Transition experiences of qualified nurses moving into hospice nursing

EXPERIENCE BEFORE AND THROUGHOUT THE NURSING CAREER

Transition experiences of qualified nurses moving into hospice nursing

Megan Rosser BSc MSc RGN

Macmillan Lecturer, Macmillan Education Unit, Florence Nightingale School of Nursing and Midwifery, King’s College

London, London, UK

and Lindy King BN PhD RN

Senior Lecturer, School of Nursing and Midwifery, Flinders University, Adelaide, South Australia, Australia

Submitted for publication 27 March 2002

Accepted for publication 16 March 2003

Correspondence:

Megan Rosser,

Macmillan Education Unit,

Florence Nightingale School of Nursing

and Midwifery,

Kings College,

57 Waterloo Road,

London SE1 8WA,

UK.

E-mail: [email protected]

ROSSER M. & KING L. (2003)ROSSER M. & KING L. (2003) Journal of Advanced Nursing 43(2), 206–215

Transition experiences of qualified nurses moving into hospice nursing

Background. Over a short period of time a number of nurses had joined the staff at

a hospice. Many of these nurses were palliative care novices, and thus their trans-

ition into hospice nursing constituted a move both to a new workplace and a new

clinical specialism.

Aim. The aim of the study was to gain a deeper understanding of the experiences of

qualified nurses making the transition into hospice nursing in order to support

future nurses in this transition.

Method. A constructivist approach was used; data were collected through semi-

structured interviews with four new nurses, three mentors and four team leaders.

Data were analysed using a constant comparative method.

Findings. Five major themes were identified: expectations, personal and profes-

sional development, professional respect, mentorship and support. Nurses came to

the hospice with individual expectations, some of which were realized. All identified

areas of personal and professional development. Whilst it was acknowledged that

new nurses brought transferable skills, there was consensus that they needed to

develop palliative care knowledge and skills. Professional respect was demonstrated

by the degree of acceptance or questioning of new nurses by established staff. New

nurses experienced a variety of emotional responses to hospice nursing. Mentorship

enhanced the transition experience and strong support was also gained from each

other.

Conclusions. New nurses need individual support during their transition into hos-

pice nursing in response to their own expectations, experiences and learning needs.

Mentors need preparation and support in their role in order to maximize their

positive influence on transitions.

Keywords: transition, hospice nursing, mentorship

Introduction

A hospice in Southern England was experiencing problems of

nurse retention and, as a consequence, 18 new nurses were

appointed within 8 months. Ten of these had no prior

palliative care experience. This study, carried out in 2000,

explored the transition experiences of four of these palliative

care novices and those of their colleagues. The new nurses

needed support during their transition and it was considered

by the researcher, whose role involved supporting them, that

a greater understanding of the processes involved would

identify how transition might be eased.

206 � 2003 Blackwell Publishing Ltd

Literature review

Experiences of transition

Transitions involve movement from one state to another,

the associated experiences, and consequential development

(Schumacher & Meleis 1994). Transitions create change

in identities, role, relationships, abilities and behaviours

(Ashforth & Saks 1995), and are associated with stress,

upheaval and disruption (Brown & Olshansky 1997).

Successful negotiation of transition enables personal adjust-

ment (Nicholson 1984). Individuals experience change,

contrast and surprise during role transition (Louis 1980).

According to Louis (1980), change, the objective difference

between old and new roles, creates the need to learn new

tasks. Contrasts represent subjective perceptions of the

differences between new and old settings; these may be

negative or positive and will impact upon role transition

accordingly. Surprise, the difference between anticipated

and actual experiences in the new role, is influenced by

expectations about self, the job, and the resultant affective

responses. People try to make sense of each surprise; this

process may be enhanced by provision of information,

support and socialization.

Transition may be influenced by meanings, expectations,

level of knowledge/skill and environment (Schumacher &

Meleis 1994). Meanings relate to an individual’s subjective

appraisal of an anticipated or actual transition and the likely

effect on her/his life. Expectations of a transition are

influenced by prior experience and may or may not be

realistic; realistic expectations reduce the stress of transition.

Knowledge and skills may be insufficient to meet the

demands of a new situation, creating feelings of uncertainty.

Important environmental factors during transition include

social and professional support, possibly provided by a

mentor.

