key: cord-0695975-8gijkfl4 authors: Casey, Kathy; Oja, Kenneth J.; Makic, Mary Beth Flynn title: The lived experiences of graduate nurses transitioning to professional practice during a pandemic date: 2021-07-30 journal: Nurs Outlook DOI: 10.1016/j.outlook.2021.06.006 sha: f567ff6c491d05f387a56e53d2105c129bf40bcd doc_id: 695975 cord_uid: 8gijkfl4 BACKGROUND: Graduate nurses face challenges during their transition to professional practice. Understanding these experiences during a pandemic has not been explored. PURPOSE: The purpose of this study is to describe the lived experiences of graduate nurses transitioning to practice during a pandemic. METHODS: Using a hermeneutic phenomenological approach, focus groups were conducted with fifteen nurses who were at three different stages of transition and participating in a 12-month Graduate Nurse Residency Program. FINDINGS: Seven themes emerged: 1) being new is overwhelming, even more so during COVID-19, 2) need to be flexible, 3) pandemic knowledge and practice disconnect, 4) communication barriers worsened with masks, 5) being a “COVID nurse,” 6) no self-care, and 7) gratitude: still glad to be a nurse. DISCUSSION: Findings emphasize the important focus on graduate nurse support and educational foundation for role transition into professional practice, especially during a pandemic. Participants expressed lack of preparedness for practice but remain excited about being a nurse. Transitioning from the role of nursing student to professional nurse is widely recognized as a period of stress, role adjustment, and reality shock (Casey et al., 2004; Casey et al., 2021) . The first year of nursing professional practice is an important role transition since the knowledge and experiences that students gained while in school are typically not enough to allow them to function independently and competently as nurses (Goode et al., 2013; Hickerson et al., 2016) . There is a plethora of evidence that describes the challenges of nurses new to practice and the stressors associated with the transition to practice. Graduate Nurse Residency (GNR) Programs were developed to facilitate this critical first year of practice by optimizing the new nurse's competency development, offering additional support, and retaining nurses in the profession (Goode, et al., 2016; Institute of Medicine, 2010) . In their 10-year panel study of new nurses, Kovner et al. (2014) reported 17.5% of new nurses leave their first job within one year of starting. This is consistent with the study by Blegen and colleagues who found that oneyear retention of newly licensed nurses was 83% and hospital characteristics that correlated to longer retention was found when nurses worked in urban areas, Magnet designated hospitals, and were younger (Blegen et al., 2017) . In response to high nursing turnover rates, this hospital developed a 12-month nurse residency program to help facilitate transition into practice and improve retention rates. The first year of practice is critical for organizations to offer support and mentorship as it can be overwhelming, stressful, and full of uncertainty for graduate nurses. These emotions were heightened during the severe acute respiratory syndrome coronavirus 2 pandemic, more commonly known as the coronavirus disease of 2019 . Many new nurses had lost valuable unit clinical orientation hours due to staffing needs and restrictions imposed by the pandemic. When hired into the practice setting, they encountered additional stress, anxiety, and fear created by the COVID-19 pandemic. As hospitals shifted to develop education and protocols for healthcare professionals due to the complexity of care in managing these patients, graduate nurses, new to the practice setting, needed to adjust to the demands of being a nurse, adapt to frequent disruptions of routines, and learn how to cope with their emotions and expectations around starting a nursing career at this unprecedented time in healthcare. Since there is little known about graduate nurses' experiences of role transition during a pandemic, it was vital to describe what they experienced, what they had in common, and the impact of the COVID-19 pandemic as they transitioned into professional nursing practice. The purpose of this phenomenological study was to describe graduate nurses' role transition experiences and understand their level of perceived preparedness for practice during a pandemic. The context for understanding role transition experiences of graduate nurses, new to professional nursing practice, include Kramer's (1974) work which suggests that graduate nurses experience a reality shock with the discovery that the many ideals and values instilled during their educational preparation conflict with the work-world values and norms they are expected to conform to. The term "reality shock" is used to describe the shock-like emotions and reactions of graduate nurses when they find themselves in a work situation for which they thought they were prepared for and then suddenly find they were not (Kramer, 1974) . According to Kramer (1974) , nurses new to the profession progress through four stages of transition. The first stage of transition is the honeymoon phase, described as a period of