*3.1. Dealing with Death*

Of concern to many participants were the difficulties with increased frequency of experiencing the death of patients despite intense efforts to keep them alive. They felt responsible to be there for their patients during end of life when family were not able to be there. Gabby described, "So most of my patients with COVID die. So if they're in the ICU, they don't leave the ICU alive. So, I think that's a big fear, just knowing I'm the last person to be there with them because most of they don't make it." Participants described being greatly impacted by each passing, but after a while, could not recall each patient in their care who had died. Irena put it this way: "The amount of loss that I've seen since March, at first it was always in front of my mind. I would say, I've lost four patients so far, I've lost six patients so far and now the sad truth is, I can't even keep track anymore."

Emma noted that even her experienced nurse colleagues had never experienced so many deaths, "A lot of the nurses that I worked with have literally never experienced a death, even in five or six years of nursing. Now we're seeing it every shift so it's a big adjustment for us. We're used to having patients have good outcomes." She also noted that the Ethics Committee was needed more frequently to make final, end-of-life decisions for patients. Amy noted the emotional toll of withdrawing care: "When you have to sit there and withdraw care at the bedside, it kind of just takes a little bit of your soul away every time you have to do it."

#### *3.2. Which PPE Will Keep Us Safe?*

Participants expressed concerns about how to protect themselves in patient rooms, and how the guidelines for personal protective equipment (PPE) changed frequently in the early stages of the pandemic. They sometimes experienced daily changes to PPE protocols. Jane and Hattie shared their perspectives on PPE requirements they described as changing each shift:

Jane noted, "Things were changing every day with their recommendations saying you can wear two masks and then no, it's not a good idea to wear two masks and you can use and reuse these certain types of N95s and things were just changing all the time and it kind of felt like we weren't ever getting the most accurate information which is pretty scary ... so every shift, things were changing and the protocols were different. So it just kind of felt like chaos."

Hattie said, "I think they're trying their hardest to keep us up to date on the rules, but one day we're wearing safety glasses. The next day, you only wear them if you're in rule-out rooms ... later everyone would be going to the COVID unit if they're rule-outs and then for a week, rule-outs would come to the floor."

Nurses felt some PPE decisions were made based upon available supplies. Jane said, "It was hard to know if changing PPE requirements were based on new evidence and knowledge or because the hospital has to mitigate low stock of N95s." They worried about personally getting COVID and taking it home to family members. Irena put it this way

"My first reaction I had the first day that I heard that I was going to a COVID unit was sheer fear ... so much unknown about the virus and how it spreads and how we protect ourselves. They would allow us to go into the patient rooms with just surgical masks on. And we weren't wearing N95s as long as we stood within this box that they had taped off on the floor, because if you were 6 feet away from the patient, they thought you were safe."

#### *3.3. Caring for High-Acuity Patients with Limited Training*

Participants reported that the medical demands of COVID patients required them to pivot quickly to caring for patients of a much higher acuity. As Emma stated, "the level of acuity of my patients increased exponentially overnight with no training and we just had to go with the flow and figure out how to handle it." Many felt inadequately prepared for this transition, as Irena described, "The reality for us is that we basically had an ICU situation on almost every floor that we were on, so our house supervisor basically said, you're working on an ICU unit without ICU training right now." Nurses mentioned that managing critically ill patients is stressful for new nurses under normal circumstances, but the pandemic compounded the stress. Bill gave an example of caring for a challenging trauma patient with multi-organ system dysfunction who also had COVID, "they're not only a trauma patient but now they've contracted COVID, so where they would otherwise not need aggressive respiratory support, now they're needing respiratory support."

Nurses described an increase in daily code events and uncertainty about code outcomes that added to their stress. Denise noted a particularly difficult two-week time period during the pandemic's peak, "The ER (emergency room) is one of those units where it does happen from time to time ... I've never had so many codes in one short time frame." Many described uncertainty about whether they would recognize key symptoms that indicate clinical decline. As Irena stated, "It's just always in the back of your mind. Am I doing enough? Did I catch everything? You know, did I miss something ... I think you're always kind of second-guessing yourself, especially as a new grad because you're still learning what all that stuff sounds like and feels like and presents as." Participants also described uncertainty with the new disease process of COVID itself, and the speed at which symptoms appear and patients deteriorate. As Marie said, "The other thing with COVID is just, it just happens so quickly. These patients are declining so rapidly."
