Newly graduated nurses’ experiences with death and dying patients in medical units at patient safety hospitals in Denmark


This is the second of two entries from Carsten Juul Jenson, a colleague from Denmark, who is undertaking a PhD in self-blame among nurses.

In my PhD thesis, I employed institutional ethnography (IE) with participant observations, interviews and analysis of political documents to inquire newly qualified nurses’ (NQN) work at death and with dying patients in medical units. NQNs who are unfamiliar working with death and dying may consider themselves as failed nurses (murderers) if patients die; death could be perceived as a mistake. In patient safety hospitals, the political goals of quality improvements are related to health, survival and hardworking productivity. Though, as I emphasize below “is isn’t your fault”, NQN cannot be found guilty of the deaths of older acute ill patients with comorbidities in the medical unit in which they work.

One NQN, Anja raises her voice: “I, am afraid of killing patients” and Martha said: “I do kill the patients”, which I present in a poetic representation with inspiration from critical feminism. It is Martha’s first week in a medical unit, which starts on the first day of Martha’s employment. I followed Martha in the morning round to check patients’ health conditions:

Ole, Christian, Hans, Christa and Andrew die.

Is he?

No, it can´t be true?

Look at Carsten who looks back at Ole.

Carsten says: “I think he is….”

I have to go in there. He isn’t breathing.

I just have to look at my notes – he is not supposed to be resuscitated


I have to learn it

I have to feel what his skin feels like

He´s cold, but not that cold.

His skin feels weird but not as spooky as I had imagined


Christian died today too

I almost cried because his daughter cried


Hans died on Tuesday


Christa died on Wednesday


Andrew died on Friday


I was able to manage the first one, but enough is enough

No, I´m not allowed to cry

Nurses don’t cry

I can’t help it – my eyes get filled with tears



Most activities in hospitals including medical rehabilitation units, health promotion, resuscitation and identification of critical illness use various “early warning” tools. The clinical guideline for these activities no longer apply if patients are incurably ill, although, as Rebecca says: “I would rather not give her the death blow,” when she must give an incurably ill woman morphine.

“It’s not your fault that you break down” – a study of self-blame in newly qualified nurses in medical units in Denmark

cajujeThis is the first of two entries from Carsten Juul Jenson, a colleague from Denmark, who is undertaking a PhD in self=blame among nurses.

In an institutional ethnography (IE) with participant observation, interviews with newly qualified nurses (NQNs) and analysis of political documents, I show that NQNs consider themselves as individually responsible for inadequate capacities in problem solving in medical units in Denmark.

However, individual self-blame varies according to gender and age: Thor’s (male), Anja’s (35 years old) and Martha’s (29 years old) emotional responses to their new role as a nurse seem less self-blaming than that of Emilie (25 years old) and Rebecca (23 years old).

Emilie has to go off sick due to physical symptoms of anxiety, as she felt personally responsible for leaving unfinished nursing tasks for her colleagues, even if she has to provide care for a patient, who has been incontinent of urine.

Rebecca reflects, “Why did I do bathroom 6 first?”, while she had helped a talkative and time-consuming patient, instead of answering a bell from a bathroom, where she unexpectedly found a patient, who has collapsed from incurable respiratory distress.

These young NQNs blame themselves even though they are working in conditions that it are above human capacity to predict and live in constant fear of harming patients fatally despite mainly working with older patients with comorbidities and acute illnesses. Anja, who explicitly expressed fear of being blamed for patients’ death, states: “You know, I went home crying, but it’s not my fault, it’s the working conditions that are unreasonable.”

The service-minded approach of new public management reforms of hospitals in Denmark stresses individualism thus these young new nurses find themselves shouldering this responsibility The young women Emilie and Rebecca appear overly responsible and conscientious in their efforts to handle nursing care for the least amount of money in medical units overcrowded with older patients

In an interview for the Danish Nurses Organization in May 2018, I raise my voice emphasizing: “It’s not your fault that you break down”. I wish to relieve the pressure of individualism. NQNs cannot be held individually responsible for discrepancies between delivering health for the least amount of money and demographic changes with an ageing population more than 80 years old, of whom 80 % are hospitalized with acute illnesses.

