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. 2022 Dec 18;45(5):432–442. doi: 10.1177/01939459221144178

Transitioning to Independent Nursing Practice during COVID-19: A Mixed Methods Study

Keli Blanco 1, Elizabeth Ely 1, Katelyn DeAlmeida 1, Nicole L Bohr 1,✉
PMCID: PMC9768533  PMID: 36529992

Abstract

The COVID-19 pandemic presented challenges to onboard and support new graduate nurses (NGNs). This study sought to explore the perceptions of nurses entering clinical practice during the COVID-19 pandemic. Using mixed methods, we investigated the experiences of NGNs entering the field during the pandemic and how a nurse residency program (NRP) adapted to meet their needs. Newly graduated nurses entering practice in November 2019 described their transition through nurse experience surveys and focus group discussions. Results from the quantitative data reported on compassion satisfaction, burnout, and exposure to secondary traumatic stress. The qualitative data mirrored these findings with the discovery of the following five themes: transitioning through an NRP, impact to nursing care, value of coworkers, coping, and professional growth. These findings illustrate the need to better support future practice transitions in times of disruption and change.

Keywords: nurses, COVID-19, program development, mentors, burnout, professional

Transitioning from classroom into independent practice as a new graduate nurse (NGN) is challenging. To help aid in this transition, many hospitals have incorporated nurse residency programs (NRP) into onboarding processes for those starting their first job as a nurse. NRPs are designed to lessen stress and boost competence and confidence in delivering safe nursing care by providing professional and social support (Asber, 2019; Chant & Westendorf, 2019; Fink et al., 2008; Van Camp & Chappy, 2017). The NRP curriculum at UChicago Medicine, a single Magnet-recognized academic tertiary care medical center in the Midwestern United States, provides an opportunity for collaboration with other NGNs to focus on the development of quality initiatives. Over the course of a year, NGNs attend monthly four-hour seminars. During the seminars, cohorts hear presentations from interdisciplinary team members, work on their evidence-based quality initiative projects, and share their own bedside experiences, all under the guidance of a mentor. Goals of the NRP are to help safely transition NGNs from advanced beginner to a competent professional nurse. Nursing skills reviewed during the NRP are critical thinking related to clinical judgment, incorporating evidence-based practice into bedside care, utilizing resources, enhancing communication skills between disciplines, and ensuring safety and quality patient care.

Data prior to the COVID-19 pandemic show significantly higher levels of stress between the first and second years of transition for an NGN (Lin et al., 2020; Zhang et al., 2019). Mastering tasks as well as role clarity have been found to assist in this transition (Frogeli et al., 2019). However, since the pandemic, nurses’ fears have expanded past their roles at the bedside to include worrying about infecting family and friends as well as themselves (Gonzalez-Gil et al., 2021; Gordon et al., 2021; NurseGrid, 2020). Given that even experienced health care providers are struggling with stress during the pandemic, it stands to reason that NGNs are also experiencing increased stress (Albott et al., 2020; Ripp et al., 2020; Ruiz-Fernandez et al., 2020; Smith et al., 2021). The stress experienced while providing care during the pandemic may undermine confidence, create anxiety, and discourage future nurses from entering the profession. Given the limited evidence, methods to support NGNs during the pandemic may have been attempted, however those practices were potentially inadequate. Evidence is needed to adapt NRPs to meet the unique experiences of NGNs. Thus, we sought to understand the dynamics of the transitioning NGN during the COVID-19 pandemic.

Purpose

The purpose of this study was to understand the struggles and growth opportunities of NGNs entering the field of nursing during the COVID-19 pandemic. Secondary aims are as follows: (a) describe the impact of the NRP on NGNs, (b) quantify levels of stress and compassion fatigue, as well as (c) compare how attitudes and beliefs might be affected among cohorts after experiencing COVID-19 as an NGN.

Methods

Design

This descriptive mixed-methods study features initial quantitative data collection, followed by qualitative data from focus groups. After analyzing both, triangulation was conducted to better describe the saturation and comparison of the data. This study was approved by the University of Chicago Biological Sciences Division Institutional Review Board (IRB21-0381).

