Challenges confronting nurses caring for persons diagnosed with intellectual disability at a Mental Health Institution in Gauteng, South Africa

This paper aims to explore and describe the challenges experienced by nurses caring for persons diagnosed with intellectual disability. Caring for persons with intellectual disability is understood be challenging for families. This could be worse for nurses due to the challenging behaviour the persons with intellectual disability present with. This may be exacerbated by the attitudes nurses have towards persons with intellectual disability. The researchers ask the following questions: “What are the challenges experienced by nurses caring for persons with intellectual disability?” We employed an exploratory-descriptive research design, using in-depth individual face-to-face interviews to explore the nurses’ experiences. Using Tesch’s method of open coding, two overarching themes emerged: (1) Care-related challenges and (2). Facilitation of a supportive, caring environment. The findings of the study demonstrate that the experienced challenges are related to the mental status of the persons diagnosed with intellectual disability, the therapeutic environment, shortage of specialized personnel and role ambiguity. Hence, the nurses yearn for a supportive environment that includes family support and support from the institution's management, including the provision of psychosocial support, which plays a pivotal role in achieving a safe, caring environment. The findings of this study could be used to develop strategies to facilitate a supportive, caring environment to minimize these challenges. © 2024 by the authors. Licensee SSBFNET, Istanbul, Turkey. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).


Introduction
This paper reports on the challenges experienced by nurses caring for persons diagnosed with intellectual disability (ID).In the South African context, families are identified in the Mental Health Care Act no 17 of 2002 as key role players in caring for persons with mental illness, including ID.However, Persons with ID often present with challenging behaviours that include having less drive, energy, and motivation, making them vulnerable to personal and emotional problems, presenting as poor self-esteem and acting out behaviour (Middleton, 2021).As such, it is recognized that being a caregiver provides a variety of gratifications and obstacles, with some caregivers reporting chronic physical and emotional health issues.At the same time, families find it challenging to manage those with complex, challenging behaviours and ID in their homes due to the severity of the mental health status of the persons with intellectual disability.This makes the nurse central to caring for persons with severe forms of ID, mostly in inpatient settings.Caring for persons with ID requires specialized psychiatric nursing skills, which may be deficient for South African nurses.While there may be a lack of these skills and knowledge for the nurses providing care to persons with ID, the attitudes of nurses towards those with ID could also influence their experiences during this time (Desroches et al., 2022;Pelleboer-Gunnink et al., 2021).
Whilst there is a paucity of published literature on ID in South Africa, there is extensive literature internationally that reports on challenges experienced by nurses and other mental health care providers caring for persons with ID.Studies conducted by Brown and Kalaitzidis (2013); Lewis et al (2019) reported nurses' role as complex in managing those with mental illness in general; however, it is met with a lack of preparedness, skill and capacity the additional time required to provide care to persons with ID.The studies conducted in the South African context focused on student nurses whose experience was met with an extremely profoundly unsettling impact on their whole being when caring for persons with ID and the experiences of parents of adolescents with ID (Chauke et al., 2021;Temane et al., 2016).Other studies explored the nurse carers' experiences for persons with severe and profound ID (Manaka et al., 2018).There is still a gap in the description of the challenges confronting nurses while caring for persons with ID in South Africa.Thus, the challenges of these nurses must be recognized to facilitate a supportive caring environment that allows for planning for the needs of those with ID across their lifespan.The study used an exploratory-descriptive study to explore and describe the challenges experience by nurses when providing care to persons diagnosed with ID.
The paper is structured as follows: the second part, after the introduction, consists of a literature review that examines both theoretical and empirical studies that elucidate the connection between theory and practice.The third section provides an introduction to the background information on the research and methodology.Following the analysis and findings of the study, the authors present discussions and implications.Ultimately, this paper concludes by summarizing the main points, providing recommendations, suggesting areas for future research, and acknowledging any limitations.

Literature Review
The purpose of literature review in this study is to provide a clear definition of ID, prevalence in the world and South Africa as well as the role of the mental health Act in defining who the key role players in provision of care to persons with ID are .Furthermore, provide an overview of the challenges experienced by those caring for persons with ID.