James Buchan writes:

We have a new government. Time to revisit an election promise, which has a direct connection to the STaR project. “50, 000 more nurses by 2024/5” was the Conservative manifesto commitment in December last year. This was immediately brokered down to 31, 000 additional “new” nurses, because part of the plan was to encourage about 19,000 existing nurses to stay on[i].

Boris Johnson had barely re-crossed the threshold at number 10 Downing Street before the new government made an announcement about changed funding modalities for student nurses in England. An annual grant of £5,000 to cover living costs is promised to all new and current undergraduate student nurses[ii]. A further £3,000 will be available for people studying hard-to-recruit disciplines, such as mental health and learning disability nursing. This new money will not cover tuition fees. Students will still be required to pay tuition fees of £9,000 a year.

Even with this “new” money, the scale of the nursing shortage in NHS England will take some solving. Recent research by the Health Foundation[iii] highlighted that that nursing remains the key area of shortage and pressure across the NHS, and that recent modest growth in nurse numbers has not kept pace with demand. NHS nursing vacancies increased to almost 44,000 in the first quarter of 2019/20, which is equivalent to 12% of the nursing workforce. To prevent nursing shortages growing further, urgent action is needed to increase the numbers of nurses in training, reduce attrition and improve retention.

In 2019 the number of applicants to nursing courses in England increased for the first time since the NHS bursary was withdrawn in 2017. The number of applicants in England had risen to 40,780, but nevertheless remained below the figure for 2017. In contrast, Scotland, where the NHS bursary has been retained and its value increased, saw a 6.7% increase in student nurses in 2019, taking the number of applicants to its highest ever level.

If the NHS is to reduce vacancies and grow the pool of qualified nurses to recruit from, the forthcoming NHS People Plan will need to set out measures that will rapidly expand the number of people starting undergraduate nursing degrees in England. Analysis by the Health Foundation shows that there are different patterns of applications and acceptances by age, branch of nursing and geography.

For example, the numbers of students starting mental health and learning disabilities nursing fell significantly between 2014 and 2018. All continuously running learning disability courses had fewer students in 2018 than in 2014. This is in contrast to children’s nursing, where around two-thirds of courses (63%) had increased in size. Fewer over-25s started nursing degrees in 2018 compared with 2016, particularly impacting learning disability and mental health courses.

Overall trends can also hide pressure points in different areas of the country. Adjusting for population size London and the South East are in the bottom three regions for the number of acceptances to study nursing and the top three for the number of vacancies per 100,000 people.

As highlighted in the work for STaR, a relatively high proportion of students who start a nursing degree do not graduate within three years – either dropping out completely or putting their studies on hold. The latest data analysed by the Health Foundation showed that attrition remains stubbornly high despite government commitments to reduce it. One in four nurses who were expected to graduate in 2018 did not do so, and the overall attrition rate was highest for learning disability courses.

There is a time lag of four years before new student nurses become productive professionals. Even if the newly promised funds attract more student nurses, there can be no quick win for the government in achieving the 31,000 target by 2024/25 just by increasing the intakes of new student nurses this year and next. It will also have to work effectively with universities and employers to then reduce attrition rates of those who have been attracted to a student nurse place. STaR is well placed to give insights and support to an evidence-based approach to reduce attrition and support successful transition into practice.

[i] Buchan J (2019) How will the Conservative election pledge of 50,000 more nurses by 2024/25 be realised? Nursing Standard, 18 December 2019

[ii] Jones-Berry S (2019) Nursing students in England to receive £5,000 grant from next September. Nursing Standard, 18 December 2019.

[iii] Buchan J, Gershlick B, Charlesworth A, Seccombe I (2019) Falling short: the NHS workforce challenge. Workforce profile and trends of the NHS in England. Health Foundation, London

‘Should I stay, or should I go?’ Are NQNs leaving their first post within 12 months?

Jane Wray writes:

I recently posted a comment on Twitter about the fact that several of my former students had contacted me for a reference for a new job all within the space of three weeks. All had qualified about a year ago (Oct 2018) and it prompted me to ask on Twitter “is this usual? 12 months and then move?”.IMG_6712

There were a few responses to my poll (28 in fact) with 25% indicating that they would move to a new role, 36% were staying where they were and the biggest group – 39% were ‘still deciding’. However, what was interesting was the number of people who commented on the poll and this very issue of whether they should stay or move on.  Most of the comments indicated that NQNs did leave within 12 months or so of qualifying or they were about to leave sometime soon. This was because they got promoted or a better job offer from another organisation. Some left because they were seeking a new challenge and a few (the minority) said that they had not settled in their first post or did not feel it was a supportive environment.