Sample

All NGNs participating in an NRP at a single Magnet-recognized academic tertiary care medical center in the Midwestern United States were identified and recruited to participate in both the quantitative and qualitative arms of this study. Verbal consent was obtained for both the survey and the focus group sessions. The NRP is 12 months long and accredited by the American Nurses Credentialing Center; all NGNs are automatically enrolled into cohorts that start every four months. The only inclusion criterion was to be an NGN who started their NRP between November 2019 and July 2020. This timeframe was selected to reflect the start and height of the COVID-19 pandemic.

Measures

Quantitative data included five surveys and a demographic questionnaire, all of which were collected via REDCap (Harris et al., 2009). Surveys were chosen to include not only traditional measures of NRP effectiveness but also to evaluate the possible effects of trauma and stress associated with practice during the pandemic. The demographic survey captured descriptive data (e.g., age, gender, race/ethnicity, marital status, residence, and education). Examining growth potential along with the stress experienced by NGNs provides a more complete understanding of NGNs entering profession during the pandemic. The following five measures were chosen to examine their experience:

  1. The Casey-Fink Graduate Nurse Experience Survey is a 30-item scale that provides an evaluation of an NRP. It measures concepts such as competence and confidence in care delivery, professional development, and commitment to one’s organization by rating answers from 1 = Strongly Disagree, to 4 = Strongly Agree. Scores can range from 30 to 120 with higher scores indicating a greater level of satisfaction with their NRP (Casey et al., 2004, 2021b).

  2. The Perceived Stress Scale is a 10-item scale used to measure how stressful an individual may interpret life events. Participants are asked to reflect on stressful situations while taking this questionnaire and rate their preferred methods of coping from 0 = Never, to 4 = Very Often (Cohen et al., 1983). Scores for this scale range from 0 to 40, with higher scores indicating higher levels of perceived stress (Lee, 2012; Pang & Ruch, 2019).

  3. The Professional Quality of Life Scale v.5 is a 30-item survey that assesses compassion fatigue via three subscale components—burnout, secondary traumatic stress, and compassion satisfaction. Questions focus on participants’ work environment and how often they experience each scenario from 1 = Never, to 5 = Very Often. Scores for each subscale range from 10 to 50, with higher scores indicating elevated levels of either burnout, secondary traumatic stress, or compassion satisfaction (Figley, 1995).

  4. The Posttraumatic Growth Inventory-Short Version assesses experiences in the aftermath of highly stressful life experiences. This 10-item scale includes five subscales: relating to others, personal strength, new possibilities, appreciation of life, and spiritual change. Participants were instructed to reflect on their experiences caring for patients during the COVID-19 pandemic as their stressful event. Ratings are made from 0 = No Change, to 5 = Very Great Degree of Change. Scores range from 0 to 50, with higher levels indicating a greater degree of growth (Cann et al., 2010b).

  5. The Core Beliefs Inventory is a 9-item scale that measures how a significant life event can lead one to examine core beliefs about the world, themselves, and their future. Ratings are made from 0 = “I did not experience this change,” to 5 = “I experienced this change to a great degree.” Scores range from 0 to 45, with elevated levels indicating a greater degree of questioning one’s core beliefs (Cann et al., 2010a).

Surveys such as the Casey-Fink scale focused on support measures, the Posttraumatic Growth Inventory measured growth, and the Core Beliefs Inventory measured beliefs/spirituality, all of which reveal positive attributes. In contrast, undesirable impacts were measured by the Professional Quality of Life Scale, which examined burnout, and the Perceived Stress Scale which measured stress. In addition to the surveys, one-year retention data was collected on all NGNs who started employment between November 2019 and July 2020. Qualitative data were collected via focus groups with probing and open-ended questions to encourage and capture discussion to better understand the collective experience of the culture, norms, and experiences of the NGNs at this institution.

Procedures

All eligible NGNs were contacted to participate in the study. Informed consent was obtained from interested participants and a unique survey link was sent to collect the quantitative data. Participants were then scheduled for focus group sessions, being matched with other members from their NRP cohort when possible. Focus groups were conducted after the completion of the survey. Each of the participants attended only one focus group and the focus groups were independent of one another. Focus group sessions were conducted via a secured online virtual platform between June and July 2021 and were led by two moderators; one moderator was the facilitator and did not have any prior relationship with the participants and the second moderator encouraged participation and facilitated recording. Four broad categories of questions guided the focus groups: program evaluation of the nurse residency, skill and confidence development, self-care management, and impact of COVID-19 on nursing practice and patient care. Questions were open-ended to encourage group participation. Questions were shared with participants prior to the focus groups so they could reflect on their experiences and contribute to a group discussion.

