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Abstract

Background

Individuals with intellectual and developmental disabilities (IDD) face significant health disparities, often exacerbated by ethical and legal complexities in nursing care. Nurses are frequently challenged to balance autonomy, informed consent, patient safety, and human rights, especially in settings with unclear guidelines or insufficient training. This narrative review explores the ethical and legal considerations in nursing care for individuals with IDD, aiming to highlight challenges and propose best practices.

Methods

A narrative review methodology was employed to synthesise evidence from qualitative, quantitative, mixed-methods studies, theoretical articles, and grey literature. A comprehensive search was conducted across PubMed, EBSCO, Embase, Scopus, and Web of Science, using keywords related to ethical issues, legal rights, nursing, and intellectual disability. Studies were included if they addressed the ethical or legal dimensions of nursing care for people with IDD. Data were synthesised narratively and visually mapped using conceptual mapping techniques. Quality was assessed using the SANRA scale.

Results

Eighteen studies met the inclusion criteria. The findings reveal ethical tensions in obtaining informed consent, maintaining autonomy, and ensuring dignity against communication barriers and behavioural challenges. Nurses reported experiencing an emotional burden and ethical uncertainty when institutional constraints limit person-centred care. The overuse of restrictive practices and limited access to tailored healthcare were recurrent concerns. Legal challenges included complexities in guardianship, consent to treatment, and discriminatory practices. Emerging issues, such as the ethical use of artificial intelligence in care planning, were also noted.

Conclusion

Nursing care for individuals with IDD requires ethically grounded, legally informed, and person-centred approaches. Best practices include accessible communication, interdisciplinary collaboration, tailored education, and advocacy. Nurses must receive support through training and organisational frameworks to navigate complex ethical decisions and uphold the dignity and rights of individuals with IDD. These findings have direct implications for nursing practice and policy, offering actionable guidance to improve ethical decision-making, communication, and inclusive care delivery for individuals with intellectual disabilities.

Keywords

Guardianship informed consent intellectual disability legal considerations nursing ethics person-centred care

Introduction

Individuals with intellectual and developmental disabilities (IDD) experience significant health disparities and often face challenges in accessing appropriate and equitable healthcare.^1,2 These disparities are compounded by ethical and legal complexities that arise in the provision of nursing care.³ Nurses, who are at the forefront of healthcare delivery, require a strong understanding of these dimensions to ensure optimal and ethical care for this vulnerable population.^4,5 This understanding is particularly crucial given the increasing lifespan of individuals with IDD and the corresponding rise in chronic illnesses.⁶

Ethical considerations in nursing care for individuals with IDD encompass a wide range of issues, including informed consent, decision-making capacity, respect for autonomy, and the balancing of beneficence and non-maleficence.^3,7,8 Legal frameworks further shape the landscape of care, with regulations and guidelines impacting areas such as guardianship, advocacy, and the protection of rights.⁹ Navigating these ethical and legal dimensions can be challenging for nurses, particularly in acute care settings where they may feel underprepared and face communication barriers.¹⁰

The experiences of nurses caring for individuals with IDD are shaped by various factors, including their education, training, attitudes, and the availability of resources.^4,11,12 Understanding these experiences is vital for developing effective strategies to support nurses and improve the quality of care.¹ Furthermore, exploring the impact of intellectual disability nursing interventions is essential to inform best practices and promote positive outcomes.¹³

The narratives of caregivers offer essential perspectives on the ethical complexities inherent in supporting individuals with intellectual and developmental disabilities. Caregivers often grapple with moral dilemmas and ethical challenges related to autonomy, informed consent, and quality of life for the individuals they support.^14,15 Understanding these narratives provides a framework for addressing these intricate issues. Centring on the stories and experiences of patients and caregivers highlights the significance of acknowledging each individual’s viewpoint and encourages person-centred care. Additionally, it recognises the concept of “disabled authorship” that individuals with IDD often encounter and aims to empower them in crafting their narratives.¹⁶ Disabled authorship refers to the challenges individuals with IDD face in expressing themselves and creating their narratives, while also emphasising efforts to empower them in this area.¹⁷