So yes – NQNs are leaving within the first 12 months but this appeared to be for mainly positive reasons. If you have the offer of promotion (more money!), or a job that suits you better or a different role that provides you a new challenge then why would you not move? Alongside these comments were also some from nurses who had been qualified for over 20 or even 30 years who indicated that they too had moved on within or around 12 months of qualifying. This ‘moving on’ within the first 12 months is not a new phenomenon and is something that perhaps many NQN do. Nor does it appear to be a consequence of negative circumstances and situations.

I am mindful that NQNs moving on within 12 months impacts on workforce retention and that this is currently a huge challenge for most healthcare organisations particularly in the NHS. However, some of these reasons for moving on (promotion, different job or a new challenge) might easily be provided by the organisation that the NQN is currently with – and if this was offered, would they stay or still go?

Celebrating at the National Retention Awards in London

On Tuesday 19th November the first ever celebrating nursing retention awards were held in London. Jointly hosted by the Burdett Trust for Nursing and NHS Improvement, this was an opportunity to celebrate and thank those that have been doing brilliant work around staff retention across the country. There were several formal presentations on good practice –showcasing work done by NHS Trusts with support from NHS improvement to improve staff retention. Alongside the formal presentations, there were awards for excellent retention work across several categories. My take home message was definitely “place staff at the centre of your retention work; support and value them and then you will retain them”.

Jane Wray talks to Shirley Baines, Chief Executive, The Burdett Trust for Nursing celebrating at the National Retention Awards in London

Nominations (and winners) were as follows;

  • Best career planning and development offer (Warrington and Halton Hospitals NHS Foundation Trust)
  • Best retention offer to support equality, diversity and inclusion (Sherwood Forest Hospitals NHS Foundation Trust).
  • Best Support for those approaching retirement (Mid and South Essex University Hospitals Group)
  • Best Flexible working offer to support work-life balance (Lancashire and South Cumbria NHS)
  • Best Staff Engagement and Communications offer (Northumbria Healthcare NHS Foundation Trust)
  • Best use of Data to inform Retention Initiatives (Tameside and Glossop Integrated Care NHS Foundation Trust)
  • Best Health and Wellbeing, Rewards and Benefits offer (Kingston Hospital NHS Foundation Trust)
  • Best Support to New Starters and Newly Qualified (The Mid Yorkshire Hospitals NHS Trust)


The final award of the day, the coveted “Retention Team of the Year”; this award went to University Hospitals of Derby and Barton NHS Foundation Trust.

Congratulations to all the award winners, and those who were nominated.  The day was rounded off nicely by Professor Mark Radford, Chief Nurse for Health Education England and Deputy Chief Nursing Officer at NHS England and NHS Improvement providing an update on the National Retention Programme (see the website for more details). Retention of the nursing workforce, and other professional groups working in the NHS remains a huge concern amidst reports of workforce deficits and safe staffing issues. From this event it was evident that there are organisations working hard to make a difference not just for NQNs but for all nurses.

Team members in Vancouver

We have been capturing newly qualified nurses (NQNs) experiences of transition via interviews during the last 12 months. We recently had several discussions with international colleagues on this important issue and the challenges experienced by NQNs during this time seem to be common and occur in different countries – despite the different educational preparation, health care systems and policy and practice context. In addition, this experience also transcends professional disciplines and it is evident that this period of transition challenge also applies to different professions and disciplines allied to health. The importance of support during the transition period, as well as on-going mentorship and/or preceptorship throughout careers to deal with and process challenging emotional situations is fundamental to the wellbeing of healthcare staff. This is relevant to NQNs as well as more experienced healthcare professionals.IMG_6526.JPG

These conversations took place whilst we were attending the International Institute for Qualitative Methodology “Qualitative Health Research Conference” (25-29 October) in Vancouver. This was such a great experience – a diverse and eclectic inter disciplinary mix of keynotes and concurrent sessions exclusively focused on qualitative health research. A conference full of stimulating debate in a welcoming and supportive environment. This was an opportunity to showcase the qualitative elements of our study – the student reflections on transition in a poster presentation (Change Challenge and Excitement: Reflections on the transition from student to newly qualified nurse). We also did an oral presentation focused on the interview data from the study – ‘Perspectives on transition from student to newly qualified nurse views of students, NQNs, academics and clinical managers’.IMG_6556

Our work was well received with lots of positive feedback. It has provided us with some great ideas for future research and some food for thought on how we can further interrogate our research findings.