Data Analysis

Quantitative data

All data manipulation and statistical analyses for the quantitative data set were completed using SAS software (version 9.4; SAS Institute, Cary, NC). Survey instruments detailed above were scored; descriptive statistics were then calculated for each item, subscale, and total scale, as well as one-year retention data. Group comparisons were made using Fisher’s exact test for categorical variables and the Wilcoxon Mann–Whitney U-test for continuous variables due to the limited number of participants.

Qualitative data

Qualitative description was used as the methodological approach. Data from focus groups were transcribed verbatim and then analyzed using conventional qualitative content analysis (Hsieh & Shannon, 2005). Investigators independently read through all transcripts and identified major themes discussed. Coding was completed at an individual level and then as a group of analysts. Like-codes were then grouped to form categories expressing common responses. Findings were compared to create a preliminary list of categories; codes were then formed. Once coding was completed, the investigators identified any overlap or lack of clarity in categories to achieve consensus. Exemplar quotes were identified independently by investigators and compared in an additional round of analysis with the intention of linking categories to quotes to further represent participants’ experiences. Finally, themes were chosen based on categories. To establish credibility of the analysis, two participants were invited for member checking to review the results and themes selected. Member checking established trustworthiness and proper representation of the captured data.

Triangulation

Surveys were completed prior to holding the focus groups and an analysis of the quantitative surveys were completed independent of the focus group transcripts. Triangulation of findings occurred when investigators examined statistically significant findings from survey data along with qualitative themes, categories, and quotes from focus groups (Bekhet & Zauszniekski, 2012; Moon, 2019). Specifically, findings that were complementary along with findings that were disparate were reviewed and discussed.

Results

Participants

A total of 40 eligible NGNs were enrolled in the NRP between November 2019 and July 2020. As of March 2021, 35 (87.5%) of the NGNs were still working at the institution; this includes two (5.7%) who transferred units. Of those 35 nurses eligible for participation in this study, 12 (30%) participated in the survey (Figure 1). All but one of the participants who completed the quantitative surveys participated in the focus groups. The majority of participants were female (n = 11, 84.6%), single (n = 9, 69.2%), and nonparents (n = 9, 69.2%). Over half of the sample identified as Hispanic (n = 7, 53.8%); the remaining participants identified as non-Hispanic White (n = 5, 38.5%) and non-Hispanic Black (n = 1, 7.7%). Overall, the NGNs who participated were employed as full-time BSN-degree registered nurses, between 20 and 34 years of age and living in an urban community. The NGNs who participated reported working in intensive care, surgical, cardiac, trauma, medical-surgical, or oncology units at time of hire. To evaluate for potential group differences, the NGNs were divided into two categories based on their NRP start date (pre-pandemic and mid-pandemic); there were no statistically significant differences in demographics between these two groups (Table 1).

Figure 1.

Figure 1.

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Eligibility and enrollment of new graduate nurses (NGNs) in the study.

Table 1.

Demographics and Characteristics of NGNs in Relation to Start Dates during COVID-19.

Pre-Pandemic (n = 6) During Pandemic (n = 7)
n % n % p
Gender .462
 Male 0 0.0 2 28.6
 Female 6 100.0 5 71.4
Marital status 1.00
 Married 1 16.7 2 28.6
 Divorced 1 16.7 0 0.0
 Single 4 66.7 5 71.4
Children .559
 Yes 1 16.7 3 42.9
 No 5 83.3 4 57.1
Location of residence 1.00
 Urban 5 83.3 5 71.4
 Suburban 1 16.7 2 28.6
Race/ethnicity 1.00
 Non-Hispanic White 3 50.0 2 28.6
 Non-Hispanic Black 0 0.0 1 14.3
 Other 3 50.0 4 57.14
Number of preceptors 1.00
 Less than or equal to 2 2 33.3 3 42.86
 Greater than or equal to 3 4 66.7 4 57.1
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Percentages may not add up to 100% due to rounding; p-values obtained using Fisher’s exact for categorical variables.