This paper presents a narrative review of the literature exploring the ethical and legal dimensions of nursing care for individuals with intellectual disabilities. By synthesizing existing research, this review aims to: (1) identify key ethical and legal challenges faced by nurses; (2) examine the experiences of nurses in providing care; (3) explore the role of narrative ethics in promoting ethical practice; and (4) highlight strategies for improving nursing education and support to ensure equitable and ethical care for individuals with IDD. This review contributes to a deeper understanding of the complexities within this field. It provides a foundation for future research and practice development to promote the well-being and rights of individuals with intellectual disabilities.¹⁸ Furthermore, the increasing application of Artificial Intelligence (AI) in healthcare, including nursing,^19,20 introduces new ethical considerations that must be addressed in caring for individuals with IDD. The potential benefits and risks of using AI to support nursing care for this population warrant careful examination.

Methods

This narrative review aims to synthesise existing literature on the ethical and legal considerations of nursing care for individuals with intellectual disabilities. A narrative approach was chosen to allow for a broad and flexible synthesis of diverse perspectives and study designs.²¹ Unlike systematic reviews with strict inclusion/exclusion criteria, a narrative review allows for the inclusion of a broader range of evidence, including qualitative studies, theoretical papers, and expert opinions.

Search strategy

A comprehensive search of relevant databases, including PubMed, EBSCO, Embase, Scopus, and Web of Science, was conducted. The search strategy in Table 1 combined keywords related to “ethical issues,” “legal rights,” “nursing,” and “intellectual disability.” Search terms were adapted for each database to maximise retrieval. In addition to database searching, grey literature, including relevant reports and policy documents, was identified through targeted web searches and organisational websites.

Table 1.

Search terms and strategy used to identify literature on ethical and legal dimensions of nursing care for individuals with intellectual disabilities.

Concept	Keywords
Population: Individuals with intellectual disabilities	“Intellectually disabled persons”, “intellectually disabled person”, “persons with intellectual disability”, “persons with mental disabilities”, “cognitive impairment”, “intellectual developmental disability”, “learning disability”, “developmental disability”, “general learning disability”, “intellectual disabilities”, “intellectual development disorder”
Context: Nursing care	“Nursing care”, “nursing practice”, “nursing professionals”, “nurses”, “healthcare providers”
Focus: Ethical and legal dimensions	“Ethics”, “ethical issues”, “moral considerations”, “professional ethics”, “bioethics”, “legal issues”, “legal considerations”, “law”, “legislation”

Inclusion and exclusion criteria

Studies were included if they explored ethical or legal dimensions related to individuals with intellectual disabilities in nursing care. Studies were excluded if they: (a) were not available in English; (b) did not directly address the research question.

Study selection

Retrieved articles were initially screened based on their titles and abstracts to determine their relevance to the research question. Full-text articles of potentially eligible studies were retrieved and assessed against the inclusion and exclusion criteria. A PRISMA flow diagram²² was used to document the study selection process, see Figure 1.

Figure 1.

The PRISMA 2020 flow diagram shows the selection process of included studies.

Data extraction and synthesis

Data were extracted from the included studies using a standardised data extraction form. The extracted data included study design, sample characteristics, key findings, and relevant conclusions. The extracted data were then synthesised using a narrative approach. This involved identifying common themes, patterns, and contradictions across the studies and developing a coherent narrative that addresses the research question. As part of this synthesis process, a conceptual mapping technique was employed to visually represent the thematic connections within the ethical and legal dimensions of nursing care for people with intellectual disabilities. Key concepts were derived from the thematic analysis of the included literature, focusing on topics related to nursing ethics, care delivery, health equity, and patient rights. The central concept, “Ethical and Legal Dimensions in Nursing Care,” was placed at the core, with branches extending to thematically related areas such as nurse-patient relationship, care planning, health inequality, and human rights. This visual representation, Figure 2, supported the narrative synthesis by clarifying the multidimensional nature of ethical considerations in nursing care and highlighting their relevance to the care of individuals with intellectual disabilities. Special attention was paid to the methodological rigour of the included studies, and limitations were noted.

