Clinical placements in intellectual disability nurse education_ A scoping review

https://doi.org/10.1016/j.nedt.2020.104593 Received 17 March 2020; Received in revised form 12 July 2020; Accepted 8 August 2020 ⁎ Corresponding author. E-mail addresses: owen.doody@ul.ie (O. Doody), louise.l.murphy@nuigalway.ie (L. Murphy), mairead.moloney@ul.ie (M. Moloney). Nurse Education Today 94 (2020) 104593 0260-6917/ © 2020 The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/BY/4.0/). T disability go unrecognised and unmet (Hatton and Emerson, 2015; Trollor et al., 2017), their health care needs have become more complex (Mason and Phipps, 2010; Clapham, 2014) and there is a growing ageing population (Cleary and Doody, 2017). Ireland and the United Kingdom (UK) continue to recognise the need for specialist intellectual disability nurses, now and into the future. This is endorsed by the regulatory bodies (NMC, 2010; NMBI, 2016), and reviews of intellectual disability nursing by the Scottish Government (2012) in the modernising learning disabilities review and in Ireland Shaping the Future of Intellectual Disability Nursing in Ireland (McCarron et al., 2018). This paper aims to identify the range and efficacy of clinical placements currently utilised within intellectual disability undergraduate nurse education. 2. Method A scoping review was chosen as it enables the presentation of a broad understanding and knowledge synthesis of the available literature centered on the review question/s and is not restricted by study quality or design (Arksey and O'Malley, 2005). Scoping reviews ascertain what available evidence has/has not been explored and their results are utilised to plot the publications by classifying constituents of the literature, such as; design of the study, population, setting, intervention, theoretical/conceptual framework, aspects of importance, and results. This leads to an understanding of the extent and gravity of the literature. Scoping reviews are utilised to discover literature on a specific topic, recognise key ideas, highlight gaps in existing literature and disseminate results (Arksey and O'Malley, 2005; Levac et al., 2010). Within this scoping review Arksey and O'Malley (2005) and Levac et al. (2010) methods are utilised. This involved a five step process: (a) identifying the research question, (b) identifying relevant studies, (c) study choice, (d) plotting the data, and (e) arranging, summarising, and communicating the outcomes. While the five step process is styled in a sequence direct approach, it is an interactive approach where each step is returned to and advanced during the course of the review. Results are conveyed by means of a narrative in addition to charts, tables and diagram illustrations (Arksey and O'Malley, 2005; Levac et al., 2010; Colquhoun et al., 2014). 2.1. Identification of the research question This review planned to address the following questions: (a) What type of clinical placements are utilised within intellectual disability undergraduate nurse education? (b) What methods have been used to assess effectiveness of clinical placements within intellectual disability undergraduate nurse education? (c) What factors guide the decision to include clinical placements within intellectual disability undergraduate nurse education, and (d) What gaps in the literature exist on clinical placements within intellectual disability undergraduate nurse education? 2.2. Identification of relevant studies To gain a greater range of literature a broad range of keywords for search terms were adopted (Arksey and O'Malley, 2005). Procedures for searching incorporated, subject headings and Boolean operators to broaden and combine searches. Searches were performed using the Title OR Abstract and Keyword options, with each search string searched individually and subsequently all three strings combined (Table 1). Inclusion and exclusion criteria were devised and applied to the search strategy (Table 2) and this systematic search strategy was utilised to detect relevant papers across eight electronic databases (CINAHL, Academic Search Complete, MEDLINE, PsycArticles, PsycINFO, EMBASE, Scopus, Web of Science). 2.3. Study selection The electronic database searches produced an original set of 699 papers and after duplications removed, 498 papers remained. Initial screening of title and abstracts was conducted. Papers were deemed pertinent if their abstracts described clinical placement and included intellectual/learning disability student nurses in their samples. Papers were included if they related to clinical placement, or intellectual/ learning disability student nurses. Guided by inclusion and exclusion criteria (Table 2) within the title and abstract review 476 papers were excluded with twenty-two papers making it through to full text review. Full text papers were assessed, appraised and agreed by the authors and within this process the reference lists of each paper were screened for further additional relevant literature. The paper selection process followed the Preferred Reporting of Items for Systematic Reviews and MetaAnalyses (PRISMA) Statement (Moher et al., 2009). Fig. 1 illustrates the process of papers selection and after applying the inclusion/ exclusion criteria, ten papers met the criteria for this review. 2.4. Plotting the data The aims of this scoping review were to map the existing literature in terms of volume, nature, characteristics and sources of evidence (Daudt et al., 2013). Therefore, it was decided that research design was not an inclusion criterion. All papers that met the inclusion criteria were included. Plotting the data stage involved charting the selected papers (n = 10) as per Arksey and O'Malley's (2005) process involved extracting summaries from each paper related to: author, year, title, country, aim, placement type, design, sample, study methods, summary and considerations. Detail of the extracted data is included in Table 3 and of the ten included papers six were qualitative, one quantitative, one literature review and two discussion papers. 2.5. Arranging, summarising and communicating the outcomes Arksey and O'Malley's (2005) final stage summarises and communicating findings. This scoping review generated ten papers from two countries, nine of which were from the United Kingdom (UK) and one from Australia. Of note was an absence of literature from Ireland which is one of only two countries that has direct entry intellectual disability Table 1 Search strategy. String 1 Intellectual disability OR learning disability OR developmental disability String 2 Clinical placement OR practice placement OR placement OR clinical learning environment String 3 Student nurse OR undergraduate OR student OR pre-licensure OR baccalaureate String 4 S1 AND S2 AND S3 Table 2 Inclusion/exclusion criteria. Criteria for inclusion Clinical/practice placement Intellectual disability student nurses Possible to extract data regarding intellectual/learning disability placement Articles published prior to 04-02-2020 Exclusion criteria Simulated environments General/Adult nursing students Mental health/psychiatric nursing students Children's nursing students Midwifery students O. Doody, et al. Nurse Education Today 94 (2020) 104593