Quantitative

Overall, participants reported moderate to high levels of compassion satisfaction (Median = 41.0), and low to moderate levels of burnout (Mdn = 22.0), and secondary traumatic stress (Mdn = 18.0); medians and interquartile ranges for these subscales and all other instruments are presented in Table 2. The only statistically significant difference noted was in the spiritual change subscale of the Posttraumatic Growth Inventory (p = .028); NGNs who started pre-pandemic had significantly higher spiritual scores (Mdn = 6.0) as compared to those who started mid-pandemic (Mdn = 3.0) (Table 2).

Table 2.

Compassion Fatigue, Growth, NGN Experience, Stress, and Core Beliefs for NGNs in Relation to Start Dates.

Pre-Pandemic (n = 6) During Pandemic (n = 7)
m(IQR) Range m(IQR) Range p
Professional Quality of Life
 Compassion satisfaction 43.0 (40.0, 46.0) 31.0–48.0 40.0 (33.0, 43.0) 32.0–48 .473
 Burnout 25.0 (20.0, 28.0) 17.0–29.0 20.0 (18.0, 22.0) 16.0–24.0 .115
 Secondary traumatic stress 22.5 (18.0, 31.0) 18.0–35.0 16.0 (15.0, 24.0) 14.0–27.0 .062
Posttraumatic Growth Inventory* 3.4 (2.8, 4.0) 2.8–4.7 3.0 (2.3, 3.4) 0.0–3.5 .228
 Relating to others 7.0 (5.0, 8.0) 0.0–10.0 5.5 (5.0,7.0) 0.0–8 .415
 New possibilities 7.5 (5.0, 9.0) 4.0–10.0 5.0 (4.0, 7.0) 0.0–8 .145
 Personal strength 8.5 (7.0, 10.0) 4.0–10.0 6.5 (3.0, 9.0) 0.0–9.0 .169
 Spiritual change 6.0 (5.0, 8.0) 5.0–8.0 3.0 (1.0, 5.0) 0.0–6.0 .028
 Appreciation of life 8.0 (7.0, 9.0) 4.0–9.0 7.5 (6.0, 8.0) 0.0–10.0 .567
Casey Fink New Graduate Experience 71.0 (68.0, 72.0) 65.0–83.0 73.0 (68.0, 83.0) 68.0–90.0 .249
 Support 3.2 (3.1, 3.6) 2.9–3.9 3.2 (3.0, 3.9) 2.9–4.0 .718
 Organization/prioritization 2.8 (2.8, 3.0) 2.6–3.0 3.0 (2.8, 3.2) 2.8–4.0 .073
 Communication/leadership 2.9 (2.8, 3.2) 2.8–3.5 3.3 (3.2, 3.3) 2.8–3.8 .124
 Professional satisfaction 3.2 (3.0, 3.3) 2.7–4.0 3.3 (3.0, 3.7) 2.3–4.0 .715
 Stress 1.0 (1.0, 1.0) 0.0–3.0 2.0 (0.0, 3.0) 0.0–4.0 .768
Perceived Stress Scale - Total Score 16.5 (12.0, 18.0) 11.0–22.0 13.0 (13.0, 17.0) 10.0–20.0 .517
Core Beliefs Inventory - Mean Score 3.0 (3.0, 4.0) 2.0–4.0 3.0 (1.0, 4.0) 0.0–4.0 .654
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*

Data missing for one subject in During Pandemic group; p-values obtained using Wilcoxon Mann-Whitney U-test; m = median; IQR = interquartile range

The number of preceptors an NGN reported having during their orientation was also associated with differences in measures of their orientation experience. Among the Posttraumatic Growth Inventory subscales, those with three or more preceptors reported significantly lower personal strength (p = .032) and appreciation of life (p = .046). Similarly, there were statistically significant differences noted in the Casey-Fink survey, with those having three or more preceptors reporting both lower overall scores (p = .018) and lower scores in the support subscale (p = .010) (Table 3).

Table 3.

Compassion Fatigue, Growth, NGN Experience, Stress, and Core Beliefs for NGNs by Number of Preceptors during Orientation.