Nurses’ experiences of transition

Bradby (1990) studied the transition of students into nursing

and found that they had made strong sense of their role

6–10 months into nursing. However, they described ‘being

overwhelmed, feeling lost, bewildered, strange and useless’

(p. 1222) when starting on wards. Similar feelings were

expressed by novice primary care nurse practitioners experi-

encing role transition (Brown & Olshansky 1997). Kelly and

Matthews (2001) also studied new nurse practitioners’

transition, noting that as nurses were moved from clinical

areas in which they were confident they experienced uncer-

tainty and insecurity about their new role.

Transition into palliative care role

Few studies have considered the transition of qualified nurses

into palliative care. Samarel (1991) studied the transition of

10 nurses caring for acutely sick and dying patients on one

ward and found that they experienced neither role insuffi-

ciency nor role conflict. The ability to care for both groups

simultaneously related to nurses’ central value of caring,

preparation for the work, continued support and shared

hospice philosophies. Rasmussen et al. (1995, 1997) carried

out phenomenological studies with new hospice nurses and

identified that their personal expectations influenced adjust-

ment to a new role. They held idealistic expectations about

patient care, and the personal benefits they would experi-

ence, and struggled to reconcile the conflict between their

ideals and the reality of hospice nursing. Fisher (1996)

explored how members of a hospice team adjusted to the

demands of palliative care and concluded that adjustment

was a continual process, and adaptation to professional

bereavement, i.e. the emotional responses and processes

evoked in hospice staff by the death of patients, was part of

that process. All staff expressed a commitment to holistic

care; decisions to move into hospice care were partly

influenced by previous personal or professional bad experi-

ences of palliative care.

Mentorship during transition

There is consensus that mentorship potentially aids role

transition (Louis 1980, Andersen 1990, Earnshaw 1995,

Cahill 1996, Phillips et al. 1996a, b, Smith & Gray 2001).

Darling (1984) identified desirable mentor qualities and roles

that influence the mentoring relationship. Initially, people

were attracted to their mentor through a sense of admiration

or a wish to emulate them, and during the relationship the

mentor invested time and energy in the mentee. Affective

responses of respect, encouragement and support under-

pinned effective mentoring relationships, through which

mentors fulfilled the roles of inspirer, investor and supporter.

Student nurses have reported that their mentors played a

significant role in their clinical training and development,

offering security and a role model (Earnshaw 1995, Cahill

1996, Phillips et al. 1996a, b). Effective mentors were

identified as consistent, genuine and respectful. However,

arbitrary allocation of mentors and students produced

personality clashes and allocation to unwilling mentors

(Earnshaw 1995, Cahill 1996, Phillips et al. 1996a, b, Smith

& Gray 2001). Ineffective mentors served as gatekeepers to

clinical knowledge and integration into the ward (Cahill

1996, Spouse 1996), and emphasized established values,

Experience before and throughout the nursing career The transition into hospice nursing

� 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(2), 206–215 207

hierarchy and conformity, thus impeding personal develop-

ment (Burnard 1990, Earnshaw 1995).

Mentors have described their roles as supporting and

facilitating student nurses’ learning, and have identified an

element of reciprocity (Atkins & Williams 1995). However,

the role of mentor is complex and not all nurses are able to

cope with its demands, and there is potential for conflict

between the roles of staff nurse and mentor (Atkins &

Williams 1995). Mentors need formal preparation and

continued support, and there is a lack of both (Atkins &

Williams 1995, Earnshaw 1995, Cahill 1996, Phillips et al.

1996a, b, Andrews & Chilton 2000).

The study

Aim

The aim of the study was to gain a deeper understanding of

the experiences of qualified nurses making the transition into

hospice nursing in order to support future nurses in this

transition.

Design

The transition experiences of the new nurses were explored

using a constructivist approach (Guba & Lincoln 1989) to

represent the nurses’ meaningful descriptions of reality (con-

structs) (Koch 1996). This methodology was used to acknow-

ledge and explore the subjective realities of nurses involved in

the transition of the new colleagues. These realities (constructs)

emerged from the interpretation of individual interview data.

The constructivist approach encouraged exploration of the

convergent and divergent constructs held by new nurses, their

mentors and team leaders. Constructs were explored with the

view to reaching consensus about the transition experiences for

the new nurses, and how to enhance these.