Figure 2.

Conceptual map of ethical and legal dimensions in nursing care for people with intellectual disabilities: Thematic linkages to key nursing and healthcare topics.

Quality assessment

Given the nature of a narrative review, the Scale for the Assessment of Narrative Review Articles (SANRA) was used.²³ The strengths and weaknesses of different study designs were acknowledged, and the potential for bias was considered. We acknowledge that the inclusion of studies with varying designs (e.g., qualitative, quantitative, and mixed methods) introduces the potential for methodological bias. Although a formal appraisal of study quality was not conducted, we sought to manage this limitation by carefully describing the characteristics and contexts of each included study. During the synthesis process, we paid close attention to differences in study design, data collection methods, and scope, and we interpreted the findings with caution to avoid overgeneralization. This reflective approach was intended to enhance transparency and support a balanced interpretation of the evidence.

Results

Search outcomes

A total of 212 papers were identified through databases and grey literature searches. After removing duplicates using EndNote, 113 articles remained and were screened by title and abstract. This screening led to the exclusion of 77 articles, leaving 36 for further review. Of these, 2 articles could not be retrieved, so 34 articles were screened for eligibility. After full-text screening, 16 articles were excluded for the following reasons: wrong population 11, and 5 foreign language articles. Ultimately, 18 articles were included in the study: four quantitative, seven qualitative, and one mixed methods study. Figure 1 illustrates the study screening and selection process.

Narrative synthesis

The analysis of the included studies, Table 2, highlights a complex web of ethical challenges experienced by nurses in the care of individuals with intellectual and developmental disabilities (IDD). A recurring theme across studies^{24,25,27,29,31,36} is the tension between safeguarding patient autonomy and ensuring safety, particularly when cognitive impairments hinder informed consent and decision-making. Studies^{24,26,29,32,36,38} emphasise the moral obligation of nurses to uphold dignity and foster meaningful, reciprocal relationships, often complicated by communication difficulties or behavioural concerns. Nurses frequently express ethical uncertainty and emotional burden when institutional constraints or unclear policies interfere with the delivery of person-centred care.^{27,28,30,33,34,37} Ethical uncertainty arises when there is a lack of clarity or consensus on the morally correct action, often due to conflicting values or principles.^42–45

Table 2.

Summary of ethical and legal challenges in nursing care for individuals with intellectual and developmental disabilities: Findings from 18 included studies.