1–2 Preceptors (n = 5) 3 or More Preceptors (n = 8)
m(IQR) Range m(IQR) Range p
Professional Quality Of Life
 Compassion satisfaction 43.0 (40.0, 48.0) 32.0–48.0 40.5 (35.5, 44.0) 31.0–46 .447
 Burnout 22.0 (19.0, 26.0) 16.0–29.0 21.0 (19.0, 24.0) 17.0–28.0 .931
 Secondary traumatic stress 27.0 (15.0, 31.0) 14.0–35.0 18.0 (17.0, 21.5) 15.0–26.0 .225
Posttraumatic Growth Inventory* 3.2 (2.9, 3.7) 2.8–4.0 3.2 (2.6, 3.5) 0.0–4.7 .798
 Relating to others 6.0 (2.5, 7.0) 0.0–7.0 6.5 (5.0, 8.0) 0.0–10 .437
 New possibilities 6.0 (4.0, 8.5) 4.0–9.0 6.5 (4.5, 7.5) 0.0–10 .932
 Personal strength 9.0 (9.0, 9.5) 9.0–10.0 6.5 (3.5, 7.5) 0.0–10 .032
 Spiritual change 3.5 (1.5, 6.0) 1.0–7.0 5.0 (4.5, 7.0) 0.0–8.0 .436
 Appreciation of life 8.5 (8.0, 9.5) 8.0–10.0 7.0 (5.0, 8.0) 0.0–9.0 .046
Casey Fink New Graduate Experience 83.0 (72.0, 83.0) 72.0–90.0 69.5 (68.0, 72.0) 65.0–77.0 .018
 Support 3.9 (3.6, 3.9) 3.2–4.0 3.1 (3.0, 3.2) 2.9–3.7 .010
 Organization/prioritization 3.0 (3.0, 3.2) 2.6–4.0 2.8 (2.8, 3.0) 2.8–3.2 .251
 Communication/leadership 3.3 (3.2, 3.5) 2.8–3.8 3.1 (2.8, 3.3) 2.8–3.3 .154
 Professional satisfaction 3.7 (3.3, 4.0) 3.0–4.0 3.0 (2.8, 3.3) 2.3–3.7 .052
 Stress 1.0 (0.0, 1.0) 0.0–3.0 1.5 (0.5, 2.5) 0.0–4.0 .406
Perceived Stress Scale - Total Score 13.0 (13.0, 16.0) 10.0–22.0 16.0 (12.5, 17.5) 11.0–20.0 .658
Core Beliefs Inventory - Mean Score 4.0 (3.0, 4.0) 1.0–4.0 3.0 (2.0, 3.5) 0.0–4.0 .320
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Note. Percentages may not add up to 100% due to rounding; p-value using the Wilcoxon Mann–Whitney U-test; m = median; IQR = interquartile range.

Qualitative

A total of five focus group sessions were conducted, with each focus group being conducted independently. Focus group sizes ranged from one to four participants. Each NGN was invited to participate in only one focus group session. Of the 11 participating NGNs, one consented subject who participated in the quantitative portion was unable to participate in a focus group due to scheduling conflicts. The focus group sessions ranged from 31 to 66 minutes.

The first and fifth focus group sessions had NGNs who started their NRP in-person and later transitioned to a virtual platform. This first group had the highest participation, completion of surveys, attendance in focus group sessions, and the lowest turnover. The second, third, and fourth focus groups only engaged with their NRP over virtual platforms.

Qualitative data from focus group transcripts and field notes yielded 14 categories that were further grouped into five themes representing the experiences of all 11 NGNs. Themes are as follows: (a) nurse residency transition, (b) nursing care impact, (c) value of coworkers, (d) coping and self care, and (e) professional growth. field notes, transcripts, and selected quotes from NGNs contributed to these themes. An overview of the themes provided the reader sufficient information to judge the confirmability of the data analysis process. A complete list of themes, categories, and exemplar quotes are presented in Table 4. All NGNs were coded for confidentiality purposes.

Table 4.

Qualitative Themes and Exemplar Quotes for NGNs Transitioning to Practice during COVID-19.