Sample

Purposive sampling was used to select nurses who had

experienced working as, or with, new nurses (Coyne 1997),

and who were willing to communicate those experiences to

enable in-depth understanding of the processes (Sandelowski

1995a). Nurses who had been working at the hospice for less

than 6 months with no previous palliative care experience

were invited to an explanatory meeting, after which they

were asked to volunteer. Eight new nurses were eligible for

inclusion, one declined prior to the meeting (reasons for

declining were not explored), the remaining seven nurses

volunteered. In order to maximize the amount of data, I

focused on new nurses in an established triad of new nurse,

mentor and team leader, which reduced possible numbers

down to five, eventually four potential triads were selected,

one from each of the wards. Mentors and team leaders were

approached after the new nurses had volunteered. The final

sample consisted of four new nurses, three mentors (one was

unwilling to discuss her responsibility as a mentor) and four

team leaders. The new nurses had between 2 and 20 years of

nursing experience, and had come from community (2), acute

medicine and oncology settings. Their ages ranged from 24 to

39 years. Demographic information about mentors and team

leaders was not recorded because it was not perceived to be

directly relevant to the processes under study (Maykutt &

Morehouse 1994).

Ethical considerations

Appleton and King (1997) and Sandelowski et al. (1989)

comment that many ethics committees are unfamiliar with

constructivist inquiry and are cautious in granting approval,

and this situation was encountered here. The researcher was

part of the support mechanism for new nurses, and the

university ethics committee believed that the position of the

new nurses could be compromised. However, after submis-

sion of extended ethical justifications, approval was granted,

these were submitted to safeguard the nurses and included

commitment to explicit communication prior to and at all

stages of the study, and the reinforcement of nurses’ freedom

to leave the study at any time. This was in part to be facilitated

through checking consent prior to and following all inter-

views. The justifications also highlighted the attempt to

remove power inequalities by using a collaborative approach

to research, and through the continued dissemination of

information during the study. Ethics approval and site access

were also obtained from the hospice. All participating nurses

were sent letters of confirmation and participant information

sheets. Written consent was obtained prior to each interview.

Verbal reconfirmation of consent was enacted following the

interview; this ‘process consent’ (Munhall 1991) optimized

facilitation of consent (Behi 1995).

Data collection

Tape-recorded, semi-structured interviews of between 40 and

60 minutes were used as the method of data collection, using

the researcher as a human instrument. Guba and Lincoln

(1989) suggest that the human instrument is flexible

and adaptable, and therefore appropriate for data collection

in a constructivist inquiry. Furthermore, semi-structured

interviews allow the researcher to focus on issues that are

M. Rosser and L. King

208 � 2003 Blackwell Publishing Ltd, Journal of Advanced Nursing, 43(2), 206–215

particularly important to the study, whilst affording partic-

ipants freedom to address personal issues relevant to the topic

under study. The researcher is able to probe and clarify

responses (Rose 1994). The combination of a semi-structured

interview guide and use of the human instrument enabled the

researcher to respond to emerging constructs and explore

convergent and divergent views. Each participant was inter-

viewed once, firstly the new nurses, then mentors and finally

team leaders. Initially, the issues shaping the interview guide

were drawn from the literature. As data were analysed after

each interview, emergent constructs were incorporated in

subsequent interview guides to enable further exploration

and understanding.

Issues of trustworthiness

Guba and Lincoln (1989) advocate use of the criteria of

trustworthiness in relation to issues of credibility, transfera-

bility, dependability and confirmability. Credibility reflects

the accurate representation of constructs of the nurses.

Member checking is identified by some (Guba & Lincoln

1989, Koch 1994, 1996, Appleton 1995) as one way of

assuring credibility. However, Sandelowski (1993) disputes

the use of member checking for a number of reasons, not least

of which is the continually changing realities of participants.

At the end of each interview, a verbal summary was given by

the researcher, enabling a form of member checking without

the possibility of temporal distortion of data (Sandelowski

1993), whilst also offering each person the opportunity to

challenge interpretation of the data, or to volunteer additional

information, thus increasing the credibility of the study.

Transferability relates to the degree of contextual similarity

between the study situation and the situation that readers find

themselves in (Lincoln & Guba 1985), and the burden of

establishing transferability lies with the reader (Appleton &

King 1997). Dependability is created by the whole research

process being made transparent. It is enhanced by tape

recording the interviews for auditability (Appleton 1995),

using the constant comparative method of analysis, which

provides a clear replicable path for data analysis (Maykut &

Morehouse 1994), and use of raw interview data to illustrate

interpretations. Demonstration of credibility, transferability

and dependability facilitates confirmation that the data,

interpretations and outcomes come from the nurses inter-

viewed (Koch 1994).