Study	Title	Objective	Population	Key findings	Practical implications
²⁴	A nurses’ ethical commitment to people with intellectual and developmental disabilities	Explores the issues of knowledge deficits of healthcare professionals in meeting the needs of people with IDD throughout the life span, and to identify factors that contribute to these deficits	Nurses	Nurses face ethical dilemmas balancing paternalism and autonomy in IDD care	Emphasise individualised care that respects autonomy while providing necessary support
²⁵	Ethical and legal challenges in caring for older adults with multimorbidities: Best practices for nurses	Explores the ethical and legal challenges faced by nurses in caring for older adults with multimorbidities, focusing on issues related to patient autonomy, polypharmacy, and end-of-life care	Nurses	Informed consent is complex for older adults with cognitive impairments	Provide training to enhance nurses’ understanding of consent processes and legal requirements
²⁶	Ethics in caregiving services for people with serious intellectual disabilities	Explore the ethical considerations and challenges that caregivers face when providing services to individuals with serious intellectual disabilities	Not mentioned	There is a need to reemphasize the concept of dignity in caregiving for individuals with profound intellectual disabilities, distinguishing between general dignity, which all individuals inherently possess, and strict dignity, which is often associated with moral agency. This distinction is essential for understanding how to ethically support those who are highly dependent and unable to exercise autonomy. It underscores the importance of explicit ethical frameworks in caregiving, including civic ethics that promote justice and human worth, alongside professional and organizational ethics aimed at enhancing the quality of life for individuals with disabilities	Foster personalised interactions that uphold the inherent dignity of individuals with serious intellectual disabilities
²⁷	Ethical dilemmas and legal ambivalence affects the midwives’ perception for providing sexual and reproductive health consultation to women with intellectual disability	Explore and identify the key ethical dilemmas that midwives face when providing sexual and reproductive health consultations to women with intellectual disabilities	Midwives	Midwives encounter ethical and legal challenges in reproductive health consultations for women with IDD.	Develop clear guidelines and training to navigate these consultations ethically and legally
²⁸	Disabling violence: Intellectual disability and the limits of ethical engagement	Explore the ethical challenges and complexities that arise when caregivers for people with intellectual disabilities, attempt to foster reciprocal, friendship-like relationships	Person with IDD	- Caregivers struggle with reciprocity in relationships, especially when facing aggression	Implement support systems and training to manage complex interactions without compromising ethical engagement
²⁸			Person with IDD	- Attempts to maintain intimate engagement in the face of aggression can lead to distrustful and tense relationships, complicating the ethical project of fostering positive intimacy and accountability
²⁹	Ethical practices and policies in the health care of people with intellectual and developmental disabilities and their families	To provide various building blocks for the development of an ethical framework to guide practice and policy in the health care of people with intellectual and developmental disabilities (IDD)	Not mentioned	Ethical frameworks are needed in care models for individuals with IDD.	Encourage collaborative care that values meaningful relationships and considers decision-making capacities
³⁰	Nurse education: Meeting the needs of people with intellectual disabilities?	Promote debate regarding this issue with particular reference to the role of education in effecting change	Not mentioned	Highlights significant health disparities in people with intellectual disabilities, such as higher rates of epilepsy and respiratory diseases and lower life expectancy. Reports that nurses and other professionals feel inadequately prepared to care for this population, indicating a need for improved educational interventions to enhance knowledge and attitudes	Integrate IDD-focused education into health curricula to reduce disparities and improve care quality
³¹	Narrative ethics in nursing for persons with intellectual disabilities	Argues that narrative ethics not only offers an appropriate moral framework for practices of life story work, but that these practices are a narrative ethics in action	Not mentioned	Narrative ethics enhances understanding in life story work for individuals with IDD.	Utilize narrative approaches to acknowledge personal identities and foster mutual understanding
³²	Innovative approaches to ethical issues in the care of people with intellectual disabilities and potentially problematic sexual behaviours	To reports on ethical issues arising in a clinic devoted to the assessment and treatment of men and women with intellectual disabilities (ID) and potentially problematic sexual behaviors	Not mentioned	Ethical principles apply equally to individuals with IDD in clinical settings	Apply standard ethical principles to improve treatment outcomes and reduce stigma
³³	Ethical challenges in the treatment of individuals with intellectual disabilities	Provides an overview of major ethical considerations with guidance for clarifying and resolving common ethical concerns	Psychologists	Use of aversive techniques in behavioral interventions raises ethical concerns	Advocate for non-aversive methods and expand access to mental health services for individuals with IDD.
³⁴	Ethical evaluation of nursing care: severe cognitive deficits	Describes the case of a woman with severe cognitive deficits who underwent an episode of neurological rehabilitation	Person with IDD	Ethical issues arise in caring for patients with severe cognitive deficits	Engage in discussions about ethical dilemmas to align care with patients’ best interests and dignity
³⁵	The challenges for nurses communicating with and gaining valid consent from adults with intellectual disabilities within the accident and emergency care service	Reports the challenges experienced by nurses within accident and emergency departments in communicating with and gaining valid consent from adults with intellectual disabilities	Nurses	Communication barriers hinder effective care in emergency settings	Enhance training on communication strategies and consent processes for adults with IDD.
³⁶	Legal and ethical issues in seeking the consent of adults with learning disability	Provides an overview of how English law applies to the partnership approach to seeking consent from learning disabled adult clients	Nurses	Consent processes are complex for adults with learning disabilities	Ensure nurses have up-to-date knowledge of legal and ethical frameworks, such as the Mental Capacity Act 2005
³⁷	Addressing health inequality and inequity for people with intellectual disabilities: a Collective responsibility for all nurses	Explore key issues relating to the role nurses play in providing equitable health care for people with intellectual disabilities	Nurses	- The findings emphasise the critical role of nurses in advocating for and supporting the health needs of people with intellectual disabilities, highlighting the necessity for nurses to take on leadership roles in this area	Provide education and training to implement reasonable adjustments and promote well-being
³⁷			Nurses	- It is essential for nurses to implement reasonable adjustments in their care practices, which should be supported by education and training focused on the specific health needs of individuals with intellectual disabilities to promote their health and well-being effectively
³⁸	Navigating end-of-life needs for a person with intellectual disabilities and their caregivers	Explore the complexities and unique considerations in ensuring ethical and practical end-of-life care for people with IDs	Caregivers	People with intellectual disabilities (IDs) face significant barriers to accessing palliative care and hospice services, often due to clinician bias and communication difficulties, which can lead to their exclusion from important health and life discussions	Adopt collaborative care models that include individuals with IDD in decision-making processes
³⁹	“A little bit more challenging, but more rewarding”: Medical-surgical nurses’ perspectives on caring for adults with intellectual disabilities	Explore medical-surgical nurses’ perspectives on the rewarding aspects of and significant influences on caring for adults with intellectual disabilities	Medical-surgical nurses	Nurses experience challenges and rewards in caring for adults with IDD.	Improve training and preparedness to enhance care quality and nurse-patient interactions
⁴⁰	Approach to caring for developmentally disabled adults in the community: Medical, ethical, and legal considerations	To review the medical, ethical, and legal obligations in caring for adults with developmental disabilities (DDs) living in the community	Not mentioned	Transition to community care lacks effective support strategies	Develop research-informed approaches to enhance community care services for adults with developmental disabilities
⁴¹	Autonomy and professional responsibility in care for persons with intellectual disabilities	Clarify how different understandings of the “self” (autos) influence the ethical and professional responsibilities of caregivers, ultimately arguing for a more relational and dialogical approach to autonomy in the context of intellectual disability care	Not mentioned	Concepts of autonomy influence caregiver-care receiver relationships	Shift towards a dialogical approach that values authenticity and personal identity in caregiving