Introduction
In tertiary education, nursing programmes are highly reliant upon their clinical partners in order to provide the clinical placement necessary for their programmes. In intellectual disability the profile of clinical placements and organisations that provide placements have changed over the years, representing the growing diversity of healthcare delivery (moving from congregated settings to community and primary care, and the personalisation of services). Although the significance of the clinical placement element of pre-registration nurse training is engrained (Lofmark et al., 2008;Bernsten and Torunn Bjork, 2010), the changing healthcare landscape has given rise to the need to reconsider the areas most appropriate to support and develop student learning. The progression and change of service configuration and service provision has resulted in a reduction of the number of traditional (residential) clinical placements areas available. This change is reflective of the fact that people with an intellectual disability previously supported in institutional settings now being assisted to live more independently and included within their community (Turner et al., 2004) and demanding a more person centred approach to care (Anderson, 2009). There are also evolving demands on healthcare related to the ageing profile of the population (Department of Health, 2013), with increasing life expectancy associated with higher levels of disability (Henderson et al., 2008;Hughes-McCormack et al., 2018) and more severely ill people receiving care at home (Lofmark et al., 2008;McCarron et al., 2018). This suggests a continued increase in the shift of care from residential facilities and the role of nurses in order to meet these evolving needs. Thereby, intellectual disability nursing now and into the future necessitates an exclusive amalgamation of both practical and relational skills (Jaques et al., 2018).
The philosophy changes over the years, has led to curriculum changes, as the care of people with intellectual disability did not fit fully with the medical model that persisted as the dominant force in some educational programmes (Seccombe, 2007a). For students having an affirmative clinical placement exposure is related to the growth of clinical skills (Henderson et al., 2007) however, exposure alone lacks value in creating confident outlooks (Ten Klooster et al., 2009). Therefore, there is a need to consider students' attitudes towards placement areas and client groups (Seccombe, 2007b). Placement areas need to reflect the holistic approach expected within modern healthcare provision, and meet the required standards as set by the regulatory bodies such as the Nursing and Midwifery Board of Ireland (NMBI, 2016) and the Nursing and Midwifery Council (NMC, 2010). This is essential as often the healthcare needs of persons with intellectual https://doi.org/10. 1016/j.nedt.2020.104593 T disability go unrecognised and unmet (Hatton and Emerson, 2015;Trollor et al., 2017), their health care needs have become more complex (Mason and Phipps, 2010;Clapham, 2014) and there is a growing ageing population (Cleary and Doody, 2017). Ireland and the United Kingdom (UK) continue to recognise the need for specialist intellectual disability nurses, now and into the future. This is endorsed by the regulatory bodies (NMC, 2010;NMBI, 2016), and reviews of intellectual disability nursing by the Scottish Government (2012) in the modernising learning disabilities review and in Ireland Shaping the Future of Intellectual Disability Nursing in Ireland (McCarron et al., 2018). This paper aims to identify the range and efficacy of clinical placements currently utilised within intellectual disability undergraduate nurse education.