excitement about joining the profession; the shock phase is the second stage in which nurses express negative feelings toward the profession, are most vulnerable, and at risk to quit or leave their unit; the third stage is the recovery phase, where the new nurse is able to view the job realities with a more open perspective; and lastly, the resolution phase, which usually occurs around one year, is when the new nurse can see the professional role in perspective and fully contribute to the profession. This role transformation process allows the new nurse to separate themselves from the expectations held for them in school and, concomitantly, take on new expectations that arise in the context of their new jobs (Kramer, 1974 ). Kramer's work has provided a foundation for guiding professional role socialization and the sequencing of GNR program content and length to reflect the different stages of reality shock that may occur during the first year of practice. Duchscher's Stages of Transition Theory (2008) and Transition Shock Model (2009) built on Kramer's (1974) work. The Stages of Transition Theory describes role transition as progressing through three main stages: doing, being, and knowing. According to Duchscher (2009) , graduate nurse role transition reflects a non-linear process of change that moves the new practitioner through several stages of developmental, professional, intellectual, emotive, skill, and role-relationship changes. These three stages are overarched by what Duchscher (2008) describes as transition shock, occurring in the first three to four months of transition, and transition crisis, culminating at approximately eight to nine months into the first year of professional practice. The first three to four months of practice is called the "doing" phase. This initial phase is consumed with adjusting to new roles, responsibilities, and integrating into an environment that emphasizes teamwork. New nurses in this phase require high levels of intense cognitive, physical, and emotional energy in order to meet the heavy workloads and steep learning required to keep up with practice expectations that differ from what they were taught in their nursing education programs. Duchscher (2009) describes the exhaustion and isolation that result from this disorienting, confusing, and chaotic period as transition shock which can lead to emotions such as withdrawal, rejection, and hostility toward others. After these few months in practice, graduate nurses report feeling more comfortable, accept their limitations, ask questions of their colleagues, and are mentally ready to move to the next phase of learning (Duchscher, 2008) . The second phase "being," encompasses the next four to five months of practice, and is characterized by a consistent and rapid increase in knowledge level, skill competency, and critical thinking. During this stage, new nurses gain trust and confidence in their own capabilities and begin to apply practical meaning to their theoretical knowledge (Duchscher, 2008) . The final stage, "knowing," is where the new nurse sees a shift in personal and professional socialization, views the influences of stress on themselves, and moves from a position of insecurity and abilities to frustrations with the system and being at the bottom of the pecking order (Duchscher, 2008) . In this final phase, graduate nurses are now engaging as professionals, beginning to critique aspects of their N u r s O u t l o o k 6 9 ( 2 0 2 1 ) 1 0 7 2 À1 0 8 0 work environments, and accepting their role as a professional nurse. As such, Duchscher's research suggests that it is important to include knowledge about professional role transition into GNR programs. Informed by Duchscher and Kramer's research, this study was designed to explore the transition experiences of graduate nurses during a pandemic. Phenomenology is the study of the lifeworld, as experienced by individuals; a way of being in the world (Swanson-Kaufman & Schonwald, 1988) . Phenomenology aims at gaining a deeper understanding or meaning of our experiences (Van Manen, 1990) . To better understand the experiences of the nurse new to practice during a pandemic, we conducted a qualitative phenomenological study. The purpose of the study was to describe the lived experiences of graduate nurses transitioning to practice during a pandemic. Specific aims were to 1) explore practice experiences of graduate nurses during the COVID-19 pandemic and 2) understand graduate nurses' perceived preparedness for practice during the COVID-19 pandemic. A hermeneutic phenomenological approach was used to understand the graduate nurse experience of beginning practice during a pandemic (Van Manen, 2007) . Using a qualitative research method, specifically phenomenology, allowed the researchers to underscore the graduate nurses' lived experiences as novices entering the profession. The three researchers engaged in this study have diverse experiences in working with, and mentoring, graduate nurses. One researcher has been a GNR Program Coordinator for numerous years and leads the program where this study was conducted. The other two researchers have taught extensively in undergraduate nursing programs and facilitated courses as