Transition experiences of qualified nurses moving into hospice nursing

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<ul><li><p>EXPERIENCE BEFORE AND THROUGHOUT THE NURSING CAREER</p><p>Transition experiences of qualified nurses moving into hospice nursing</p><p>Megan Rosser BSc MSc RGN</p><p>Macmillan Lecturer, Macmillan Education Unit, Florence Nightingale School of Nursing and Midwifery, Kings College</p><p>London, London, UK</p><p>and Lindy King BN PhD RN</p><p>Senior Lecturer, School of Nursing and Midwifery, Flinders University, Adelaide, South Australia, Australia</p><p>Submitted for publication 27 March 2002</p><p>Accepted for publication 16 March 2003</p><p>Correspondence:</p><p>Megan Rosser,</p><p>Macmillan Education Unit,</p><p>Florence Nightingale School of Nursing</p><p>and Midwifery,</p><p>Kings College,</p><p>57 Waterloo Road,</p><p>London SE1 8WA,</p><p>UK.</p><p>E-mail: megan.rosser@kcl.ac.uk</p><p>ROSSER M. &amp; KING L. (2003)ROSSER M. &amp; KING L. (2003) Journal of Advanced Nursing 43(2), 206215</p><p>Transition experiences of qualified nurses moving into hospice nursing</p><p>Background. Over a short period of time a number of nurses had joined the staff at</p><p>a hospice. Many of these nurses were palliative care novices, and thus their trans-</p><p>ition into hospice nursing constituted a move both to a new workplace and a new</p><p>clinical specialism.</p><p>Aim. The aim of the study was to gain a deeper understanding of the experiences of</p><p>qualified nurses making the transition into hospice nursing in order to support</p><p>future nurses in this transition.</p><p>Method. A constructivist approach was used; data were collected through semi-</p><p>structured interviews with four new nurses, three mentors and four team leaders.</p><p>Data were analysed using a constant comparative method.</p><p>Findings. Five major themes were identified: expectations, personal and profes-</p><p>sional development, professional respect, mentorship and support. Nurses came to</p><p>the hospice with individual expectations, some of which were realized. All identified</p><p>areas of personal and professional development. Whilst it was acknowledged that</p><p>new nurses brought transferable skills, there was consensus that they needed to</p><p>develop palliative care knowledge and skills. Professional respect was demonstrated</p><p>by the degree of acceptance or questioning of new nurses by established staff. New</p><p>nurses experienced a variety of emotional responses to hospice nursing. Mentorship</p><p>enhanced the transition experience and strong support was also gained from each</p><p>other.</p><p>Conclusions. New nurses need individual support during their transition into hos-</p><p>pice nursing in response to their own expectations, experiences and learning needs.</p><p>Mentors need preparation and support in their role in order to maximize their</p><p>positive influence on transitions.</p><p>Keywords: transition, hospice nursing, mentorship</p><p>Introduction</p><p>A hospice in Southern England was experiencing problems of</p><p>nurse retention and, as a consequence, 18 new nurses were</p><p>appointed within 8 months. Ten of these had no prior</p><p>palliative care experience. This study, carried out in 2000,</p><p>explored the transition experiences of four of these palliative</p><p>care novices and those of their colleagues. The new nurses</p><p>needed support during their transition and it was considered</p><p>by the researcher, whose role involved supporting them, that</p><p>a greater understanding of the processes involved would</p><p>identify how transition might be eased.</p><p>206 2003 Blackwell Publishing Ltd</p></li><li><p>Literature review</p><p>Experiences of transition</p><p>Transitions involve movement from one state to another,</p><p>the associated experiences, and consequential development</p><p>(Schumacher &amp; Meleis 1994). Transitions create change</p><p>in identities, role, relationships, abilities and behaviours</p><p>(Ashforth &amp; Saks 1995), and are associated with stress,</p><p>upheaval and disruption (Brown &amp; Olshansky 1997).</p><p>Successful negotiation of transition enables personal adjust-</p><p>ment (Nicholson 1984). Individuals experience change,</p><p>contrast and surprise during role transition (Louis 1980).</p><p>According to Louis (1980), change, the objective difference</p><p>between old and new roles, creates the need to learn new</p><p>tasks. Contrasts represent subjective perceptions of the</p><p>differences between new and old settings; these may be</p><p>negative or positive and will impact upon role transition</p><p>accordingly. Surprise, the difference between anticipated</p><p>and actual experiences in the new role, is influenced by</p><p>expectations about self, the job, and the resultant affective</p><p>responses. People try to make sense of each surprise; this</p><p>process may be enhanced by provision of information,</p><p>support and socialization.</p><p>Transition may be influenced by meanings, expectations,</p><p>level of knowledge/skill and environment (Schumacher &amp;</p><p>Meleis 1994). Meanings relate to an individuals subjective</p><p>appraisal of an anticipated or actual transition and the likely</p><p>effect on her/his life. Expectations of a transition are</p><p>influenced by prior experience and may or may not be</p><p>realistic; realistic expectations reduce the stress of transition.</p><p>Knowledge and skills may be insufficient to meet the</p><p>demands of a new situation, creating feelings of uncertainty.