Method
A scoping review was chosen as it enables the presentation of a broad understanding and knowledge synthesis of the available literature centered on the review question/s and is not restricted by study quality or design (Arksey and O'Malley, 2005). Scoping reviews ascertain what available evidence has/has not been explored and their results are utilised to plot the publications by classifying constituents of the literature, such as; design of the study, population, setting, intervention, theoretical/conceptual framework, aspects of importance, and results. This leads to an understanding of the extent and gravity of the literature. Scoping reviews are utilised to discover literature on a specific topic, recognise key ideas, highlight gaps in existing literature and disseminate results (Arksey and O'Malley, 2005;Levac et al., 2010). Within this scoping review Arksey and O'Malley (2005) and Levac et al. (2010) methods are utilised. This involved a five step process: (a) identifying the research question, (b) identifying relevant studies, (c) study choice, (d) plotting the data, and (e) arranging, summarising, and communicating the outcomes. While the five step process is styled in a sequence direct approach, it is an interactive approach where each step is returned to and advanced during the course of the review. Results are conveyed by means of a narrative in addition to charts, tables and diagram illustrations (Arksey and O'Malley, 2005;Levac et al., 2010;Colquhoun et al., 2014).

Identification of the research question
This review planned to address the following questions: (a) What type of clinical placements are utilised within intellectual disability undergraduate nurse education? (b) What methods have been used to assess effectiveness of clinical placements within intellectual disability undergraduate nurse education? (c) What factors guide the decision to include clinical placements within intellectual disability undergraduate nurse education, and (d) What gaps in the literature exist on clinical placements within intellectual disability undergraduate nurse education?

Identification of relevant studies
To gain a greater range of literature a broad range of keywords for search terms were adopted (Arksey and O'Malley, 2005). Procedures for searching incorporated, subject headings and Boolean operators to broaden and combine searches. Searches were performed using the Title OR Abstract and Keyword options, with each search string searched individually and subsequently all three strings combined (Table 1). Inclusion and exclusion criteria were devised and applied to the search strategy (Table 2) and this systematic search strategy was utilised to detect relevant papers across eight electronic databases (CINAHL, Academic Search Complete, MEDLINE, PsycArticles, Psy-cINFO, EMBASE, Scopus, Web of Science).

Study selection
The electronic database searches produced an original set of 699 papers and after duplications removed, 498 papers remained. Initial screening of title and abstracts was conducted. Papers were deemed pertinent if their abstracts described clinical placement and included intellectual/learning disability student nurses in their samples. Papers were included if they related to clinical placement, or intellectual/ learning disability student nurses. Guided by inclusion and exclusion criteria (Table 2) within the title and abstract review 476 papers were excluded with twenty-two papers making it through to full text review. Full text papers were assessed, appraised and agreed by the authors and within this process the reference lists of each paper were screened for further additional relevant literature. The paper selection process followed the Preferred Reporting of Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement (Moher et al., 2009). Fig. 1 illustrates the process of papers selection and after applying the inclusion/ exclusion criteria, ten papers met the criteria for this review.