The persistent misuse or overuse of restrictive practices, such as physical restraints or sedation, is reported in studies,^{27,30,31,34,39} raising critical concerns about human rights and the ethical use of power in caregiving relationships. Restrictive practices are intentional interventions that limit a person’s freedom or autonomy, often employed to manage risk or maintain order.^46–51 A lack of formal education and ethical training specific to IDD populations is a barrier noted in several studies,^{25,28,35,40,41} leaving practitioners feeling underprepared and unsupported. Structural limitations, including poor access to specialised palliative care or healthcare tailored to the needs of people with IDD, are further documented in studies.^{29,32,38,40,41} Collectively, these studies call for ethically grounded, person-centred care frameworks that integrate narrative, relational, and human rights-based approaches. They also highlight the necessity for training, ethical leadership, and policy reforms to support nurses and midwives in advocating effectively for this marginalised population.

Thematic synthesis

In Figure 2, the conceptual map developed in this study illustrates the core ethical and legal dimensions relevant to nursing care for individuals with intellectual disabilities. It comprises four interrelated domains: ethical issues, legal framework, human rights perspective, and practical nursing applications. Under ethical issues, key principles include respect for autonomy, emphasising informed consent and decision-making support; beneficence, which focuses on promoting well-being and quality of life; non-maleficence through harm prevention and ethical risk management; justice, encompassing fair access to care and non-discrimination; and the promotion of dignity and respect via person-centered care and communication adaptation.