Definition of the concept Intellectual Disability (ID)
Intellectual disability (ID) is a neurodevelopmental disorder manifesting in early development before the person starts school (Middleton, 2021).Persons with ID present with deficits in intellectual functions such as reasoning, problem-solving, planning, abstract thinking, and judgment.The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) further mentions that the deficits in ID include impairment in everyday adaptive functioning, particularly the conceptual, social, and practical domains (American Psychiatric Association [APA], 2013; Townsend & Morgan, 2017).ID is classified into mild, moderate, severe, and profound intellectual disability.Those with mild and moderate may be capable of independent living with assistance during times of stress and can perform some activities independently; however, they may require some form of supervision where necessary.Although persons with severe forms of ID may be trained in elementary hygiene skills, they require complete supervision.Supervision for those with profound ID is through constant aid (Townsend Morgan, 2017).
The worldwide prevalence of ID is estimated at 3%.The National Institute of Health suggests that 2% to 3% of children in the United States have some form of ID, whilst it is estimated that ID in India shows a lifetime prevalence of 1.4% (Kapoor et al., 2023).Developing countries within the Sub-Saharan African nations such as Cameroon and Ghana, have an estimated 10 to 15 individuals per 1,000 (0.01 to 0.02%) living with some form of ID, compared to 1% to 3% of the population in Western countries (Opoku et al., 2021).South Africa has the highest prevalence of ID at 12% compared to other countries globally (Foskett, 2014).

South African care context for persons with ID
Although families play a role in the treatment, care, and rehabilitation of those with ID, the South African Mental Health Care Act no 17 of 2022 in Chapter III also makes provision for those with severe and profound ID to be cared for at a mental health institution.According to the Mental Health Care Act no 17 of (2002), "Severe or profound intellectual disability" means a range of intellectual functioning extending from partial self-maintenance under close supervision, together with limited self-protection skills in a controlled environment through limited self-care and requiring constant aid and supervision, to severely restricted sensory and motor functioning and requiring nursing care.This provision makes it clear that the nurse, as a mental health care provider, plays a vital role in providing care for those with ID.

Challenges linked to caring for persons with ID
The nurses experience challenges when caring for anyone with mental illness, particularly those related to challenging behaviours such as violence, self-destructive behaviour, and manipulation.These challenges extend to the availability of resources and the perceived lack of support from mental health institutions, including families.Ee et al (2022) argue that feelings of intimidation, vulnerability and inadequacy exacerbated by repeated exposure to violence, as well as lack of knowledge and experience, contribute to the challenges faced by the nurses.Their experience could be worse when caring for persons with severe and profound ID due to the challenging behaviours, which could be linked to the inability of the persons diagnosed with ID to reason, make judgments and chronic deficit in cognitive functioning.A study conducted by Desroches et al (2022) reported that nurses' attitudes towards persons with ID were significantly less optimistic compared to persons without ID linked to challenging experience in the provision of care to those with ID.Furthermore, a scoping review conducted by Pelleboer-Gunnink et al (2021) revealed that nurses also present with stigmatizing attitudes towards persons diagnosed with ID, which might affect the quality of nurses' support.

Research and Methodology
The study used an exploratory-descriptive qualitative research design to explore and describe the therapeutic or care-related challenges experienced by nurses whilst caring for persons diagnosed with ID at a mental health institution in Gauteng, South Africa.A Constructivist paradigm guided the study, which passed on the assumption that reality is multiple and subjective and is constructed by individuals.According to Polit and Beck (2018), constructivist studies yield rich, in-depth information from the natural setting where the nurses experience caring for persons diagnosed with intellectual disability.In this section, the researchers describe the process followed to conduct the research, the context of the study, the study population and sample, data collection and analysis methods, trustworthiness, and ethical considerations.The findings of the study are presented in the light of literature.Finally, conclusions are presented with recommendations to nursing practice.