</p><p>Important environmental factors during transition include</p><p>social and professional support, possibly provided by a</p><p>mentor.</p><p>Nurses experiences of transition</p><p>Bradby (1990) studied the transition of students into nursing</p><p>and found that they had made strong sense of their role</p><p>610 months into nursing. However, they described being</p><p>overwhelmed, feeling lost, bewildered, strange and useless</p><p>(p. 1222) when starting on wards. Similar feelings were</p><p>expressed by novice primary care nurse practitioners experi-</p><p>encing role transition (Brown &amp; Olshansky 1997). Kelly and</p><p>Matthews (2001) also studied new nurse practitioners</p><p>transition, noting that as nurses were moved from clinical</p><p>areas in which they were confident they experienced uncer-</p><p>tainty and insecurity about their new role.</p><p>Transition into palliative care role</p><p>Few studies have considered the transition of qualified nurses</p><p>into palliative care. Samarel (1991) studied the transition of</p><p>10 nurses caring for acutely sick and dying patients on one</p><p>ward and found that they experienced neither role insuffi-</p><p>ciency nor role conflict. The ability to care for both groups</p><p>simultaneously related to nurses central value of caring,</p><p>preparation for the work, continued support and shared</p><p>hospice philosophies. Rasmussen et al. (1995, 1997) carried</p><p>out phenomenological studies with new hospice nurses and</p><p>identified that their personal expectations influenced adjust-</p><p>ment to a new role. They held idealistic expectations about</p><p>patient care, and the personal benefits they would experi-</p><p>ence, and struggled to reconcile the conflict between their</p><p>ideals and the reality of hospice nursing. Fisher (1996)</p><p>explored how members of a hospice team adjusted to the</p><p>demands of palliative care and concluded that adjustment</p><p>was a continual process, and adaptation to professional</p><p>bereavement, i.e. the emotional responses and processes</p><p>evoked in hospice staff by the death of patients, was part of</p><p>that process. All staff expressed a commitment to holistic</p><p>care; decisions to move into hospice care were partly</p><p>influenced by previous personal or professional bad experi-</p><p>ences of palliative care.</p><p>Mentorship during transition</p><p>There is consensus that mentorship potentially aids role</p><p>transition (Louis 1980, Andersen 1990, Earnshaw 1995,</p><p>Cahill 1996, Phillips et al. 1996a, b, Smith &amp; Gray 2001).</p><p>Darling (1984) identified desirable mentor qualities and roles</p><p>that influence the mentoring relationship. Initially, people</p><p>were attracted to their mentor through a sense of admiration</p><p>or a wish to emulate them, and during the relationship the</p><p>mentor invested time and energy in the mentee. Affective</p><p>responses of respect, encouragement and support under-</p><p>pinned effective mentoring relationships, through which</p><p>mentors fulfilled the roles of inspirer, investor and supporter.</p><p>Student nurses have reported that their mentors played a</p><p>significant role in their clinical training and development,</p><p>offering security and a role model (Earnshaw 1995, Cahill</p><p>1996, Phillips et al. 1996a, b). Effective mentors were</p><p>identified as consistent, genuine and respectful. However,</p><p>arbitrary allocation of mentors and students produced</p><p>personality clashes and allocation to unwilling mentors</p><p>(Earnshaw 1995, Cahill 1996, Phillips et al. 1996a, b, Smith</p><p>&amp; Gray 2001). Ineffective mentors served as gatekeepers to</p><p>clinical knowledge and integration into the ward (Cahill</p><p>1996, Spouse 1996), and emphasized established values,</p><p>Experience before and throughout the nursing career The transition into hospice nursing</p><p> 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(2), 206215 207</p></li><li><p>hierarchy and conformity, thus impeding personal develop-</p><p>ment (Burnard 1990, Earnshaw 1995).</p><p>Mentors have described their roles as supporting and</p><p>facilitating student nurses learning, and have identified an</p><p>element of reciprocity (Atkins &amp; Williams 1995). However,</p><p>the role of mentor is complex and not all nurses are able to</p><p>cope with its demands, and there is potential for conflict</p><p>between the roles of staff nurse and mentor (Atkins &amp;</p><p>Williams 1995). Mentors need formal preparation and</p><p>continued support, and there is a lack of both (Atkins &amp;</p><p>Williams 1995, Earnshaw 1995, Cahill 1996, Phillips et al.</p><p>1996a, b, Andrews &amp; Chilton 2000).</p><p>The study</p><p>Aim</p><p>The aim of the study was to gain a deeper understanding of</p><p>the experiences of qualified nurses making the transition into</p><p>hospice nursing in order to support future nurses in this</p><p>transition.</p><p>Design</p><p>The transition experiences of the new nurses were explored</p><p>using a constructivist approach (Guba &amp; Lincoln 1989) to</p><p>represent the nurses meaningful descriptions of reality (con-</p><p>structs) (Koch 1996). This methodology was used to acknow-</p><p>ledge and explore the subjective realities of nurses involved in</p><p>the transition of the new colleagues. These realities (constructs)</p><p>emerged from the interpretation of individual interview data.</p><p>The constructivist approach encouraged exploration of the</p><p>convergent and divergent constructs held by new nurses, their</p><p>mentors and team leaders. Constructs were explored with the</p><p>view to reaching consensus about the transition experiences for</p><p>the new nurses, and how to enhance these.