**4. Discussion**

In this study, the experience of being a new nurse during a pandemic left nurses feeling that they were being challenged by the experience and that, at times, they were overwhelmed and struggled to cope with the intensity of the experience. Nurses found that patients were of high acuity and they felt they lacked adequate training to care for them, many patients did not survive despite the best medical and nursing efforts, guidance about PPE was regularly changing, and units were working short-staffed. In a study by Garcia-Martin et al. of novice nurses in the Emergency Department (ED), similar themes emerged from an analysis of 16 semi-structured interviews [16]. One of the themes identified was titled "Fears and concerns" which addressed the nurses caring for highly complex patients with limited training in the ED and fear of becoming ill or taking the illness home to family [16]. A subtheme called "Dealing with new challenges" under a separate theme spoke to the confusion surrounding appropriate PPE to be worn to remain safe and free of illness [16].

In this study, support from colleagues who understood the experiences of caring for these extremely ill patients helped nurses when the process of caring for patients had become difficult for them to handle. While the Garcia-Martin et al. article identified a theme of "Support for novice nurses," the subthemes focused primarily on the need for information and organizing resources to provide care for the patients during a short stay in the ED setting [16].

One of the themes unique to this study was "Everything is not okay" which spoke to the personal coping of nurses who were caring for patients during the pandemic. Some participants described experiencing signs and symptoms such as inability to eat and sleep, nightmares, crying over difficult work situations, reluctance to return to work, and feeling depressed. that are potential evidence of extreme anxiety and stress, depression, or burnout and intention to leave nursing. In an article by Chen et al., the authors looked at predictors for leaving the nursing profession during the pandemic and concluded that clinical stress and frequency of caring for patients with COVID-19 infections impacted the nurses' decision to stay in their career [17].

A systematic review of the literature by Carmassi et al. concludes that post-traumatic stress disorder (PTSD) was present during the first two pandemics and may be present in nurses caring for acutely ill patients during the recent pandemic [18]. An article by d'Ettore et al. also suggests that health care workers have experienced mental health issues during previous epidemics, such as SARS and Middle East respiratory syndrome (MERS) [19]. PTSD is a disorder characterized by recurring symptoms such as bad dreams, flashbacks, avoidance, hyperarousal, difficulty sleeping, and negative thoughts that develops in some people following exposure to a traumatic event [20]. In the Carmassi review, the authors identified exposure level to ill patients, years of work experience, female gender, and a number of other risk and resilience factors as determining if individuals might experience PTSD in the performance of their duties during a pandemic [18]. The International Council of Nurses published a COVID-19 Update suggesting that globally, nurses are experiencing burnout and mental distress associated with extreme pressures of working during the pandemic and number of nurse deaths exceeded 2200 as of January 2021 [21]. In this study, even those nurses without daily direct contact with COVID-19 patients experienced

negative psychological effects, such as guilt that they were not doing enough to assist fellow co-workers.

Uncovering the experiences of novice nurses in a pandemic and understanding the unique challenges being faced provides a foundation for educational interventions that have the potential to strengthen and preserve the nursing workforce. In the theme "Nursing school preparation for a pandemic" students described how the demands of nursing school had instilled the ability to plan, organize, think critically, and be flexible in their practice. Clinical rotations and high intensity simulation experiences, post-clinical debriefings, and end-of-life or palliative care discussions were also helpful. In the article by Sparacino, role transition as novice nurses is inevitable but expert, caring, professional experiences with faculty can make a real difference for students in knowing how to engage in a positive way in their professional role especially during stressful times [6]. This education must continue to be enhanced with a focus on self-care and effective team communication.

For nurses in the stressful situation of providing care for patients in a pandemic, hospital management must provide additional support such as counseling sessions at no cost for nurses experiencing symptoms of anxiety, depression, or PTSD, nurse mentoring programs pairing nurses with several years of nursing experience with novice nurses, and providing structured weekly opportunities for debriefing with nursing unit managers, administrators, and colleagues to provide support. Staff educational sessions on the most effective techniques in caring for ill patients and preferred PPE equipment should be conducted.

Participants were asked whether they had used any resilience resources since the pandemic began. Interestingly, only one of 13 participants reported using employerprovided resilience resources, which included support webinars, counseling hotlines, and talking with hospital chaplains. Many sought their own forms of support with physical activity, media vacations, engaging in pleasurable and distracting hobbies, seeking help from their own counselors, or talking with friends and family members. This may point to a lack of understanding on the part of organizations about what resources are most needed by novice frontline nurses, and how best to connect employees to employer-offered resources, which supports findings of the meta-analysis by Pollock and colleagues [9].