The legal framework comprises multiple layers, beginning with national health laws that govern the rights of people with disabilities and consent-related matters. This is supported by international conventions such as the UN Convention on the Rights of Persons with Disabilities (CRPD) and WHO guidelines. Furthermore, legal dimensions extend to documentation and accountability, which cover legal reporting requirements and record keeping, as well as professional responsibility, defined by codes of conduct and scope of practice standards.

The human rights perspective highlights key entitlements, including the right to health, the right to autonomy and participation, the right to non-discrimination, and the right to privacy and confidentiality. Finally, the practical nursing applications encompass ethical dilemmas encountered in clinical practice, the advocacy role of nurses, the importance of ongoing training and awareness, interdisciplinary collaboration, and the engagement of families and caregivers. This conceptual framework serves to guide ethical decision-making and ensure legally compliant and rights-based care for individuals with intellectual disabilities.

The results reveal multifaceted ethical and legal challenges faced by nurses caring for individuals with intellectual disabilities, highlighting tensions between autonomy, safety, and legal responsibilities. Building on these findings, the following discussion explores their practical implications for nursing practice, education, and policy, and proposes strategies to address identified gaps and promote person-centred, rights-based care.

Discussion

Nursing care for individuals with intellectual developmental disabilities (IDD) encompasses complex ethical and legal dimensions. These are essential for ensuring that care is both effective and respectful of the rights, autonomy, and individual needs of this vulnerable population.⁸ This discussion outlines key ethical and legal challenges, along with best practices to guide nursing professionals.

Ethical challenges

Informed consent and autonomy

Obtaining informed consent from individuals with IDD can be challenging due to potential cognitive impairments.^25,35 Nurses must communicate information in accessible formats, using simplified language, visual aids, or alternative communication strategies.³⁵ Respecting autonomy means supporting individuals in making their own decisions, even when these differ from caregivers’ or professionals’ views.^25,52 Balancing autonomy with patient safety is a central ethical concern.²⁵ Caregivers’ long-term relationships with individuals with intellectual and developmental disabilities (IDD) provide unique insights into their needs and preferences, especially for non-verbal individuals.⁵³ Recognising and valuing caregivers is critical for person-centred care.^54–56 Simultaneously, empowering individuals with IDD to express their own choices is essential for promoting autonomy and respecting their rights.^57–59 Balancing caregiver insights with individual empowerment is a key challenge in providing holistic and rights-based care.

Best interests decision-making

When individuals lack decision-making capacity, healthcare professionals must act in their best interests.³³ This requires consideration of the individual’s values, preferences, and overall well-being, with input from family members, caregivers, and interdisciplinary teams.^33,60

Access to services

Individuals with IDD often face systemic barriers in accessing general and specialised healthcare, including palliative care.^2,61 Addressing issues such as provider bias, communication challenges, and transportation barriers is an ethical imperative to promote health equity.² The COVID-19 pandemic significantly impacted access to healthcare services for individuals with intellectual disabilities (IDD), exacerbating existing health disparities and creating new challenges.^62–64 In the United States, the COVID-19 pandemic has had a particularly severe impact on individuals with intellectual disabilities. Studies have found that having an intellectual disability was one of the strongest independent risk factors for receiving a COVID-19 diagnosis, and, aside from older age, was also one of the highest risk factors for COVID-19-related mortality.⁶⁵

End-of-life care

Palliative and end-of-life care for individuals with ID demands attention to their unique physical, emotional, and spiritual needs.⁶¹ Ethical considerations include pain management, respecting individual preferences, and making life-sustaining treatment decisions in line with the patient’s expressed wishes or, when unavailable, their best interests.³ Literature reviews have highlighted key barriers to equitable end-of-life care for individuals with intellectual disabilities, including diagnostic overshadowing, delayed recognition of symptoms, and inadequate healthcare adjustments.⁶⁶ Studies emphasise the importance of tailored communication, emotional sensitivity, and the active inclusion of individuals with intellectual disabilities in care planning.⁶⁷ Additionally, there is an ethical imperative to embed equity, dignity, and cross-national standards into palliative care for this population.⁶⁸