Supporting student nurses as they are preparing to move into the world of work

david-barrettDr David Barrett writes: As part of the STaR project work with our students and partners in practice, we have been exploring different ideas to facilitate the transition period, when students exit the university and move into the world of work. One of the ideas that came out from our interviews (with students and clinical leaders) was the need for an opportunity for students to meet their future colleagues and see their place of work prior to starting their newly qualified nurse (NQN) role.

“…it will give them the opportunity to meet people…you know the code for the door…silly little things, it will make them less anxious on the day they start”

“…I would always advise people to start somewhere where they have already had a placement, just for simple things like you know where the coffee room is…you know how things work …they know your work ethic…they know what you are like”

The message from interviews was very clear: students would benefit from spending time with their first employer ahead of qualification. It was suggested that this would promote familiarisation and orientation, allow pre-induction processes to commence, potential training needs to be identified and for the ‘transition shock’ of new employment to be reduced.

From a University perspective though, final placements with the first employer raises some issues. It is important that the decision of a sign-off mentor/practice assessor on a student’s readiness for registration is entirely objective. If the final placement (and final assessment) takes place on the area where a student will be taking up employment, this may compromise objectivity. Equally, students must be judged as competent to work in any area as a Registered Nurse, not simply the specialty or area in which they will commence employment. For these reasons, the policy of the University of Hull is not to give student final placements in the setting in which they will be taking up employment (though other Universities do allow this).

Nonetheless, the STaR findings demonstrated a desire to allow students some exposure to their place of first employment (PFE) during their final placement. As a compromise, an initiative was designed that would allow them to spend up to two weeks (75hrs) of their final 12-week placement working within their PFE. Their performance during this time would not be formally assessed, though supervisors could provide testimony that was fed back to sign-off mentors. The PFE initiative was developed and agreed with our main local employers, and first implemented in the summer of 2019.

Initial feedback from the project has been positive. Two-thirds of students took the opportunity to spend time with their PFE (reasons for not doing so included previously having had a placement there or the area being too geographically distant to be practical). We asked those who had spent time with their PFE to rate (on a scale of 0-10) how useful the time had been. Orientation to the area (mean score 8.3) was deemed the area in which the initiative was most useful, followed by building confidence (7.9) and understanding the RN role (7.7).STaR mentimetre

We also asked the students what they found most useful. Many students highlighted that the time enabled them to meet their future colleagues (and vice versa) – “Getting to know the staff”; “Getting my face recognised before starting”. For other, there were practical benefits – “…getting uniforms and shifts and booking holidays” – and the ability to become orientated – “Understanding the ward’s routine”. One unexpected ‘benefit’ was raised by five respondents whose time on their PFE made them realise that they had made a mistake in accepting the post: “I learnt I did not want to work there”.

There were some teething troubles with the initiative. Awareness amongst practice areas – particularly those further afield – could be better, and the processes for arranging and recording time with the PFE could be enhanced. We are continuing to review the student feedback, and that from our partners, to refine the process and governance around this but we are really pleased to see that the initiative has been broadly successful and seems to have helped some students prepare for the transition from student to employee.

“If we are serious about nurse retention we must nurture and support our staff”

pic from RCN.png

(Left to Right: Jane Wray; Helen Gibson; David Barrett; Judy Brook; Rosie Stenhouse)

At this year’s Royal College At this year’s Royal College of Nursing (RCN) International Nursing Conference and Exhibition 2019 (Sheffield Hallam University, 3-5 September), the STaR project team were delighted to share our preliminary findings with an international audience of nursing academics, practitioners and researchers.