The Study Context
The study was conducted at a mental health institution in Gauteng, South Africa.The mental health institution is located in Tshwane's western region which has an estimated population of 3.6 million inhabitants.There are over 1,200 beds and over 500 nurses, some working different shifts to ensure continuity of care when others are off duty.Persons admitted to this mental health institution suffer from various mental disorders.The mental disorders include intellectual disability, schizophrenia, bipolar disorder, anxiety disorders, and substance-induced psychosis.At the time of data collection, only three long-term units admitting persons with ID were in use, with a carrying of 35 patients per unit and at least 20-30 nursing personnel per unit.

Study Population, Sampling, and sample characteristics
The study population consisted of six (n=6) participants, two males (n=2) and four females (n=4).females of different nursing categories were interviewed.The participants' ages ranged from 28-45 years.These participants worked with persons diagnosed with intellectually disability in long-term units of the mental health institution for least three years.The participants who took part in the study were within the following categories: two professional psychiatric specialised nurses, three professional psychiatric general nurses and one enrolled nurse.Purposive sampling was used to select nurses who experienced caring for persons diagnosed with ID (Bertram & Christiansen, 2018).The sample size was guided by data adequacy, which is the point where the phenomena and all pertinent conceptual categories have been found, examined, and exhausted, and no new problems or insights emerge from the data.Thus, data adequacy refers to the sufficiency and quality of data the sample yielded (Polit & Beck, 2018).Although the sample size was small, the researcher who collected the data could gather sufficient data.

Data Collection Methods and Instruments
In-depth individual face-to-face interviews were conducted to collect data from the nurses.The second author conducted all interviews from January 2018 to March 2018.The author paid attention to both verbal and non-verbal communication of the participant; as such, the interviews were triangulated with field notes and observations.The field notes and observations were recorded using a diary detailing events and the participants' reactions during the interviews (Houser, 2023).The interviews lasted approximately 45 minutes, were audio-recorded with participants' consent, and transcribed verbatim.No one else was present during the interview sessions ensuring confidentiality.
A central question posed to each participant was, "Tell me about the challenges you experience whilst caring for persons with intellectual disability?".Prompts were also used as open-ended questions to expand on the participants' descriptions.The prompts were guided by how the participants responded to the questions.Examples of the prompts are: "How do these challenges impact you?"; "How do you deal with these challenges?"; "In your view, what can be done to help you deal with the daily challenges?".

Data Analysis
Data were analyzed using Tesch's open coding method described in Creswell and Poth ( 2018).This process analyzed data through careful reading of all the transcriptions, getting meaning from the information, writing down thoughts coming to mind; arranging similar topics in groups by forming columns labelled major topics; unique topics; and leftovers; organizing the data to check if new categories or codes emerged and finally placing all data materials belonging to each category together to conclude the preliminary analysis.All authors conducted the preliminary analysis independently from the coder.A consensus discussion meeting with the coder was scheduled to agree on and finalize the themes.The themes were classified into broader and more abstract meaning categories (Ravitch & Carl, 2021).See Table 1 for an overview of themes and sub-themes.

Trustworthiness
Trustworthiness is researchers' confidence in their data and analysis (Polit & Beck, 2022).To ensure credibility, data adequacy was achieved with six participants, In addition, the researcher returned to the participants to share interpretations of the findings and inquire about their accuracy from the nurses who cared for persons diagnosed with ID (Polit & Beck, 2021, p. 568).This was accomplished by scheduling appointments with the interviewees and providing them with the transcribed and analysed data for verification that it accurately reflects their description.The authors ensured the transferability of the study by providing a welldocumented account of all the processes, including a detailed description of the participants and the setting (Brink et al., 2020;Polit & Beck, 2022).Multiple data collection techniques, including interviews, field notes, and observations, were utilised to ensure the confirmability of the study.In order to avoid researcher bias, data analysis was performed by an independent coder after the findings of the researcher and the independent coder were compared.A detailed description of the research methodology, the data analysis method, and a comprehensive literature review ensured dependability.