Ethical competence

Nurses’ ability to navigate ethical challenges is deeply influenced by their ethical competence, which encompasses not only attitudes toward ethical behavior, perceived behavioural control, and social norms,⁶⁹ but also a foundational understanding of professional codes of ethics. Documents such as the ICN and ANA Codes of Ethics provide essential guiding principles for clinical integrity and professional conduct.^70,71 Ethical competence also involves knowledge of ethical theories, such as deontology, utilitarianism, and principlism, which offer structured perspectives for resolving moral dilemmas.⁷² In practice, decision-making frameworks like Robichaux’s Four-Component Model or integrative models reviewed by Mallari⁷³ support nurses in applying ethical reasoning systematically. As Lechasseur et al⁷⁴ emphasise, ethical competence is not static; it evolves with education, experience, and moral reflection, shaping the intention and capacity to deliver patient-centred, ethically sound care.

Self-determination versus protection

While self-determination is a fundamental health law principle, it may not always serve individuals with IDD adequately. Alternative principles, such as the right to receive appropriate care and developmental support, may provide better protection in certain situations.⁷⁵

Contraceptive choices

Decisions regarding contraception for women with IDD involve complex ethical and legal considerations. Informed consent is essential, and any decision, especially irreversible methods such as sterilisation, must not be made for eugenic reasons, which are both ethically and legally unacceptable.^76,77

Legal challenges

Guardianship

Legal guardianship allows a designated person to make decisions for individuals who lack capacity.³³ While it serves to protect vulnerable individuals, it may also restrict autonomy. Therefore, guardianship should be applied only when absolutely necessary, ensuring that the individual’s rights and preferences are upheld.³³

Consent to treatment

Valid consent is a legal requirement, but assessing and obtaining it from individuals with IDD can be particularly challenging.³⁵ Legal frameworks must guide the evaluation of decision-making capacity and establish procedures for substitute decision-making when needed. The use of psychotropic medication also raises legal and ethical concerns, necessitating careful oversight to avoid misuse and ensure informed consent.⁷⁸

Discrimination and inequity

Individuals with IDD are protected against discrimination under various laws and regulations.⁷⁹ Despite these protections, many experience health disparities due to systemic inequities. Nurses have a critical role in advocating for reasonable adjustments, promoting inclusion, and ensuring equitable access to healthcare services.^37,79,80

Emerging legal-ethical considerations

With advances in healthcare technologies, new legal-ethical considerations are emerging. For example, the use of large language models (LLMs) in clinical decision-making raises concerns around data privacy, consent, and transparency—issues particularly sensitive in the care of individuals with cognitive impairments.^52,81

Best practices for nurses

Person-centered care

Providing individualised, person-centred care is fundamental. This approach requires nurses to understand each patient’s unique preferences, values, and goals, and to tailor interventions accordingly.⁷⁹

Effective communication

Clear, simple language and alternative communication strategies are essential. Nurses must also be attentive to nonverbal cues and involve family members or caregivers when appropriate to support understanding and decision-making.³⁵

Collaborative practice

Interdisciplinary collaboration, including healthcare teams, caregivers, and family members, supports comprehensive care planning and ethical decision-making. Coordination of services enhances care quality and helps resolve ethical and legal dilemmas.^2,7,82

Education and training

Nurses require ongoing education to address ethical, legal, and practical challenges in caring for individuals with IDD. Training should focus on capacity assessment, legal frameworks, communication techniques, and strategies for resolving ethical dilemmas.^10,25,35,83

Advocacy

Nurses play a vital role in advocating for the rights, dignity, and needs of individuals with ID. This includes challenging discriminatory practices, improving service accessibility, and influencing policy development.^37,84