Jane Wray hosted a symposium of four papers on “Retention of newly qualified nurses (NQNs) in the UK National Health Service (NHS) on the 2nd day of the conference. David Barrett presented the findings from the STaR project Rapid Evidence Review, and this was followed by Jane and Helen Gibson (STaR project post-doctoral researcher) on the interview data “Perspectives on support during the transition from student to NQN: Views of students, NQNs, academics and clinical managers”. The third paper was by Dr Rosie Stenhouse (The University of Edinburgh) on “Job Embeddedness: Towards a Theory of Retention in Newly Qualified Nurses/Midwives” and she presented findings from interviews with 23 early career nurses about their experience of the workplace. This work is part of a larger longitudinal study exploring engagement levels, emotional intelligence, resilience and burnout yearly, retention, academic grade and following qualification, pay.  The final one was by Analisa Smythe (Birmingham and Solihull Mental Health NHS Foundation Trust) on “A qualitative study of experiences of online peer support for NQNs” – a project also funded by the Burdett Trust for Nursing that used focus groups with NQNs to refine an online peer support intervention.

There was lots of interesting comments and questions and it was great to hear from recently qualified nurses in the audience whose experiences appear to be very similar to the ones we reported – further validating our findings. The wider discussion at the end of the symposium focused on workforce and retention and the key message was that if organisations want to attract and retain staff they need to ensure that all staff (not just NQNs) are given the ‘the right support, at the right time and in the right place’ and that ‘if we are serious about nurse retention we must nurture and support our staff’.

Throughout the conference workforce issues including safe staffing, staff shortages and retention were repeatedly referred to. We also attended a symposium led by Judy Brook (City University) on “Development and implementation of an intervention to increase retention and decrease burnout of early career nurses” – another project supported by the Burdett Trust for Nursing.  It was interesting to see how coproduction is being used to develop an intervention to support transition. This team have published a systematic review related to their project and you can find out further information about their work by contacting JudyBrook (

Supporting Transition and Retention of newly qualified nurses

shaz2Sharon Aldridge-Bent

The General Practice Nursing 10 Point Plan (GPN 10PP)  has given an investment of £15 million from the General Practice Forward View (GPFV) funding allocation, to support action which will address the significant workforce challenges and support improvements in General Practice nursing (GPN) by 2020.

The Queen’s Nursing Institute (QNI) has been commissioned by NHS England to develop an Induction Template specifically designed to enable employers to ensure that nurses in a first career destination role in General Practice are well supported when taking their first career step in primary care.

As a programme manager at the QNI, one aspect of my role has been to develop and write transition resources, such as Transition to District Nursing and more recently Care Home Nursing, which I had found relatively straightforward, as in my previous role as a senior lecturer in a university I had taught widely in these aspects of nursing.

I was less familiar with general practice nursing and in particular the orientation and induction of nurses into this discipline and, initially, I did wonder whether I was the right person to write this document.   As the work continued, I began to realise that my ignorance was an advantage, as I came with absolutely no preconceived ideas about the discipline and took a neutral approach to the evidence I collected. I scrutinised and analysed every aspect of the template with a new and fresh approach to how newly qualified nurses would approach this area of nursing.

The QNI has a systematic approach to this type of work, which involves gathering evidence from a wide range of perspectives. I set about the process with an extensive literature search of the subject matter. This search reaped some good quality and relevant studies, as well as several induction templates that had been performed in the same or similar settings.

I then developed a questionnaire that was circulated via Survey Monkey to our networks, requesting insight and input into what the challenges were around orientation and induction into general practice. It was important that this questionnaire went to all stakeholders that were to be represented within the template, e.g. student nurses, nurses thinking about moving into general practice, existing general practice nurses, employers, including GPs and Practice Managers, and Higher Education Institutions. The response was tremendous and this assisted me when formulating my ideas around the format of the template.

I then set about developing an external review group that would represent all perspectives of this work and I also took advice from NHSE colleagues regarding relevant participants. The review group consisted of representatives such as student nurse groups, general practice nurses, GPs and Practice Managers, as well as input from Health Education England, The Royal College of Nursing GPN Forum, Care Quality Commission, several universities and colleagues at the QNI. I visited all the regional delivery boards of the GPN 10PP to update widely on this work and undertook telephone interviews with the external reviewers. I also attended the newly formed Association of Academic General Practice Nurse Educators (AAGPNE) to get an understanding of how academic programmes for GPNs were being developed.