Ethical considerations
The study was approved by Sefako Makgatho Health Sciences Research Ethics Committee, ethics no SMREC/H/145/ 2017: PG and the institution's Chief Executive Officer gave permission in accordance with the Gauteng Department of Health's Standard Operating Procedure.
In addition, the researchers adhered to the ethical principle of autonomy by allowing participants to make informed decisions regarding their participation and obtaining informed consent (Bergamin et al., 2022).The anonymity of the nurses was protected by not using their real names during the interviews and instead assigning them numerical codes.To maintain their privacy, no information provided by the nurses was linked to them.Participants were not harmed during interviews because they were not humiliated and treated fairly and without bias or discrimination (Mahomed & Labuschaigne, 2023).

Findings and Discussions
The results of this study are presented below in two sub-sections.First, the findings are presented.These findings are followed by detailed discussion.

Findings
Two main overarching themes emerged 1).Care-related challenges, and 2).Facilitation of a supportive, caring environment (see Table 1).These results show that caring for persons with intellectual disabilities is challenging for the Nurses linked to several factors.Thus, the nurses yearn for a supportive, caring environment.The themes and sub-themes are supported with multiple quotations from the nurses to support and provide an understanding of the nurses' description of challenges confronting them while providing care to persons with ID.The participants in this study elaborated that they experience care-related challenges that impact their day-to-day work performance.
The challenges are related to the mental status of the persons diagnosed with intellectual disability, the therapeutic environment, the shortage of specialized personnel, and role ambiguity.

The mental status of those diagnosed with ID
The nurses experience the mental status of the person diagnosed with ID as a standing challenge.Mental status in this instance refers to the mental health of persons with ID who present with poor cognitive functioning, impacting the time spent interacting with them: "…because it is more like intensive care, we need the one-on-one(s) because every patient in the ward their cognitive functioning is indigent.So, you need to explain the same thing, and every two minutes, you know you gonna be attending to the same patient for the same reason."P6 Additionally, when caring for such persons, the routine becomes of central importance and therefore requires careful consideration when providing care to persons with intellectual disability.One participant alluded: "And also, with mental retard you don't just change their routine, so you need to introduce, whatever change you want to introduce, you need to introduce it slowly, gradually."P1

Therapeutic environment
A therapeutic environment is a safe space where the psychosocial needs of persons with ID are provided.It is the physical environment where they receive care from the nurses.In the study, some of the challenges met by the nurses are based on the physical space where they render care.The nurses mentioned that the physical space is not well maintained, and there is no prompt response when questions are made to fix broken items like windows which becomes a potential danger to those they care for since they may get hurt.The following were the expressions of the participants: "Would not complain much about the way the ward is structured because we have many challenges when it comes to attending to some other things, windows and some other staff are broken every day almost.So, the management takes time to attend to that, and it courses a lot of other challenges because patients get hurt now."P6 The therapeutic or care-related challenges further extend to the non-availability of resources to deliver or render care, thus affecting their morale and motivation to continue working: "…because you, as a health care provider, you are three to say okay I'm there to nurse this patient holistically, consider everything but then if their resources are not there, then now you feel like why should I go to work."P1 Additionally, the environment is experienced as not ideal to the nature of the service delivered.A daily structure or programme's non-availability hampers how daily activities are facilitated.For instance, the nurses mentioned that they could not perform group activities that are central to their service rendering due to the nature of the persons they are caring for, making it challenging to be therapeutic.Below are the sentiments shared by one participant: "There is no clear programme of saying what can one do to take care of them.That is why I'm saying we are only taught the basics of how to feed them, how to wash them and how to build them up together; they emphasize group, but because they are intellectuals, you're unable to do groups (as a caregiver)."P2

Shortage of specialized personnel
The nurses in this study expressed staff shortage as a hindrance to rendering holistic and effective care to persons with intellectual disability.The nurses' shared their negative experiences below: "So, one of the biggest challenges we are facing is we have very few staff members."P3 "…but those patients they actually need more staffing, not necessarily the professional nurses but also the enrolled and assistant nurses."P6 The shortage of specialized personnel is not only linked to the provision of nursing services but other services provided by other nurses essential to providing care to persons with intellectual disability.This challenge extends to the non-availability of a sign language specialist, physiotherapist, and other specialists.These specialists' services are essential to provide holistic care to persons with intellectual disability: "Some of these clients cannot even talk, so you'll realize that they are no one who knows sign language.Some of them have difficulties with movement, and you will see that they are no physiotherapist who helps with those movements."P2