Plotting the data
The aims of this scoping review were to map the existing literature in terms of volume, nature, characteristics and sources of evidence (Daudt et al., 2013). Therefore, it was decided that research design was not an inclusion criterion. All papers that met the inclusion criteria were included. Plotting the data stage involved charting the selected papers (n = 10) as per Arksey and O'Malley's (2005) process involved extracting summaries from each paper related to: author, year, title, country, aim, placement type, design, sample, study methods, summary and considerations. Detail of the extracted data is included in Table 3 and of the ten included papers six were qualitative, one quantitative, one literature review and two discussion papers. Arksey and O'Malley's (2005) final stage summarises and communicating findings. This scoping review generated ten papers from two countries, nine of which were from the United Kingdom (UK) and one from Australia. Of note was an absence of literature from Ireland which is one of only two countries that has direct entry intellectual disability  undergraduate nurse education and training. The findings of the review are identified under the four key questions identified in step one of the review process.

What methods have been used to assess effectiveness of clinical placement within intellectual disability undergraduate nurse education?
Within this review many forms of data were evident to assess the effectiveness of clinical placement such as; comments from clients and students (Atkinson and Williams, 2011), survey of families providing placement (Finlayson and Darbyshire, 2015) or students (Green, 2018), graded student assessment (Goddard et al., 2010), interviews of families (McClimens et al., 2017) or students (Owen and Standen, 2007), case studies (Pollard, 2009) and student reflection (Taylor, 2016).
What factors guide the decision to include clinical placement within intellectual disability undergraduate nurse education?

What gaps in the literature exist on clinical placement within intellectual disability undergraduate nurse education?
Given that, the evidence specific to intellectual disability undergraduate nursing students' clinical placements is sparse, there is a need for further and continual research and publications in many areas. From a practice perspective, there is a need for evidence regarding preceptorship/mentorship, guidance and support for both preceptors/ mentors and students, and given the changing landscape of intellectual disability services there is a need to consider alternative placements of intellectual disability nursing students beyond that of traditional (residential) placements. However, these need to be considered in terms of how they will meet the professional training and education standards  A descriptive paper with comments from a service user (co-author) and nursing students.
Students of a learning disability nurse training programme. Number of students not identified.
Comments from a service user (co-author) and nursing students. None.
There are tremendous benefits to service user involvement in learning disability nurse education. The knowledge students gain from service users often far outweighs any insight lecturers could have given.   Content analysis (Joffe and Yardley, 2004) and arranged into themes (Braun and Clark, 2006).
Family placement afforded students with a different experience, perspective and understand of how families live.
The value of family placement needs to be considered in line with current service provision and professional education and training standards and requirements. Owen and Standen (2007) Attracting and retaining learning disability student nurses. United Kingdom.
To investigated the factors that influence students to train as learning disability nurses, and those that influence their decision to continue or leave the course.
Practice placement settings.
Longitudinal study.
Framework analysis (Ritchie and Spencer, 1994). Some students felt out of their depth in their placement, lacking basic knowledge and skills to cope in the environment and felt unsupported.
Student placement impacts their decision on their decision to remain on a course and placement staff need to be aware of the support and guidance students need.
(continued on next page) O. Doody, et al. Nurse Education Today 94 (2020) 104593 requirements. From a viability perspective there is a need to consider the effect of student placement on the students' decision to continue their undergraduate nurse training and remain in the profession post qualification. Family and client involvement in education and placement provision needs to be addressed in the context of future service provision and the rights of people with intellectual disability concerning choices that affect their lives. Thereby, the value and contribution of family placement as a learning environment for students for preparing them for their future role as a registered intellectual disability nurse needs to be investigated and highlighted. In addition, given that care and service provision occurs within a team approach, further research is warranted into the engagement, value and contribution of intellectual disability students within a team approach to care.