Data analysis

At the point of analysing the transcripts, respondents were

coded as new nurses (NN), mentors (M) or team leaders

(TL), and each triad/ pair allocated an identifying number

(1–4). This enabled systematic recording and ease of identi-

fication of data. Data were analysed through the process of

constant comparison. The data were broken down into their

smallest parts (units of meaning) and then allocated to

categories on the basis of similarity of meaning (Maykut &

Morehouse 1994). A name was attached to each developing

category to capture the essence of its meaning and rules of

inclusion, articulating the meaning captured in each category,

were written to direct inclusion or exclusion of subsequent

units of meaning. Final categories were examined for

emergent relationships between them, thus drawing a number

of categories into one theme. Five emergent themes, specif-

ically expectations, personal and professional development,

professional respect, mentoring and support are presented

here.

Findings

Expectations

All new nurses expected to provide a high standard of care

for patients and their families, and this expectation was

partly informed by their disappointment with previous

opportunities to give palliative care, and the anticipation of

higher nurse: patient ratios:

In the ward there was (sic) no facilities to deal with anyone dying, we

didn’t have the knowledge, and there was no room for relatives, we

didn’t have any time, we didn’t have any counselling skills, we had

nothing. And it just felt very inadequate and no satisfaction. (NN1)

There were expectations about ward teaching and education

programmes, as well as the hospice atmosphere and approach

to the dying, including pain and symptom management:

That’s why I chose to come here really, just to gain a lot more

experience in symptom control and just more about palliative care

itself really. (NN4)

However, there was variety in the extent to which expecta-

tions were realized by new nurses, and the majority of

mentors and team leaders (n ¼ 3 & 3) were aware of this and

the consequential disappointment:

I’ve seen a lot of people who’ve come here and been really

disappointed in the fact that they don’t have time to spend with the

patients at the bedside, they don’t have as much time as they’d like to

spend with relatives and that often they are put in at the deep end and

they are frightened. (M4)

Expectations about being able to provide a higher quality of

holistic care to patients, family and friends has been noted



elsewhere as a major driving force influencing decisions to

work in a hospice (Rasmussen et al. 1995, Fisher 1996).

Establishing effective relationships with patients, friends and

families has been found to enhance nurses’ satisfaction

(Rasmussen et al. 1995, 1997). Furthermore, being able

to provide holistic care has helped other hospice nurses

(Rasmussen et al. 1995) to find meaning in patients’ deaths,

and may explain why opportunities to provide holistic

nursing care were valued by the nurses in this study. The

gaps between expectations of care and the realities of hospice

nursing have also been experienced by others as detracting

from positive transition experiences (Rasmussen et al. 1995).

The positive reputation of the hospice in this study may have

added to the unrealistic expectations that the new nurses

brought with them. However, all had some of their expec-

tations met and were developing palliative care skills and

knowledge through their work.

Personal and professional development

Personal and professional development was integral to

becoming a confident, effective hospice nurse. Mentors and

team leaders believed that new nurses brought ‘basic’ nursing

and communication skills, and an awareness of their limita-

tions, while new nurses identified the need to develop existing

communication skills to facilitate discussions of death and

dying:

Being able to talk to people about nasty issues such as death and

dying…and that’s still quite hard but it’s not so bad…knowing when

to do that…and knowing what’s right to say to someone and what’s

not. (NN1)

Seven nurses (working across all three levels, i.e. new

nurses, mentors and team leaders) had experienced ‘deskil-

ling’, or a transient feeling of doubting their abilities, when

they had started at the hospice. All nurses had difficulties in

explaining what they meant by this, and it was perceived as

something that new nurses ‘did’ to themselves but that could

also be inflicted by others. It was agreed that deskilling

occurred because of the different nature of hospice nursing,

and deskilled nurses experienced feelings of stupidity, fear,

and inadequacy:

I remember back to my early days, feeling although I had palliative

care experience, feeling quite in awe of the place and the knowledge

that the people had. (M4)

Mentors and team leaders did not expect new nurses to have

specialist skills, only basic pain and symptom management

skills. New nurses were acutely aware of a variety of learning

needs and considered that skills could be learnt by working

alongside experienced nurses. This view was shared by

mentors and team leaders:

Watching other people is really helpful, listening to what they say,

how they phrase things, how they put things to people. (NN4)

Anxieties that new nurses initially experienced subsided as

they gained confidence in their ability to do the job:

It’s all confidence really…and just suddenly realising that you can do

it. (NN4)

Adaptation to the job was demonstrated by new nurses

practising independently, taking the initiative for patient care

and treatment decisions, and mentors and team leaders also

described this:

I see people often become much more confident and able to

co-ordinate, no problem…and be advocates for their patients and

to have a really good grasp of symptom control; and their

communication skills improve. (M1)

Similar feelings associated with deskilling have been reported

by other nurses in transition (Bradby 1990, Maben 1995,

Brown & Olshansky 1997). Gardner (1992) noted that

deskilling may arise from job conflict occurring when a

newcomer perceives that patients’ needs require skills they do

not possess. New nurses in the present study may have

perceived that they lacked the necessary palliative care skills

to optimize patient care, but equally others’ expectations may

have been too high or their judgements too harsh. Hence, the

sense of deskilling was created both by new nurses and other

staff.

Nicholson (1984) asserts that, when starting a new job,

newcomers may experience skill degeneration and associated

negative emotions similar to those expressed by deskilled new

nurses. This is overcome by the development of new skills,

hence its transient nature. New nurses in this study expressed

a need to develop pain and symptom management skills and

to extend their existing communication skills. Awareness of

the importance of these nursing skills reflects much of the

philosophy of palliative care (World Health Organization

1990) and previously identified palliative nursing skills

(Davies & Oberle 1990, Degner et al. 1991). New nurses

were observed by their mentors and team leaders to develop

skills whilst working on the wards. The concept of learning on

the job implies development of knowledge and skills through

experience, the value of which is acknowledged (Van Manen

1977, Schon 1983, Benner 1984), and now forms the basis of

the thrust for reflective practice in nursing. All participants in

this study believed that the benefits of clinical supervision and

facilitation of reflective practice through supervision would

enhance new nurses’ experiential learning.



Professional respect

Whilst new nurses brought a number of transferable skills with

them, there were varied responses from other nurses in their

willingness to acknowledge these skills, and this influenced

their perceptions of being welcomed on the ward. On the

whole, mentors and team leaders felt that the skills of new

nurses were not acknowledged by existing ward nurses. The

reluctance of new nurses to demonstrate their skills was related

to a sense of not wanting to appear too ‘pushy’, while the

reluctance of other nurses to acknowledge their skills was

partly explained by a tendency to focus on palliative care skills:

People often presume…because they haven’t got any experience of

palliative care…they can’t possibly have any experience of anything

else. (TL4)

There was pressure to conform to established practices, and

suggestions from new nurses about care were not always acc-

epted, creating a perceived lack of respect from other nurses:

Everything needs to be done before the ‘lates’ come on…because

that’s how it’s always been done and I think, ‘Does it really matter if

someone has a bath in the afternoon?’ (NN4)

Mentors and team leaders were aware of the sense and

power of conformity. All those interviewed, except one

mentor, felt that the sense of conformity in part arose as the

result of nurses having been at the hospice a long time. They

identified both positive and negative consequences of

nursing at the hospice for a long time, commenting that

with time staff became used to the constant exposure to

death and adopted coping mechanisms, such as distancing

or becoming hardened, which could compromise patient

care and job satisfaction. However, all new nurses acknow-

ledged that they could learn a great deal from some of the

experienced nurses.

The pressure to conform reported by three interviewees

(two new nurses, one team leader) extended to the point of

perceived bullying, which varied from questioning of deci-

sions to confrontation:

I was asked to come into the bathroom with two members of

staff…they wanted me to explain myself, why I had spoken to this

auxiliary like I had…it was horrible actually, especially when the

bathroom door was locked. (NN3)

A further two nurses were aware of colleagues having been

bullied. It was difficult for them to report bullying, because

of the threats they had received or because of the position

the bully held on the ward, or because of a perceived

reluctance by senior managers to tackle the problem

effectively.

Being criticized and questioned by colleagues have been

identified by other nurses in transition as unsupportive and

anxiety provoking (Oermann & Moffitt-Wolf 1997), and

associated with workplace bullying (Quine 1999). Some new

nurses had to ‘prove’ themselves, and this has been noted in

another area with a large proportion of newly appointed

nurses (Chapman 1993).

Bullying, as acknowledged by nurses in this study, is

prevalent in the workplace and is only now beginning to gain

necessary attention (Quine 1999). Whilst failure to report

bullying is frustrating, it is often because of disempowerment

of the person being bullied or anxiety about how it will be

dealt with (Grove 2000), as observed with the nurses

interviewed.