Role ambiguity
The challenges related to provider-relationship are linked to the inability of the nurses to draw boundaries when providing care.Boundaries in this context mean the inseparable role of the family the nurses find themselves performing.Participants noted the following: "…because you have to take care of them and act as a parent, and at the same time as a health care provider."P1 "…because these patients are long stay here, they become our families.So, when they pass away is another loss, then we have to deal with it."P4 Furthermore, the nurses reported that whilst they cannot separate their roles from that of families, they also grow fond of persons with intellectual disability.Instead of experiencing this as a challenge, they use the situation to learn more about persons diagnosed with intellectual disability: "…you just work because you have that heart of working with the mental health care users; you love them, so you even understand their condition, and you have insight on that."P5 Theme 2: Facilitation of a supportive, caring environment Even though the challenges expressed and experienced by the nurses hinder the quality of care delivered, the nurses make recommendations to enhance a supportive, caring environment.

Support from families
The nurses in this study verbalized that support is integral to their work.A supportive environment could be enhanced by family support.This could be achieved by families showing gratitude towards the nurses, thus lessening the frustration.Acknowledging and appreciating the nurses' extra efforts while caring for persons with ID could be helpful.One participant stated the following: "So, from time to time, you would find family members not appreciating the work that we are doing, and what makes one angry or disappointing is some of these family members have neglected this person from the word go.So now here you're trying to do your best, but they will always find faults in whatever you're doing, so it can be very strenuous."P3 Physical presence and involvement of the families could help curb the incidents of aggression, which complicates the work of nurses.Another participant further alluded: "As I have highlighted about their aggression, they become hostile towards us, so we would have injuries on duty resulting from poor family support because when they get the chances are they are likely to be physically hostile to others…" P6 Support from management Support is anticipated not only from the family members but from managers of the institution where persons with ID are admitted.
Participants in this study verbalized that they receive untoward reactions from managers, and they do not demonstrate appreciation for their work.The following sentiments were shared: "…there is a need to have proper support from the management, and in terms of support, I mean if my supervisor was to say to me just one day to say to us, 'You know what?You guys are doing a good job' Saying that alone at least says that the supervisor cares about you, but now it seems like those are some of the small things that you don't even receive from the management, it is like they are always out to get you" P3

Psychosocial support
Psychosocial support also plays a vital role in demonstrating concern for the nurses caring for persons diagnosed with intellectual disability.This could be achieved through counselling services or debriefing services for nurses, especially after an incident that might cause trauma to an individual.These incidences, such as being physically and violently attacked, harassed verbally or sexually by patients, are common in settings where persons with ID are cared for.Based on participants' reactions, working with intellectually disabled users can be emotionally draining and evoke strong emotional reactions in the nurses requiring professional attention.One of the participants in the study gave the following expression: "In my five years' experience, I have never seen anyone receiving counselling or debriefing session, even though I did not get any counselling.Actually, what is happening is it seems no one cares, or they are out of strategies of how to do it" P2