Upon drafting a first plan of the work, I chaired a small focus group of six general practice nurses where the document was scrutinised for accuracy and to ensure that there were no fundamental omissions. The external review panel were then sent the second draft for feedback before final edits and publication.

My personal reflection of developing this template was I felt very privileged to meet such committed and experienced nurses who had developed professionally, despite (at times) lack of acknowledgement and professional identity of other nurses working in adjacent specialities in the community setting. I was struck by how complex the role of the general practice nurse was and how it most definitely would appeal to newly qualified nurses, because all the knowledge and skills attained as a pre-registration nurse can be utilised in this role. Also, to add that:

‘Developing this template highlighted the urgent need for a comprehensive induction and orientation programme for all nurses new to general practice. This most certainly will assist with recruitment and retention of nurses in the primary care setting’.

The document is hosted on the GPN Single Point website. Click here to view the document (you will need to request access here.). The document can also be viewed on the QNI’s website.

Sharon Aldridge-Bent

Programme Manager, The Queen’s Nursing Institute


Twitter: @saldri01

The role of clinical educators in supporting newly qualified nurses during transition

Bill Whitehead 30 June 2019

Bill-Whitehead-(3I’ve been interested in supporting newly qualified nurses (NQNs) during their transition from student to staff nurse since I first qualified in 1990.  It seemed obvious to me then that the provision of clinical educators in practice to support students should also be there to support NQNs.  I had learned a lot during my traditional three year apprenticeship but I hadn’t realised the full range of skills needed in the specialist area of acute medicine that I landed in.  These included an understanding of all the roles of the multi-disciplinary team, the treatment and care of patients with the specialist conditions on the ward and most importantly, an understanding of the social care required for the mainly elderly and often newly infirm patients on discharge.  This took me a while to learn and there were times when I thought it was beyond.  As a newly qualified former mature student, I knew that really what I needed was the time and support to learn.  Consequently, I started looking into the theory and evidence around NQN transition nearly thirty years ago.

The transition from student to registered nurse has long been known to be a difficult time for NQNs joining the register.  Marlene Kramer made this the subject of her PhD thesis in the 1960s and published her seminal book “Reality Shock: Why Nurses Leave Nursing” in the 1970s.  The main finding of her research, over fifty years ago, was that NQNs were less likely to leave early in their career if they had a supportive programme linking their time as a student to registrant to support the transition.  In the twenty-first century we have developed this supportive programme into preceptorship support programmes.  These are usually run entirely by the employer of the NQN but as Kramer found in what she described as the “anticipatory socialisation programme” the support for transition works best if it starts during the pre-registration education programme.  Where this can run seamlessly into local employers’ preceptorship programmes the transition shock for NQNs is understandably reduced to more manageable levels.  There has been plenty of research in the intervening half a century since Kramer’s work and at least two systematic reviews of these research projects in the last few years to support the need for a period of good supported transition arrangements.  The latest research includes Health Education England’s recent RePAIR project and the ongoing STAR project.

I’m the general secretary of the UK Clinical Nurse Educator Network (CNEnet). The network was set up to link up and share good practice between CNEs.  I co-founded this organisation with Liz Allibone because we had both done this job and both, separately, completed research which indicated the need for it.  One of the central roles of CNEs is supporting the transition of NQNs.  We know this from our own experience and from a recent survey of members which indicated that over 90% had a role in supporting NQNs and believed that it encourages NQNs to join their organisation and to stay with them.  Our research indicated that for best results an organisations preceptorship programme needs to provide three levels of support:

  1. A named more experienced registrant in their team as a preceptor
  2. A supportive team who recognise the need for NQNs to have time and support to learn the ropes
  3. An organisational level support programme ideally linked to local pre-registration programmes to provide a feeling of seamless supportive environment for the senior student transitioning into an NQN

This all needs dedicated staff to organise and sustain.  Therefore, the clinical nurse educator is not an “expensive luxury”, as some employers have believed in the past, but a “practical necessity”.  Without them, as Kramer proved fifty years ago, “nurses leave nursing” too early in their careers.

Could you add this to the bottom – For more information about the Clinical Nurse Educators Network see this link.