Mentorship

Formal mentorship had recently been established for new

nurses, but their experiences of it varied. Mentors expressed

commitment to supporting new nurses in their transition:

I have a responsibility to that person to be there, to help them

orientate to the ward…to give them an understanding what the

hospice is about…to give people information that means they can go

and find things out for themselves, also to be there for them if they’ve

got a problem…so I think that it’s my responsibility to put myself in

the relationship with them. (M1)

Threats to the relationship included lack of time, not working

shifts together, and perceived lack of power in the relation-

ship. Mentors felt that their role was most important for the

first 3–6 months of new nurses’ experience, and all partic-

ipants identified a necessary period of negotiation and a

shared responsibility for developing the relationship:

They have to nurture a relationship and if it’s not working effectively

then they need to change mentor, and they need to be adult enough to

actually say that. (TL2)

Three of the new nurses were very positive about the

mentorship scheme, but the mentor identified for the fourth

was unwilling to enter a formal relationship. The main

benefits for new nurses were support and education, whilst

two mentors identified reciprocal benefits:

It keeps you up to date, it keeps you on your toes. When they put a

question to you, you’ve got to give them a proper answer. (M4)

Less favourable aspects of mentorship included lack of

opportunities to work together and the perception of pressure

being put on mentors during busy times.

All mentors felt ill-prepared for their role, and conse-

quently some adopted their own approach:



I know what patients need…then you know what the nurses looking

after them need to know…I also go from my own experience…this

person isn’t going to not have what I was not given. (M3)

Mentors and team leaders considered that the hospice needed

to be more committed to mentorship. However, the situation

was improving, with regular preparatory workshops being

held for mentors; nevertheless, all mentors expressed the need

for ongoing support.

On the whole, nurses in this study found their relationships

with their mentors to be positive and mutually beneficial;

however, some spoke of being overprotected, personality

clashes, and being allocated an unwilling mentor. Similar

benefits and problems have been previously identified

(Earnshaw 1995, Phillips et al. 1996a, b).

Mentors studied by Atkins and Williams (1995) experi-

enced similar mentorship issues to those expressed by

mentors and team leaders in this study. Both identified the

educational and supportive responsibilities of the mentor,

and acknowledged the potential reciprocity of the relation-

ship. The need for adequate preparation and support from

colleagues has also been identified in other studies (Atkins &

Williams 1995, Earnshaw 1995, Cahill 1996, Phillips et al.

1996a, b).

Support

Patient situations most likely to distress new nurses were

close connections with patients, young patients, those in

similar situations to individual nurses, and those with

distressing symptoms:

The ones I find really difficult are when they’re petrified, you can

see the fear in their eyes,…and I find that very hard to cope with.

(NN4)

All new nurses expressed increased self-awareness from

repeated exposure to death, and a tendency to contemplate

mortality in their personal lives. Mentors and team leaders

were aware of the emotional cost of hospice nursing:

You give so much yourself…you can go to places you don’t want to

go, and it’s a good place to go if you want to learn a lot about

yourself and about life but I think that you can only go there every so

often otherwise you can get lost in that desert. (M3)

The recent introduction of clinical supervision was acknow-

ledged by all as an invaluable support mechanism. As a result

of the recent employment initiative, there were a number of

new nurses on each ward, and this created a sense of

solidarity that was facilitated further through meetings for

new nurses:

There was (sic) quite a lot of new staff all at the same time, it was nice

to be able to come…you could talk about how you felt…probably a

lot of the other people were feeling exactly the same as you and that

was quite reassuring. (NN4)

The emotional responses expressed by new nurses have also

emerged in previous studies. Nursing young people or those

with uncontrollable symptoms evoked a sense of injustice or

lack of meaning (McNamara et al. 1995, Rasmussen et al.

1995, 1997, Dean 1998). Patients dying with uncontrolled

symptoms may contravene new nurses’ expectations, and

therefore the impact of this can be great. New nurses’

increased awareness of their own mortality and that of

significant others arises, according to McNamara et al.

(1995), as a consequence of dealing with the reality of death

and dying, and has been reported by other hospice nurses

(Rasmussen et al. 1997). Palliative care nursing has explicit

emotional components, described by Smith (1992) as ‘emo-

tional labouring’. When labouring emotionally, nurses need

to appear caring to their patients, regardless of how they feel,

and this may produce the atmosphere of ‘institutional

niceness’ perceived by some team leaders in the present

study. Support for colleagues is important and may be an

extension of patient care, confirming the value of emotional

labour (Smith 1992).