Discussion
This study aimed to explore and describe the challenges confronting nurses while caring for persons with ID at a mental health institution in Gauteng, South Africa.Two themes emerged from this study: care-related challenges and facilitation of a supportive, caring environment.These challenges are linked to the mental health status of those diagnosed with ID, therapeutic environment, shortage of specialized staff and role ambiguity, which the nurses yearn for facilitation of a supportive, caring environment.
The findings indicated that nurses experience challenges while caring for persons diagnosed with ID that impact the quality of nursing care.The impact related to caring for persons diagnosed with ID is mainly linked to the mental health status of the patients, which determines the intensity of support needed to provide care (Evans et al., 2020).Poor cognitive functioning and diminished general mental abilities that impact adaptive functioning are some of the distinct features of ID which make caring difficult due to poor comprehension of processes (De Kock & Pillay, 2016).Therefore, time becomes a crucial consideration when providing care, as every action requires the nurses to be patient to allow the persons diagnosed with ID to process situations as they occur.
It is also essential to consider that persons with ID do not adapt quickly to changes.These sentiments were shared by the nurses in this study and are supported by findings of a study conducted by Moodley et al (2022), who mentioned that persons with ID experience challenges hearing and incorporating feedback to nurses.It, therefore, becomes imperative for the nurses to normalize the environment of the persons diagnosed with ID to achieve positive care-related outcomes.Otherwise, it becomes more challenging to provide care.The normalization principle is applied when caring for persons diagnosed with ID, and it emphasizes key elements such as a normal rhythm every day, every week throughout the year (Middleton, 2021).
The nurses in this study argued that the therapeutic environment where they render care is not conducive to caring for persons diagnosed with ID, making it unsafe.Furthermore, the environment is poorly maintained without resources to deliver care.Similar findings were shared by Moro et al (2022), in Ghana who reported that infrastructures were poorly maintained and there were no resources, including the fact that the facilities were not disability friendly.This is contrary to the elements of an optimal healing environment that stipulates that the physical spaces must be stimulating to promote healing (Middleton, 2021).Additionally, the therapeutic environment should be supportive to enhance the quality of care rendered to those diagnosed with intellectual disability.Somehow, participants in this study experienced their environment as unsupportive, thus contributing to their frustration.
A unit caring for persons diagnosed with ID should be well-resourced and staffed to ensure holistic care.However, participants in this study expressed being overwhelmed because of a shortage of staff members with specialized skills, such as speech specialists and other specialists who are role players in providing care to persons with ID.Engetou, (2017) reported that insufficient staff members lead to poor work performance.According to Aydın et al (2023), the nurse shortage, particularly those who possess specialized skills, is still an important issue that impacts the treatment and care of persons with ID and prolongs care to persons diagnosed with ID.This finding is consistent with that of Chiang et al (2022), who confirmed that a lack of human resources negatively impacts the quality of care as more time is dedicated to completing tasks than the nature of care required.
In this study, the nurses reported that the shortage of nurses and other multidisciplinary team members with specialized skills contributed to their experience of therapeutic or care challenges.As in this study, Ambani et al (2020) recommended staffing and resource adequacy improvements to relieve the burden on the nurses.Caring for persons diagnosed with ID requires a team approach.
The importance of having a psychologist, social worker, doctor, and specialized team is prominent.However, specialized team members are insufficient in the South African Context (Morris et al., 2019).According to Lewis et al (2017), there are fewer speciality trained nurses in the mental health field in the hospitals, thus directly impacting the quality of care the nurses provide to persons diagnosed with ID and their families.Similarly, findings of studies by Appelgren et al (2018); Morris et al (2019) agree that the staff shortage impacts the quality of care.
It is evident that nurses in this study experienced role ambiguity when providing care to persons diagnosed with ID as they found themselves demonstrating more compassion than focusing on other care-related activities, making it difficult to set boundaries related to the therapeutic relationship.This is a potential challenge to the nurse-patient relationship as setting boundaries becomes an issue.Such is referred to as overidentification which later becomes challenging to manage.In mental healthcare, role ambiguity can have deleterious effects, including emotional exhaustion, burnout, and loss of job satisfaction on nurses (Delaney & Johnson, 2014;Ee et al., 2022).Role ambiguity has also been identified as a leading cause of stress and uncertainty in many organizations.The nurses find themselves becoming more than just nurses but families to persons with ID, as supported by (Lewis et al., 2017).Although there are challenges related to caring for persons diagnosed with ID, the nurses still become fond of the persons diagnosed with ID.A study conducted by (Auberry, 2018) also identifies with the findings of this study, confirming that role ambiguity frustrates nurses when caring for persons diagnosed with an ID.
Support stood out to be the most crucial factor for the nurses.Merriam-Webster Dictionary (2023) defines support as keeping something going and is used synonymously with the word comfort.Thus, the nurses long for support from families, management, and psychological support.The nurses in this study long for support from families to encourage them to continue with their excellent work; they refer to support as appreciation by the families.additionally, the nurses in the study were adamant about needing more support from patients' families to help them meet the patients' needs.In their study, Mert and Köşgeroğlu (2022) concluded that nurse-led collaboration with families and relevant institutions positively contributed to meeting the care needs of persons with ID.Thus, support from families of those diagnosed with ID could benefit the nurses to improve their morale and interest towards those diagnosed with ID.Furthermore, Molehabangwe et al (2018) asserted that appreciation of nurses is essential for them as it facilitates engagement and coping with their work, which is what the nurses of this study long for.
Management of the mental health institution where persons diagnosed with ID were identified as one of the critical role players in the provision of support to the nurses whilst providing care.Provision of support to staff by hospital leaders was recommended to make the work of nurses more satisfying and, in turn, bring a favorable environment to provide care to persons diagnosed with ID (Ambani et al., 2020;Labrague Al Sabei et al., 2022).The findings of the study are not different to those of Sobekwa and Arunachallam (2015) , where the participants feel that management should check on them to encourage them and make them feel appreciated confirming the need the need for the facilitation of a supportive and caring environment.Thus, such a supportive and caring environment could benefit the nurses as they are likely to cope with their work if they receive appreciation (Pregnolato et al., 2017;Molehabangwe et al., 2018).
Counselling as a form of support serves as a psychological intervention to facilitate the modification of feelings, cognition, attitudes, and behaviour of nurses (Evans et al., 2020).The participants in this study were convinced that providing psychosocial support in the form of counselling and debriefing could benefit them while facilitating a caring environment.These sentiments are similar to recommendations made by Sobekwa and Arunachallam (2015), who aver that debriefing sessions are necessary for nurses working in demanding environments with challenging mental healthcare user populations.Furthermore, counselling and debriefing are understood to be a deliberate way of enabling persons to cope with challenges practically, allowing each person to vent their feelings and reactions to events (Baumann, 2017;Middleton, 2021).The provision of counselling and debriefing could benefit the nurses working with persons diagnosed with ID as a supportive and caring environment could be facilitated.