practice-based research scientists in GNR Programs for more than a decade. The study was approved by the Institutional Review Board associated with the hospital and affiliated academic institution. The study was conducted at a 525-bed level I trauma, safety-net, hospital in a metropolitan city in the Western Mountain Region of the United States. The hospital recruits and employs graduate nurses to practice in diverse inpatient settings except for critical care and the emergency department. The GNR Program Coordinator enrolls the nurses, according to hire dates, into cohorts resembling Spring, Summer, and Fall groupings. Graduate nurses participate in a 12-month transition to practice program consisting of monthly education classes, support sessions, hands-on clinical experiences, and engagement in the initial development of an evidence-based practice project which are all designed to ease the transition from student to practicing professional nurse. The program builds on the knowledge and skills acquired in nursing education programs to assist graduate nurses in developing the competence and confidence required for professional practice. At the completion of the 12-month program, a graduation ceremony is conducted to mark the transition from the role of advanced beginner to competent nurse. A purposive sampling technique was used to facilitate selection of participants based on their ability to provide the information required to address the research question (Miles & Huberman, 1994) . The GNR Program Coordinator identified nurses from all three cohorts that were currently enrolled in the GNR Program at the time of the study. Potential participants were emailed by the GNR Program Coordinator inviting them to participate in the study. Graduate nurses were informed that participation in the study was entirely voluntary, no evaluation of them as employees would occur, nor would results of the study be connected to their employment at the organization. Consistent with empirical methods to gather information about lived experiences (Errasti-Ibarrondo et al., 2018) , the researchers conducted three focus group interviews. Focus group interviews facilitated a deeper understanding of the participants' experiences as a graduate nurse during a healthcare pandemic providing discovery of meaning, understanding, and shared experiences. Focus group participants were cohorted by months of experience which allowed the researchers to learn more about the practice experiences based on the participants' current phase of transition. Focus groups were held in July 2020. Prior to holding focus groups, the three researchers engaged in the practice of bracketing one's thoughts, ideas, and personal biases (Speziale & Carpenter, 2007) . Since all three researchers have been engaged in practice for many years and working with graduate nurses, bracketing our thoughts prior to the focus group interviews was important to bring consciousness to the researchers' beliefs and facilitate a more open and honest discussion. Focus groups were held on the hospital campus, away from inpatient units, in a quiet and secluded room. Participants were informed about the purpose of the study, asked permission to allow digital recording of the meeting, and provided with a review of the risks and benefits of participating in the study. After obtaining consent, the participants completed a demographic questionnaire that inquired about the participants' self-identified gender, age, race, type of nursing program attended (i.e., Bachelor of Science in nursing or associate degree in nursing), months in practice, unit, number of weeks of orientation, and current shift (i.e., day, nights, rotating). A semi-structured interview guide (Box 1) was used to stimulate the focus group discussion. Table 1 : Semi-Structured Interview Guide Can you tell us a little bit about what it is like for you to be a nurse with ______ months of experience Tell us about your preparation / training related to infection prevention competencies When you think about your practice before the pandemic and then when the pandemic started, did you experience any changes in your practice or practice routines? What has it been like to be a new nurse during a pandemic? The researchers started each focus group asking about months of experience and current knowledge about infection prevention knowledge and practices. These initial questions allowed the researchers to gain a rich experience of the academic preparation and nurses' self-perception of confidence in practice. The focus group discussion then evolved into the lived experiences of being a nurse during a pandemic. Participants were encouraged to share their diverse thoughts about their experiences and the moderator intervened as little as possible to avoid disrupting the conversation. Focus group interviews lasted approximately 60 minutes and participants were given a $5.00 gift card for engaging in the study. All three researchers were present during the focus groups, but the interview was moderated by only one researcher. The other researchers took notes to clarify any discrepancies from the recordings as well as nonverbal reactions of the participants. Immediately after each focus group, the