There was a high level of mutual support, enhanced by the

large number of new nurses employed in close succession.

Bradby (1990) explains this phenomenon as the consequence

of a ‘collective passage’ (p. 1223) of people starting at the

same time, and being ‘all in the same boat’ (p. 1223). The use

of informal peer support in palliative care is well-documented

(Alexander & Ritchie 1990, Adams et al. 1991, Fisher 1996),

but should not be relied upon above the provision of formal,

structured support (Alexander & Ritchie 1990). Nurses of all

levels in the study acknowledged the need for structured

support through clinical supervision.

Discussion

The findings must be interpreted in the light of the limitations

of the study. The sample was small and because of the

research design, the findings are not generalizable. The fact

that the new nurses were self-selecting introduced selection

bias, and their views/constructs may not represent those of

the new nurses who declined to take part, or were not

interviewed. Use of a single self-report data collection tool

may have limited the richness and depth of data obtained.

Further, nurses may have felt inhibited by the position of the

researcher within their professional support system, and

therefore felt obliged to give positive responses. The self-



reported data could have been supplemented by other

methods of data collection, such as observation.

Central to nurses’ decisions to move into hospice nursing

was the wish to provide ‘better’ care to patients and their

families. Such high expectations were heralded by the

speciality of palliative care and the hospice movement.

Both strive to overcome the perceived shortcomings of care

provided by other specialities in other settings, but this may

result in unrealistically high expectations of such a trans-

ition and an element of surprise. Any role transition creates

uncertainty and anxiety, and these emotions may have been

exacerbated for the new nurses when coupled with trans-

ition into a stressful speciality. Anxieties associated with

transition were exacerbated or ameliorated by the structures

put into place, and collegial support at all levels. Effective

mentorship emerged from this study as vital components of

the less difficult transition experiences.

Although the mentorship experience was a positive one for

the majority of new nurses, one nurse received no support.

This raises the question of the value of arbitrary allocation of

‘contractual’ mentors (Morton-Cooper & Palmer 2000), a

question echoed by mentors who were charged with the

responsibility with little or no preparation. Would the

mentoring system work more effectively if, in keeping with

the classical model of mentoring, new nurses approached a

potential mentor to whom they were drawn? Willing mentors

could then receive formal training and, in response to the plea

here for continued support, join action learning sets (McGill

& Beaty 2001) to aid their own role transition.

Whilst common views were expressed by interviewees,

each also expressed individual opinions and experiences;

therefore, provision of sensitive, individualized support and

professional development is important. This could have been

hampered by the collective passage of so many new nurses,

resulting in failure by others to see each as an individual.

Whilst the study has highlighted the need for, and presence

of, support for new nurses, it may be that all staff had support

needs during this time of major organizational transition. The

sense of conformity might have been created by established

staff feeling threatened by further change and retreating into

the security of established practices. Some support might have

been gained by those with access to clinical supervision, but

alternative formal support mechanisms might have been

beneficial to other staff.

Conclusion

Preliminary understandings of some of the transition experi-

ences of nurses entering hospice nursing have been identified

from this study. Transition is a time of uncertainty which can

be helped by the presence of formal support structures

including effective mentorship and plans for professional

development. Failure of established staff to acknowledge the

skills of new nurses and to allow them to contribute to

developing new and effective ways of caring for patients

makes the transition much more uncomfortable. All staff on

wards are affected by the advent of new staff and conse-

quently have their own support needs.

It was not possible to continue the exploration of the

emergent themes to the point at which outcomes could be

confirmed and differences clarified (Appleton & King 1997).

Therefore, the interpretations from this small study are

preliminary and need further investigation to reach consen-

sus. Ward auxiliaries and other professionals should be

included in future studies to explore the themes from the

point of view of the whole ward team.

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• Role transition is potentially unsettling for newly qual-

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number of factors.

• Mentorship enhances the transition experience and

mentors require adequate preparation and continued

support in their role.

• Nurses bring a number of expectations with them as

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What this paper adds

• Role transition is also unsettling for experienced nurses

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• New nurses experience a sense of deskilling during their

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• New nurses experience a need to conform to established

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Transition experiences of qualified nurses moving into hospice nursing