</p><p>Sample</p><p>Purposive sampling was used to select nurses who had</p><p>experienced working as, or with, new nurses (Coyne 1997),</p><p>and who were willing to communicate those experiences to</p><p>enable in-depth understanding of the processes (Sandelowski</p><p>1995a). Nurses who had been working at the hospice for less</p><p>than 6 months with no previous palliative care experience</p><p>were invited to an explanatory meeting, after which they</p><p>were asked to volunteer. Eight new nurses were eligible for</p><p>inclusion, one declined prior to the meeting (reasons for</p><p>declining were not explored), the remaining seven nurses</p><p>volunteered. In order to maximize the amount of data, I</p><p>focused on new nurses in an established triad of new nurse,</p><p>mentor and team leader, which reduced possible numbers</p><p>down to five, eventually four potential triads were selected,</p><p>one from each of the wards. Mentors and team leaders were</p><p>approached after the new nurses had volunteered. The final</p><p>sample consisted of four new nurses, three mentors (one was</p><p>unwilling to discuss her responsibility as a mentor) and four</p><p>team leaders. The new nurses had between 2 and 20 years of</p><p>nursing experience, and had come from community (2), acute</p><p>medicine and oncology settings. Their ages ranged from 24 to</p><p>39 years. Demographic information about mentors and team</p><p>leaders was not recorded because it was not perceived to be</p><p>directly relevant to the processes under study (Maykutt &amp;</p><p>Morehouse 1994).</p><p>Ethical considerations</p><p>Appleton and King (1997) and Sandelowski et al. (1989)</p><p>comment that many ethics committees are unfamiliar with</p><p>constructivist inquiry and are cautious in granting approval,</p><p>and this situation was encountered here. The researcher was</p><p>part of the support mechanism for new nurses, and the</p><p>university ethics committee believed that the position of the</p><p>new nurses could be compromised. However, after submis-</p><p>sion of extended ethical justifications, approval was granted,</p><p>these were submitted to safeguard the nurses and included</p><p>commitment to explicit communication prior to and at all</p><p>stages of the study, and the reinforcement of nurses freedom</p><p>to leave the study at any time. This was in part to be facilitated</p><p>through checking consent prior to and following all inter-</p><p>views. The justifications also highlighted the attempt to</p><p>remove power inequalities by using a collaborative approach</p><p>to research, and through the continued dissemination of</p><p>information during the study. Ethics approval and site access</p><p>were also obtained from the hospice. All participating nurses</p><p>were sent letters of confirmation and participant information</p><p>sheets. Written consent was obtained prior to each interview.</p><p>Verbal reconfirmation of consent was enacted following the</p><p>interview; this process consent (Munhall 1991) optimized</p><p>facilitation of consent (Behi 1995).</p><p>Data collection</p><p>Tape-recorded, semi-structured interviews of between 40 and</p><p>60 minutes were used as the method of data collection, using</p><p>the researcher as a human instrument. Guba and Lincoln</p><p>(1989) suggest that the human instrument is flexible</p><p>and adaptable, and therefore appropriate for data collection</p><p>in a constructivist inquiry. Furthermore, semi-structured</p><p>interviews allow the researcher to focus on issues that are</p><p>M. Rosser and L. King</p><p>208 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(2), 206215</p></li><li><p>particularly important to the study, whilst affording partic-</p><p>ipants freedom to address personal issues relevant to the topic</p><p>under study. The researcher is able to probe and clarify</p><p>responses (Rose 1994). The combination of a semi-structured</p><p>interview guide and use of the human instrument enabled the</p><p>researcher to respond to emerging constructs and explore</p><p>convergent and divergent views. Each participant was inter-</p><p>viewed once, firstly the new nurses, then mentors and finally</p><p>team leaders. Initially, the issues shaping the interview guide</p><p>were drawn from the literature. As data were analysed after</p><p>each interview, emergent constructs were incorporated in</p><p>subsequent interview guides to enable further exploration</p><p>and understanding.</p><p>Issues of trustworthiness</p><p>Guba and Lincoln (1989) advocate use of the criteria of</p><p>trustworthiness in relation to issues of credibility, transfera-</p><p>bility, dependability and confirmability. Credibility reflects</p><p>the accurate representation of constructs of the nurses.</p><p>Member checking is identified by some (Guba &amp; Lincoln</p><p>1989, Koch 1994, 1996, Appleton 1995) as one way of</p><p>assuring credibility. However, Sandelowski (1993) disputes</p><p>the use of member checking for a number of reasons, not least</p><p>of which is the continually changing realities of participants.</p><p>At the end of each interview, a verbal summary was given by</p><p>the researcher, enabling a form of member checking without</p><p>the possibility of temporal distortion of data (Sandelowski</p><p>1993), whilst also offering each person the opportunity to</p><p>challenge interpretation of the data, or to volun...</p></li></ul>