researchers again bracketed their thoughts and experiences with each group. Audio recordings were reviewed independently by each researcher prior to subsequent focus groups and a list of emerging concepts developed and were shared with each researcher for similarities of experiences shared by the participants. All focus groups used the same semi-structured interview guide and concepts shared from prior focus groups were explored to uncover new meanings and establish saturation of shared experiences by the participants. Focus groups were digitally recorded and transcribed verbatim. Notes from the focus groups taken by the research team were used to fill in gaps in the transcripts. All research data were kept in a secure location in a locked file cabinet and on a password-protected computer. Rigor and trustworthiness were addressed following criteria established by Lincoln and Guba (1985) . Credibility of the data was confirmed through conversations with the participants moving from focus group to focus group to ensure no new concepts emerged and saturation was achieved. A record of the participants, experience in practice (in months), educational preparation, and data collection processes enhanced transferability. Dependability was established by bracketing, review of digital recordings prior to subsequent focus groups, and the independent and shared memos of each researcher sequentially throughout the study. To meet the criteria of conformability, an audit trail including bracketing notes, memos, and processes for reading and re-reading transcripts for understanding were maintained by the researchers. Finally, the reporting of this study was guided by the Consolidated Criteria for Reporting Qualitative Research (Tong et al., 2007) . Van Manen's Hermeneutic phenomenological reflection was used as the approach for data analysis (Van Manen, 1990; Van Manen, 2007) . Phenomenological reflection attempts to grasp the essential meaning of something providing insight, clarity, and structure of meaning of the lived experience (Van Manen, 1990 ). Data analysis was completed first by all three researchers independently. Digital recordings were reviewed and focus group transcripts were read and re-read several times allowing immersion in the data. Line-by-line meaning from words and phrases were coded and transcribed into a code book. Through an iterative process, larger patterns of words and phrases were coded into categories. After independent coding was completed, the three researchers met, and categories were grouped with themes identified and supported by direct quotes that accurately described the experience of being a graduate nurse during a pandemic. Fifteen graduate nurses volunteered to participate in the study. Three of the nurses identified as being in practice for three to five months; four participants identified as being in practice for nine to ten months; and eight identified as being in practice for 11 to 15 months. The majority of the participants (N = 12) graduated from a Bachelor of Science Nursing program and identified as female gender (87%). The individuals self-identified race as Caucasian/White (60%), Asian (27%), and Hispanic (13%). Most worked in acute medical surgical units, however 20% were employed in labor and delivery, one on an adult psychiatric unit, and one was in the float pool and assigned to different units every shift. Seven themes emerged from the data reflecting the participants' lived experiences with being a graduate nurse during the COVID-19 pandemic. The first theme that emerged was Being New is Overwhelming, even more so during COVID-19. One graduate nurse summarized her experience by saying "the first year of nursing is the hardest for sure and this is that, like, on steroids." Another nurse commented "I don't even know what it's supposed to feel like [being a nurse]." The participants identified the challenges of being new to practice but augmented the experience associated with the stressors of starting practice during COVID-19. One nurse shared "It's the blind leading the blind . . . Just new grads working with new grads." Nurses who were farther along in their practice acknowledged that the first year was challenging but they were glad the pandemic occurred later in their first year of professional practice. Theme 2: Need to be flexible The second theme, included challenges the graduate nurses faced with constant changes in infection control practices and policies that differed from what they learned in nursing school. Many of the graduate nurses felt that the changes were constant and "like a double standard." The participants also expressed frustration with the constant bombardment of practice changes that were communicated by hospital leadership, often electronically. "It was just every day, so many emails with so many changes." The participants described strategies they had to employ in order to handle the constant changes in acuity, work assignments, and workload. "I don't think anything could have taught us as fast. Our learning curve had to be, you know, a screaming turn, not just a gradual one." Several of the participants felt that being new nurses helped them to be more flexible because they weren't yet "set in their ways