Exemplar Quotes
Nurse residency transition Virtual platform issues The residency transitioned to ZOOM, and it was very hard to be making those connections, which I think would have been really beneficial.
You need a lot of support when you start a new job, and especially this job, and I just couldn’t physically be with people.
Content The first 30–45 minutes was probably the most useful out of the whole program.
The most useful part of the residency ended up being those half-an-hour conversations that we had with each other in terms of all of our experiences, and what we’re going through.
Misaligned expectations I was looking forward most was meeting other nurses in the same situation as me. Getting to know them.
It’s not just me struggling through being a new grad. There’s other people with similar issues, and that was nice to talk through.
Nursing care impact Clinical challenges When your families are there, I think they just help out with so much of that anxiety, that loneliness, all those negative emotions associated with a hospital today. Families make that better. Yeah, starting off when you—and absolutely, we got into this profession because we’re human beings. We understand what other people feel.
Visitor restrictions When you have a crazy shift, the nicest part would be to hold the phone next to a patient who can’t talk or move depending on what the situation is and hold the phone so their wife can talk to them.
Range of feelings I just felt the fear in the air, and I took that, and I was like, “I’m scared too.”
I think about all the time and energy you invest in someone, and then they have a bad outcome, so having to rationalize that you did everything you could. That’s really hard.
Value of coworkers Mentors It’s just that I wish I would have had a more consistent relationship with one preceptor.
Teamwork There’s a sense of you need to build your own confidence, but to have people around you just be confident in you, it’s just really important too.
Communication It would change daily. I feel there was an email almost every day with a different policy. It was so hard to keep up. I would show up at work, and they’d be like, “You can’t do that anymore per the policy this morning.” I’m like, “Oh, okay.”Cause it’s very hard to vent to people who are not in nursing. They do not get it.
Coping and self-care Exercise Exercise and keepin’ up with those that add a lot of meaning to your life. That’s what gets you through.
Talking it out That [venting with friends] just meant a lot because we understood that we weren’t alone in these feelings.
I even had to find a therapist at one point ’cause I just needed to talk to someone about it.
Time away I think I had to learn how to leave the job at the hospital and be able to come home to relax and forget about it [COVID], which I think was really hard to do initially.
Professional growth Survival The fact that we were all new grads in the pandemic, dealing with difficult patient scenarios and real-life issues, it felt good to be able to talk about that so freely with someone who’s also living it at the same time.
Personal insight But if you could have seen the first nurse residency class, when we were all talking about our preceptors, and how we were all having such a hard time with time management and the skills and how nervous we were. Then if you were there for the last session, we were talking about how we were precepting other people and teaching students.
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Nurse residency transition

NGNs sought personal connections with others in their NRP. Many said this expectation went unmet and spoke to the virtual format as being the main barrier, with one stating “I wish that we were in person so that I would know the other people.” Despite meeting monthly, NGNs reported that it was difficult to formulate relationships due to the NRP being held virtually. Several NGNs described “tales from the bedside” as a positive experience. “Tales from the bedside,” is the first portion of the NRP class that is dedicated class time allowing NGNs to share personal experiences in an effort to learn from one another and apply others’ experiences to their own practice. One participant described themselves as

Just trying to figure out yourself as a nurse and be more comfortable with your nursing skills and talking to patients - To me, it [“tales from the bedside”] did help a lot because it felt nice to be a part of a group who understood you.

Nursing care impact

The most frequently reported feelings were isolation and fear. Many identified the dichotomy of taking care of others while also fearing for their own health. One participant recalled, “The [COVID patients] had no family. Those relationships that I built with some patients; I will never forget. . . . They were having the worst experiences of their lives, and we were going through the worst of it too.”

The ongoing COVID-19 pandemic inhibited nurses from entering rooms as frequently in order to preserve the short supplies of PPE, however, this left NGNs to feel isolated and alone in a patient’s room when other nurses were not present. NGNs described feeling abandoned, especially while caring for increasingly unstable patients. As one nurse stated, “No one wanted to come in the room with me. My patient was literally desatting, and no one would step in the room with me to help me assess or, I don’t know, do anything.”

Barriers such as scarce resources and suboptimal staffing left NGNs feeling helpless. NGNs described their emotions and barriers they encountered while providing patient care. While on the unit, one NGN explained that they were

Just trying to be the nurse that they wanted you to be was stressful. It was just so much to do. I felt like we were always short in the beginning. . . . Yeah, just knowing that I couldn’t comfort them [patients] the way their families could was a little bit stressful on me. I actually wanted to do it, but I couldn’t.

NGNs noted the constant changes to practice. Protocols were altered frequently when new research was available on how to treat and care for COVID-19 patients. NGNs were asked to continuously adapt to these changes. One NGN described the change to practice as feeling like, “It almost felt like we were guinea pigs a little bit. The university was doing the best it could, but yeah, the evidence was changing every day. The practice was changing every day. There was no consistency in the practice.”

As NGNs described their own perceptions of the clinical environment they also mention the fear expressed by senior nurse colleagues who trained and mentored them, “When you’re new, and when it first started, it was crazy because all the nurses were scared. It was a little chaotic ’cause nobody wanted those patients. You’re new, and you’re seeing experienced nurses who don’t want those patients.”