Conclusions
While caring for persons with ID can be challenging, nurses require a supportive, caring environment to ensure quality nursing care is provided.Thus, it is crucial to ensure that the nurses are supported while providing care to persons with ID.As a result, the research raised awareness about the challenges confronting nurses, who yearn for a supportive, caring environment.Family support, and support from the institution's management, including psychosocial support, help the nurses work efficiently and effectively.This study's findings are consistent with other studies conducted by Appelgren et al (2018); Moodley et al (2022), noted that nurses involved in the care of persons diagnosed with ID experience care related challenges that affect their day to day working activities thus support becomes central in ensuring that the nurses function better in a supportive, caring environment (Brown & Kalaitzidis, 2013;Desroches, 2020;Chiang et al., 2022;Desroches et al., 2022;Aydın et al., 2023).Family involvement and support from management and counselling services are essential for a safe, caring environment.It is recommended for mental health institutions admitting persons with ID to provide support by ensuring that the environment is therapeutic.Furthermore, the roles of nurses need to be clear.There is also a need for specialized nurses to be hired or the current ones to be trained in order to improve the current skills set.Therefore, more work must be done to support the nurses caring for persons with ID.Thus, it is recommended that further research should include members of the multidisciplinary team responsible for caring for persons with ID to gain a thorough comprehension of their experiences, challenges confronting them and compare them to those nursing mental health care providers.
The findings could be used to identify support strategies and training needs for developing specialist knowledge and skills through the training and development of the multidisciplinary team working in such specialized areas.Additionally, it is necessary to conduct research in other mental health institutions in order to compare the results.
In addition to the strengths of the study mentioned above, there were limitations too.The findings are applicable to mental health institutions with long-term units caring for persons with ID and should be interpreted cautiously.Therefore, the findings can only be generalized to such units.Furthermore, only fewer nurses caring for persons ID participated in this study due to the number of units proving care to persons with ID.Additionally, other mental health care providers such as psychiatrists, psychologists, speech therapists, occupational therapists, and other allied specialists did not form part of this study.Thus, the findings of this cannot be generalized to other mental health care providers.

Table 1 :
Overview of themes and sub-themes.