for so long." The third theme was Pandemic Knowledge and Practice Disconnect. Graduate nurses described a lack of knowledge and preparation for practice during a pandemic in their education programs. Three of the participants were associate degree graduates. These participants pointed out the absence of a community health course in associate degree programs and lack of education around pandemic preparation. One associate degree participant stated, "Most of our discussions were what our instructors would do when they did mission work in other countries. Their descriptions were similar to what we're experiencing here as far as reusing PPE; not being able to change it out. They never really referenced a pandemic here in the States because there really wasn't anything like this. There wasn't the expectation that we would be in the position we are in now." Others felt that the focus in nursing school was more around the definition of a pandemic and not how to prepare. One graduate nurse stated, "I honestly don't remember talking about a pandemic at all." A participant reflected "In nursing school the main thing we covered as far as pandemics was personal protective equipment (PPE) use." Another commented that "We did donning and doffing; like we just had to demonstrate we could do it once and then it's over." All groups discussed the disconnect of being taught that PPE were single use items yet, due to the supply shortage, a multiple-use standard was established. A nurse commented "This is not the gold standard that we were taught, and this really isn't good patient care." Challenges associated with continual wearing of masks were noted by all participants. The theme Communication Barriers Worsened with Masks was shared as mask wearing worsened the ability to communicate with patients and co-workers. A nurse verbalized "I feel like a lot is communicated in your face and that has been hard because, especially with our non-English speaking patients, the level of comfort of just being able to smile or reassure them can't be fully communicated." A nurse who works in labor and delivery stated that wearing a mask complicated communication not only with patients but also with providers. Hand off communication was also a challenge associated with wearing a mask. "Calling report . . . like I really have to be loud so that they can hear you through [the mask]and phone." The participants also described communication challenges when working with older adults and individuals who were hard of hearing (patients and healthcare personnel) as masks inhibited lip reading. An unexpected theme that emerged was the stigma of Being a "COVID Nurse." Many graduate nurses described feeling isolated from others because they were a nurse. They felt family, friends, neighbors, and the general public were afraid of them. "I feel kind of guilty, even like going to Walmart to get groceries or something." On the other hand, some participants felt they had a responsibility to be role models for those who are not nurses or healthcare workers. "My God, I'm a nurse. I have to set an example for these people." Participants also described friends and neighbors being more socially distant because they were nurses working in a hospital with COVID-19 patients. During the focus groups all the participants identified themselves as either being a "COVID nurse today" and having to mentally prepare for the shift; or not being a "COVID nurse." They described the process of picking up green scrubs if they would be working with COVID-19 positive patients. "You know the night before your shift if you're going to be a COVID nurse." Several also discussed how they maintained separation from family after a shift and steps they put into place to not bring the virus home. A nurse commented "Yeah, we've always been careful, but now it's on a whole different level." Theme 6: Self-care No Self-care was the sixth theme that became apparent, with graduate nurses describing their inability to maintain the normal self-care activities they engaged in prior to the pandemic. There was a sense of being "ripped off" or robbed of self-care activities like going to the gym, going out to eat, or spending time with family and friends. Some of the participants felt that self-care became about personal safety and "keeping clean" in order to avoid spreading COVID or becoming infected with the virus themselves. Others found that simply being able to get out of the house and having an opportunity to be around their co-workers, who were experiencing the same things, helped make up for the loss of self-care activities. "It was kinda nice coming to work and socializing with your work people." The nurses also talked about the stress associated with being a nurse during the pandemic that inhibited their ability for self-care. One individual shared "It takes me two to three hours to decompress after I get home before I can actually get ready for bed." The majority spoke about not being able to take breaks at work and struggling to stay hydrated and eat during the shift which was complicated by staffing shortages and the constant donning and doffing of PPE. They described going into a COVID-19 patient room for hours which was necessary but was both