills development in the University setting was identified to enable participants gain greater confidence.
“There’s hands on learning all the time when you’re on placement … and most of it has been in a residential setting and that's the only limit I think but clinical skills, we don't get enough clinical skills experience or teaching …. we only got an hour on injections, and we did that was when in second year …. I know you're going to learn on the job as well but there needs to be more practical skills and OSCE’s …. you'd get it but not enough to be confident”.
Key to surmounting challenges was assuming leadership in one’s own learning.
“It's very hard sometimes to say can I do the medications with you because there's not enough people on the floor but once you just say it to them you do get more experience with medications, and they will let you help and let you get your experience with medications.
Stabilising
Exposure to clinical practice and experience enabled participants create their identity and stabilise their understanding of their role. The changing landscape of service provision meant that students were exposed to a variety of care models with a holistic care approach evident across services.
“We have the clinical, certain residential settings would be more clinical so you’re learning on the job you'd have like PEG experience …. we do all the other things that nurses do and it’s a holistic approach to like you know fulfilling somebody's life …. one community house is like the dream of community living and the other one can be all clinical or have extremely challenging behaviour and be very limited for the service users and it's opened my eyes to the congregated settings, it's not all black and white”.
While participant’s programme of study and placement were rewarding, they also created additional interests for consideration of their future careers related to intellectual disability or nursing.
“I'd love to do teaching, I'd love to teach kids with an intellectual disability or go to (named place) and do my children's nursing”.
One issue of concern to participants was the aspect of role clarity which they had to address within themselves during their programme.
“When we're on placement, and you're supposed to be getting nurse experience, but you do end up being the care staff, your kind of maybe on the floor while they're getting things done or doing their work”.
Actualising
Given the uncertainty and direction from intellectual disability nursing leadership regarding the transition of intellectual disability nurses within the changing landscape of service provision participants articulated concerns regarding limited job opportunity and job security.
“Have trained us for four years and there's not one job opportunity for us, at the moment anyway… It's kind of just a kick in the teeth then if they're not even offering one of us a job, you'd think they might have a few posts going …. a few years ago, they gave five jobs to one year but then they let them go again”.
Participants expressed insecurity regarding the recognition of the intellectual disability nurse’s role internationally which may limit opportunities to secure employment in other countries.
“But intellectual disability nursing it’s not recognised in places like America is it”.
Participants identified a clear need for direction and information regarding their role and career opportunities within Ireland.
“We don't know where it's going, you have to work a little bit harder and figure it out, it would be helpful for someone to sit down and actually tell us the possibilities for our future like I imagine someone coming in and saying you can actually do this or you can do this, there should be always someone you can go to like a manager or someone senior to you so if you are not sure of something that you can go to them”.
However, participants also saw opportunities in their nursing career pathway and role development.
“I think as it moves out to community that there's going to be a need for community CNS's (clinical nurse specialists) and community CNM’s (clinical nurse managers) and we'll be like public health nurses but for intellectual disability …. CNS’s and ANP's (advanced nurse practitioners) that's where I hope we're going …. the RNID (registered nurse intellectual disability) is overseeing care, interventions are signed up and written up by the nurse and if someone needs to go and have their medication's reviewed then a nurse will step in or if something needs support the nurse will step in”.
“For me there is a need around nutrition and also palliative care, we will be more clinical as well as we move out to community …. out in the community not in a residential setting, I'm hoping that's the future”.
To actualise their role fully some participants saw a need to further develop their nursing through a dual qualification. However, there was also a desire to do other healthcare professional training and leave nursing.
“I would like have a dual qualification, I’d do my children's nursing or I'd like to do occupational therapy or do speech and language”.
However, many want to stay within intellectual disability services but would like to diversify and compliment their nursing role.
“I'd like to still work in the intellectual disability sector, but just do something a bit different …. I'd like to do dietetics in a post grad, but that's for CNS, I still want to work in intellectual disability …. I'd love to teach kids with an intellectual disability”.
Part of the actualising process was the realisation of the role, expectations of the role and the need to transition from student to staff.
“You have to have to get at least six months work experience they expect so much when we qualify, the first six months as an actual staff nurse you will learn so much, we will be actually doing it yourself, being responsible for it as well …. medications will be a big thing but once you get into the mind frame, you're a qualified staff nurse we'll be fine”.
Participants expressed a clear desire to travel now or soon, and their plans were affected by what they understood as requirements in other countries.
“Most places require experience, if you're applying for Australia, you need a year's experience in Ireland, I'm going to Australia to work I'd love to go after a few years”.
For participants there was a lack of clarity regarding intellectual disability nursing in other countries as only Ireland and the United Kingdom have a recognised division on the register.
“It's not recognised in places like America …. there's some countries I think you can work as a psychiatric or registered nurse”.
Participants desire to travel was based on positive feedback from others and the fact that other friends had gone.
“We've heard a lot of good feedback from older nurses that have gone and come back and there’s nurses that are gone and still out there, you'd hear feedback from there and from your friends”.
The allure of travel was reinforced by what were perceived as a more positive work environment.
“It's so positive like there's such a positive working environment, it's quite appealing”.
However, some participants had to stay in Ireland due to family while other anticipated coming back in a few years. One participant intended to remain working abroad.
“At the end of the day your family is still here, I'm a home bird, I want to go but I would come back, give me two, three years over there and then I would come back well I don't know even if I came home for Christmas”.