Value of coworkers

Despite the isolation, most of the NGNs recognized that they were successful because of coworkers. Preceptors were supportive but the chaos resulted in inconsistencies, as one NGN stated that their orientation, “Felt like a baptism-in-fire type thing. I think that a lot of it—I think the reason why we were able to do what we had—our greatest asset was our coworkers.”

Feedback from coworkers gave NGNs confidence while creating a foundation for their nursing skills. In addition, positive acknowledgment from leaders was impactful and encouraging. However, many NGNs shared how punitive feedback was unhelpful during this time, “Something as simple shout-outs from a manager just go a long way. . . . I would just like to feel more support from a manager instead of just possible disciplinary issues.”

Again, coworker support was revealed to be a critical role of support for NGNs. NGNs reported having mentors who stepped in as a surrogate support system to encourage them. Trust was established while working side-by-side with coworkers. One NGN expressed that:

You need a big brother or big sister to survive when you’re new, especially in a high-stress environment. . . . If you don’t have somebody that you could trust and ask a question, who doesn’t make you feel stupid and pumps you up, you can’t make it. . .

Despite having that support from coworkers, mentors, and leaders, others described a different experience. Many NGNs were unable to maintain a consistent preceptor, illustrated by one NGN by saying, “Unfortunately, because of COVID, I mean, there was really no way that we could participate with our mentor because everyone was just. . . .isolating from each other even within work.” This later revealed that COVID-19 inhibited staff from communicating and reflecting on their shifts together.

Coping and self-care

NGNs experienced multiple challenges that were both physical and psychological. Each NGN spoke about coping strategies they used to recuperate between shifts, for example, “Exercise and keepin’ up with those that add a lot of meaning to your life. That’s what gets you through.” In addition, other psychological strains reported by many NGNs were through their experience of grief. For most NGNs, this was their first exposure to death. One NGN described their experience with a patient who was worsening throughout multiple shifts. The nurse expressed that they had

. . . . bonded really closely to this one patient. Within the span of two days, he kept deteriorating, and he ended up being intubated. Then by the end of the week, he was on ECMO. He ended up passing away, and it hit me really hard. I spent two weeks just in my head. No matter what I did, I couldn’t cope with it.

Professional growth

Each NGN described personal and professional growth. Expressions of gaining strength from conquering fear were common, “We all seem a lot more experienced after just one year than we really are because of what we went through.” Regardless of hardships that the NGNs shared, they expressed gratitude toward this life experience of new nursing skills while being thrown into a pandemic. NGNs acknowledged that as novices, they are still learning the best practices for patient care and acquiring the skills during their orientation. One participant explained that

I think that I’d say the biggest thing is just always embrace the fact that you’re learning something. Just really embrace it. Really embrace that learning role. Being a new nurse, you can’t have pride. There’s no such thing as pride. Like, “Oh, I’m not gonna ask that question. I’m too good to ask that question.”

Several NGNs stated despite all their hardships during the pandemic, they were uninterested in leaving the profession. Growth was possible for some during the pandemic, and these NGNs sought the challenge of adapting to a high-stress environment and immersed themselves in their calling into the field of nursing. One NGN closed their focus group session by stating the following:

It was just a lot of changes in such a short amount of time. I agree. I think it did make me a better nurse. Was it stressful? Yes, but I am grateful for it because we survived a pandemic. I feel like a very well-off, well-rounded nurse now because of it.

Triangulation

Both the quantitative and qualitative data reflect the importance of consistency when onboarding NGNs. NGNs expressed how they supported one another, reflected on their assignment of preceptors, and how to manage their own feelings of burnout. Based on the quantitative data, the number of preceptors reflected changes in the NGNs’ organization, prioritization, and perceptions of support. Personal strength and appreciation for life were significantly greater for NGNs with one to two preceptors as compared to those with three or more.

These findings are also supported by the qualitative data. NGNs expressed a lack of connection and added stressors from lack of consistency in mentorship. Changes in policies and procedures created doubt in clinical care skills for the NGNs faced with multiple mentors. The surveys align with the selected quotes from participants to reflect the growth during pandemic.