physically and emotionally exhausting. The last theme that emerged was Gratitude: Still Glad to be a Nurse. Despite feeling overwhelmed, participants described being thankful for having caring support from peers, feeling connected to a team, and for having high levels of teamwork. When describing working on COVID-19 specific units, the nurses described an increased sense of teamwork and support. One nurse stated, "I really feel like yeah, we all came together." Nurses from all focus groups shared they were glad they were nurses. When asked about being a new nurse during a pandemic a participant said "No, I love it. This is the career for me. I mean, I love it. I know that I'm in the right place." While the seven themes were consistently voiced within all three focus groups, there were differences noted based on months in practice. Participants who were newer to practice, those who identified as being a nurse for three to five months, seemed to be the most overwhelmed. They experienced a sudden increase in responsibility which required them to learn "a lot very quickly." Many were constantly worried that they were not doing enough for their patients because of the high patient acuity. One of the newer nurses stated, "I spend a lot of time thinking about what I could have done better." This group appeared to completely miss the initial period of excitement about becoming a nurse, and jumped directly into the shock phase citing "a lot of burnout" and being "susceptible to negative thinking." The more experienced graduate nurses, those with nine to ten months of experience, appeared to be more accepting of their situation. They felt they had the chance to lay a foundation for their nursing practice prior to the pandemic, but were still flexible and able to handle change. "Everything's new already, so you might as well add in all the new." Graduate nurses in this stage of transition also found being part of a team to be "super supportive," but also felt that more experienced team members treated them as being on the same level. "You kinda have to remind people sometimes that you're still a new grad because they'll have these high expectations." Those with almost a year or more of practice, on the other hand, were more confident. They felt they knew what to do, knew who they were as nurses, and knew their practice. "My feet were maybe a smidgen more wet" compared to nurses who started their practice in the midst of the pandemic. However, despite having more experience, the graduate nurses in this phase of transition still felt overwhelmed and that they were suddenly expected to take on "a lot more responsibility" with very brief training. "Okay, just do this, this, and this and you'll be fine." While the participants expressed differences in the depth of their lived experiences of starting practice during a pandemic, saturation in the data was achieved providing both understanding of role transition achievements and challenges faced during the COVID-19 healthcare crisis. Graduate nurses in this study voiced concerns associated with fear, anxiety, and rapidly changing practice policies that increased a sense of feeling overwhelmed. Consistent with Kramer's theory of Reality Shock, participants described the phases experienced as nurses new to practice transition from advanced beginner to competence in practice. However, all of the individuals described additional stressors associated with their role transition starting practice during a pandemic. The nurses who started their professional practice in March 2020, did not describe the traditional "honeymoon" phase often described in the literature (Casey et al., 2004; Kramer, 1974) . Rather, this group of individuals new to practice described feeling "thrown into practice" because of the healthcare crisis facing the hospital and country. Participants who had been in practice longer, six to fifteen months, shared experiences of becoming a professional nurse that aligned with Duchscher's (2008) stages of doing, being, and knowing. Their experiences followed an evolution and change in views and values learned in school, but they experienced a "transition shock" that was heightened by stressors caused by inconsistencies and unforeseen demands on practice environments due to staffing and PPE shortages. All participants described the disconnect from what was taught in school regarding isolation and infection control practices with what had become the new reality of practice which did not align with standard practices prior to the pandemic. They all expressed the physical and emotional hardship their jobs have placed on them. Graduate nurses need time to acclimate to their new work environments and process the experiences of transitioning into practice however the urgency of the COVID-19 pandemic healthcare crisis didn't allow for time to evolve into a pattern of being socialized into unit routines and building self-confidence. The pandemic stressed all levels of the healthcare organization and demands placed on the nurses inclusive of mandatory overtime shifts, cancelling of residency program classes, and floating to different units that severely compromised the nurses' sense of well-being. The graduate nurses in this study voiced