Resilience and support

Working with individuals with IDD can present emotional and professional challenges. Developing resilience and ensuring organisational support for nurses are essential to sustaining ethical, compassionate care.¹⁰ As life expectancy for individuals with intellectual and developmental disabilities (IDD) continues to increase, many are now outliving their family caregivers, raising significant ethical and practical challenges for long-term care planning.⁸⁵ This demographic shift underscores the urgent need for sustainable support systems to ensure continuity of care when aging parents or relatives are no longer able to provide caregiving support.⁸⁶ The absence of adequate future planning can result in crises in placement, caregiver burnout, and diminished quality of life for the person with IDD.⁸⁷ To address this, healthcare providers, social services, and policymakers must work collaboratively to develop person-centered care plans that incorporate legal guardianship arrangements, supported living pathways, and the proactive engagement of alternative caregivers or formal support systems.⁸⁸ Responding to these needs is a vital step toward providing ethically sound, equitable, and sustainable care for individuals with IDD.

Limitations

This narrative review has several limitations that should be acknowledged. First, although the review included a broad range of sources, including grey literature, the search was limited to articles published in English, which may have excluded relevant studies published in other languages and introduced a language bias. Second, as a narrative review, the study did not follow a formal systematic review protocol or meta-analytic procedures, which may limit the reproducibility and objectivity of the findings. While quality assessment was conducted using the SANRA scale, no standardised tool was used to appraise the methodological quality of the empirical studies included, which may affect the robustness of the conclusions drawn.

Furthermore, the inclusion of diverse study designs (qualitative, quantitative, and mixed methods) and theoretical papers led to a heterogeneous body of literature, making it difficult to compare findings directly or generalise outcomes. The review also primarily reflects the perspectives of nurses and healthcare professionals, with limited representation of the voices of individuals with intellectual disabilities and their families. This may result in an incomplete understanding of ethical and legal challenges from the service user’s standpoint.

Lastly, while conceptual mapping was used to illustrate key themes, the subjective nature of this technique may influence interpretation. Future studies should adopt more rigorous synthesis methods and incorporate stakeholder perspectives, especially those of individuals with intellectual disabilities, to ensure a more comprehensive and inclusive understanding of ethical and legal issues in nursing care.

Conclusion

Nursing care for individuals with intellectual disabilities involves navigating intricate ethical and legal landscapes. By adhering to best practices, such as person-centred care, effective communication, interdisciplinary collaboration, ongoing training, and advocacy, nurses can uphold the rights and dignity of individuals with IDD. Continued education, ethical competence, and systemic support are key to delivering high-quality, equitable care. Future research should prioritise the inclusion of first-person perspectives from individuals with intellectual disabilities to ensure that their voices and lived experiences shape ethical and legal frameworks in nursing care. Methodological strategies to support this include the use of accessible language, visual aids, simplified consent processes, and participatory research approaches such as inclusive interviews, photovoice, or involving individuals with ID as co-researchers. These approaches not only promote ethical integrity but also help bridge the gap between theory and lived experience, ensuring that care models are both rights-based and person-centred.

Footnotes

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

ORCID iD

Mohammed Elmadani

Data Availability Statement

This study did not involve the generation or analysis of primary data. All data presented in this paper are derived from publicly available sources, including published literature, legal documents, and international guidelines. Further information regarding the sources is available from the corresponding author upon reasonable request.*

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Ethical dimensions in nursing care for individuals with intellectual disabilities

Abstract

Background

Methods

Results

Conclusion

Keywords

Introduction

Methods

Search strategy

Inclusion and exclusion criteria

Study selection

Data extraction and synthesis

Quality assessment

Results

Search outcomes

Narrative synthesis

Thematic synthesis

Discussion

Ethical challenges

Informed consent and autonomy

Best interests decision-making

Access to services

End-of-life care

Ethical competence

Self-determination versus protection

Contraceptive choices

Legal challenges

Guardianship

Consent to treatment

Discrimination and inequity

Emerging legal-ethical considerations

Best practices for nurses

Person-centered care

Effective communication

Collaborative practice

Education and training

Advocacy

Resilience and support

Limitations

Conclusion

Footnotes

Funding

Declaration of conflicting interests

ORCID iD

Data Availability Statement

References