Discussion

The COVID-19 pandemic impacted the transition and retention of NGNs in the clinical setting. Our results on compassion fatigue, burnout, and secondary stress are comparable to what has been seen in global nursing populations during the pandemic (Piercy et al., 2022; Ruiz-Fernandez et al., 2020). Burnout and secondary traumatic stress were lower in this sample than in some studies examining critical care nurses (Gonzalez-Gil et al., 2021); this may reflect the fact that the NGNs in this study worked in a variety of settings, not just critical care, and data collection occurred when COVID-19 treatments were more available and patient deaths were at a lower level. Focus group conversations revealed themes of being overwhelmed and afraid; these were consistent with findings across both critical care and other settings (Ashley et al., 2021; Gordon et al., 2021). Themes such as self-care, communication, and professional growth are similar to findings in one other qualitative study also examining the transition of NGNs during COVID-19 (Casey et al., 2021a).

The unique data related to spirituality adds to a growing body of literature that has sought to understand how nurses’ spiritual well-being affects their practice (Yesilcinar et al., 2018). Prior to COVID-19, NGNs experienced a decrease in their spirituality upon initially entering the health care field (Kim & Yeom, 2018; Maglione & Neville, 2021). Coupled with the understanding we have regarding the mental health effects that working during the pandemic had on health care professionals in general (Hosseini et al., 2021; Song et al., 2019), it stands to reason that the spirituality of those NGNs who started their career during the pandemic would have suffered a larger negative impact. Next steps in this area would include analyzing whether both cohorts have spiritually recovered to the same extent and the longevity of the spiritual impacts.

While dealing with chaos and confusion during their transition to practice was evident, the NGNs who had more than three preceptors scored significantly lower on growth measures “personal strength support” and “appreciation for life.” The positive impact of consistent mentoring is a consistent theme across studies (Crismon et al., 2021; Lord et al., 2021; Simonovich et al., 2021; Soco et al., 2020). The relationships NGNs created with their preceptors over time allowed them to be independent. Current evidence indicates that preceptorship has a positive impact on improving nursing competence and retention (Masso et al., 2022). Current research is focused on supporting practice readiness for NGNs, creating NRPs, and strategies for preceptorship. However, little is reported on the quantity of NGNs’ preceptors and the value of a single preceptor (Masso et al., 2022).

Other studies have revealed that NRPs struggle to meet the expectations of the NGNs during their transition to independent practice (Crismon et al., 2021; Wyatt et al., 2021). This was also seen in the responses to this study as NGNs also expressed their misaligned expectations in the focus group responses. NGNs explained that their expectations were not met due to social distancing with an online platform, continuous changes to policies and procedures, lack of resources while training, inconsistent preceptors, and isolation. Understanding NGNs’ perceptions on these issues can guide positive changes to NRPs. This is vitally important as nurses, including NGNs, are leaving bedside practice due to the impact of the COVID-19 pandemic (Ashley et al., 2021; Crismon et al., 2021; Savitsky et al., 2021).

This single-site study reports on the perceptions and experiences of NGNs entering the field of nursing in an in-patient clinical unit during COVID-19. As with any single-center study, generalizability of findings may be limited. This study was limited by using a convenience sample, the small sample size, and focusing on only one hospital. This small sample size is in part due to the inability of all eligible NGNs to participate; external factors, including inability to contact NGNs who left the institution and scheduling conflicts, inhibited NGNs from participating. Because our sample only included nurses still employed at the institution, our results may not be truly reflective of the impact COVID-19 had on variables such as burnout and secondary traumatic stress. Reasons why NGNs might not want to participate or the stress of recalling their past stressors should be studied. It is also vital to note that data for this study were collected a year after the NGNs started their NRP.

Conclusion

The qualitative responses obtained in this study reflect that growth and success for an NGN is possible during a pandemic. However, quantitative data revealed that growth can only occur when measures such as a consistent preceptorship and spiritual/emotional support exist. With the current nursing shortage, it is within reason to recommend that action be taken to help improve conditions that support NGNs. Understanding their perceptions can help inform leadership to support this essential workforce.

Acknowledgments

We would like to acknowledge the nurses who participated in this study, with particular appreciation to those that reviewed our analysis; we would also like to acknowledge the dedication and commitment of all nurses and nurse educators who helped support NGNs during their transition during this challenging time.

Footnotes

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD: Nicole L. Bohr Inline graphichttps://orcid.org/0000-0001-7269-6658

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