Discussion
While evidence pertaining to intellectual disability nursing placement is low, this review does highlight that the involvement of families and client's assist in gaining an understanding/insight of the lived experience (Atkinson and Williams, 2011;Finlayson and Darbyshire, 2015). However, the involvement of clients' can also present a threat to placement provision where clients may refuse placement based on subjective criteria e.g., students photograph on curriculum vitae. Nevertheless, family placements are seen as positive and also enables students to develop mutuality which fosters mutual relationships, where the expertise of all parties is valued and promoted (Goddard et al., 2010;Finlayson and Darbyshire, 2015;McClimens et al., 2017), and supporting the development of communication (Finlayson and Darbyshire, 2015;McClimens et al., 2017). The inclusion of family placements provides an opportunity for diverse learning between the student and family and person with intellectual disability (McClimens et al., 2017).
The success of student placements can be influenced by a student's motivation, clinical and academic learning outcomes and a positive experience leads to skills development (Gillespie and McLaren, 2010). Within a placement the value of mentorship cannot be underestimated where an effective mentor, role model and providing time increases information provided, and instilling students confidence by, providing support and a sense of belonging, and broadening student learning in practice (Heidinger, 2009;Pollard, 2009;Jokelainen et al., 2011a;Taylor, 2016;Green, 2018). As in any system, there are many barriers to effective delivery and from a student perspective, placement experience can be influenced by a student's level of fear and confidence (Gillespie and McLaren, 2010), feeling unsupported or poor mentorship (Owen and Standen, 2007). However, not all aspects relate to students as staff negativity, undervaluing and questioning their role and a perceived poor standard of care all effect the student experience (Owen and Standen, 2007). Creating a sense of support and belongingness in clinical practice motivates students to learn and adopt critical thinking skills and a questioning approach to their practice (Levett-Jones and Lathlean, 2008) and the placements have an effect on students' career planning (McKenna et al., 2010). To develop a positive placement experience, the known barriers need to be considered such as; poor engagement, poor staffing ratios or the lack of mentors (Jokelainen et al., 2011b;Royal College of Nursing -RCN, 2013); lack of protected time for mentorship activities (Jokelainen et al., 2011a); and poor staffstudent relationships (Levett-Jones et al., 2009).
Students are inclined to relate their perceived success of a clinical placement to the level of their connection with mentors or clients, and the nature of that relationship (Pearcey and Elliott, 2004). The evidence also suggests that past experiences and exposures to intellectual disability enables greater engagement and learning (Owen and Standen, 2007;Taylor, 2016). Placement experience should prepare students for their future role and involvement within a team approach, from both a nursing and multidisciplinary team perspective. This experience is an Final-year students (n = 20).
Observations, field notes, and interviews.
Data were analysed thematically for within-case and cross-case analysis (Bryman, 2001 O. Doody, et al. Nurse Education Today 94 (2020) 104593 essential component of clinical placement, as without these experiences future practitioners will not be enabled to be effective team members (Pollard, 2009;Taylor, 2016). In order for learning and development to occur within a team approach, students' contributions should be acknowledged and valued by the team and its team members which in turn leads to the student's empowerment and willingness to engage (Pollard, 2009). Clinical placement experience is a central aspect of student nurses' pre-qualifying education and theory-related activities and clinical practice contribute equally to pre-registration training programmes (NMC, 2010;NMBI, 2016). It is anticipated that, through providing various practice experiences and enabling learning, we will produce empathetic, educated and competent nurses (NMC, 2010). Furthermore, as nurses are broadening the boundaries and duties of their work and are working across agencies and forming new services (DoH, 2012), it is vital that student nurses understand their role in relation to the person with intellectual disability and their family. For example, in today's healthcare system there is an emphasis on care provision in the community, requiring a greater community labour force and corresponding skill set. From the standpoint of providing the future labour force, it is vital that student nurses gain practice experience in the community (Harrison-White and King, 2015). Thereby appropriate flexible clinical placement experiences should be incorporated into pre-qualifying (NMC, 2011) and contemporary clinical placement should be person centred and cognisant of the person's experience and journey across health and social care services (Roxburgh et al., 2012). What is evident is that without intellectual disability placement, future generations of nurses will not have essential knowledge and experience of this population group. Given that, undergraduate nursing students' clinical placement experiences needs to be flexible to represent current health and service provision in campus and community areas, the contribution from voluntary sector organisations within programmes is endorsed to ensure nurses are prepared for the complete continuum of care (NMC, 2011). This needs to be considered in light of the fact that usually, the central drivers within placement arrangements, are programme requirement and placement accessibility (Holland et al., 2010), rather than explicitly taking into account interests, learning needs and identified client pathways. Furthermore, placement capacity is always a challenge, particularly as there are diminishing numbers of clinical placements (Smith and Seeley, 2010). Thereby, placements that were not traditionally considered/available to undergraduate nursing students need to be considered as a pool of previously untapped resources (Pease and Kane, 2010). These placements need to be considered in terms of; learning, fulfilling regulatory bodies' standards and requirements (NMBI, 2016), and the move to support people with intellectual disability in the community setting which demands a greater knowledge of nursing in the community. This subsequently results in a greater need to improve partnership in health and social care, with increased participation from educators, legislators and service leaders (World Health Organisation -WHO, 2010). With this in mind and in recognition of the health needs and changing demographics of people with intellectual disability consideration need to be given to family, community, epilepsy, ageing, complex needs, mental health, dementia and behavioural support clinical placements.

Limitations
No evaluation of the quality of evidence was performed and this paper only provides a descriptive account of available information. However, this is in line with scoping reviews as critical appraisal is not considered mandatory and its purpose is to provide an overview and map the results. From our scoping review, we have found that there is limited published evidence on clinical placements currently utilised within intellectual disability undergraduate nurse education.

Conclusion
This scoping review has sought to afford clarity on clinical placements utilised within intellectual disability undergraduate nursing education in relation to: the types of clinical placements utilised; the measures used to assess their effectiveness; the factors that guide the decision to include clinical placements within intellectual disability undergraduate nursing education; and the existing gaps in the literature on clinical placements. The areas of respite (Taylor, 2016) and family placements (Finlayson and Darbyshire, 2015;McClimens et al., 2017) were identified. However, it is evident from this review that in the main clinical placement are not identified (Owen and Standen, 2007;Gillespie and McLaren, 2010;Goddard et al., 2010;Atkinson and Williams, 2011;Green, 2018) and this may be due to the fact that they look at clinical placement across a programme rather than specific areas with an emphasis on families, students and clients and case studies, graded assessment and reflection to assess the effectiveness of intellectual disability clinical placements. Some of the factors guiding decisions to include clinical placements were a partnership approach, person centered care, working within a team and mentorship. The lack of evidence specific to intellectual disability undergraduate nursing students' placements was evident from performing this review, highlighting a significant gap in the literature that needs to be addressed through continued research in this area.
The review has also highlighted the paucity of literature from Ireland, which is one of two countries that have direct entry to intellectual disability undergraduate nurse education and training. Given the changing profile and landscape of intellectual disability nursing, this is particularly concerning, as the role of the intellectual disability nurse is continuously evolving with changes in their ways of working and practice to support and meet today's changes in health service structure. Together, these findings determine the need for further research and exploration into clinical learning opportunities for intellectual disability student nurses in their undergraduate education and training, mentorship in practice for both students and mentors, and identification of alternative non-traditional community placements such as family placements. Within Ireland, the NMBI (2016) standards and requirements for intellectual disability nurse education and training have focused mainly on traditional (residential) placements for intellectual disability nursing students. However, given the changing profile of health service structure in intellectual disability there is a clear need to utilise and put an emphasis on the value and contribution of alternative non-traditional placement options such as family placements or voluntary sector organisations in order to equip students with essential clinical skills and intellectual disability specific clinical placement learning opportunities (Pease and Kane, 2010). While these bring their own set of challenges as outlined in the discussion, such research would have the possibility of enhancing the intellectual disability nursing students' learning experience, while also potentially informing the development of nursing policy and practice and the sustainability of intellectual disability nursing experience. Through exploration of further learning opportunities and community placements this would also potentially enable collaborative productive partnerships between student nurses and people with intellectual disability and their families. An important consideration in regard to the need for clinical placements is, without them, subsequent generations of nurses will not have knowledge about the population.
The launch of Shaping the Future of Intellectual Disability Nursing in Ireland report (McCarron et al., 2018) is timely as it sets out a clear, evidence based direction for intellectual disability nursing to ensure that educational, practice, managerial and operational supports are provided for intellectual disability nursing. This will have an impact on the direction of intellectual disability nursing education and training and subsequent emphasis on future student learning opportunities and clinical placements. With this in mind, further research is warranted on family and client involvement in education and placement provision in the context of future service delivery.

Funding
No funding or financial support was received.

Declaration of competing interest
The authors declare that they have no competing interests.