concerns with lack of supplies and a push to rapidly learn new procedures, knowledge, and skills to safely care for higher acuity patients. Nurses are taught to properly don and doff PPE and consider items single use (Brown et al., 2019) . However, shortages of PPE resulted in re-use and prolonged use of PPE as well as rationing of supplies commonly available for disinfecting equipment like stethoscopes. One participant reflected on an inability to clean his stethoscope in between patients and others discussed the lack of antiseptic wipes commonly used in practice that had to be cut into smaller pieces in order to conserve the product. The inability to practice based on standards learned in school was a source of frustration and served as a personal disconnect from the care the participants wanted to provide but couldn't. Many reported a distrust in their leadership, the media, and even in their own communities. Participants expressed having moral and ethical dilemmas about the care they were providing patients which led to mental health problems and burnout. These concerns have serious consequences for graduate nurses and have been supported by the study Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being (National Academy of Medicine, 2019). Based on the knowledge generated from this study, there are opportunities to improve the GNR Program curriculum. The body of nursing knowledge and skill requirements is growing at a rapid pace. Future research is needed to study what is currently being taught in undergraduate nursing curriculums to assure that graduate nurses are competent and ready for the practice environment. Research that identifies best practices in academic environments that will translate more seamlessly to practice can build graduate nurse confidence in knowledge and perceptions of readiness for practice thus reducing stress and anxiety in their first year. Transition to practice programs are continuously evolving to support retention of our future workforce and facilitate a smooth role transition experience. Program evaluation studies are needed to examine program quality, effectiveness, elements for successful role transition of graduate nurses, and retention strategies. The importance of providing timely and structured communication to graduate nurses regarding policy and practice changes was needed. The cancelling of the monthly GNR Program classes led to a loss of peer connectedness and opportunities to share their fears and stressors brought on by the pandemic. Offering resources to facilitate emotional support and a safe place to openly share experiences was necessary to address the dynamics of the current challenges that greatly compounded what was already known about struggles with transition into practice. Adult learning principles advocate for diverse learning styles (Russell, 2006) . With the rapid and frequent changes to new knowledge and practice that needed to be taught during this healthcare crisis, pivoting to a nimbler approach to meet the graduate nurse residents' needs may have resulted in less anxieties. Moving content to online platforms, establishing virtual synchronous teaching, and increased rounding by Nurse Educators and the GNR Program Coordinator was essential in supporting the graduate nurses' ability to ask questions, affirm knowledge learned, and provide safety given the social distancing requirements of group meetings. The pandemic created significant financial challenges for this healthcare organization. Adjustments were made to accommodate and balance the fiscal mandates such as mandatory call shifts and no vacation time granted. Fortunately, only two monthly residency program classes, per cohort, were cancelled due to the rules for social distancing requirements. Classroom topics were revised to include additional COVID-19 disease management information, practice with donning and doffing PPE, emotional support sessions were offered by trained peer responders to allow the nurses to raise concerns, and dedicated classroom time was added to provide space for sharing of personal experiences and support for self-care activities. Lastly, the GNR Program Coordinator rounded more frequently on units to check in with graduate nurses and to offer support. Stressors associated with nurses new to practice are well known despite efforts to facilitate successful transitions through GNR Programs (Shatto & Lutz, 2017; Van Camp & Chappy, 2017) . However, in the face of all the new job demands, this group of graduate nurses remained amazingly committed and gratified with his or her career path as a nurse. Graduate nurses voiced being flexible during this time of crisis and highlighted their perseverance in managing this difficult transition period. Graduate nurses need to be encouraged to practice self-care so that they can care for those in need. A strength of this study was the phenomenological approach to understand the graduate nurses' experience of starting practice during the COVID-19 pandemic. Gaining a deeper understanding of the lived experiences of nurses new to practice, challenged by the pandemic, provided context to challenges not previously experienced as individuals transition into their professional role as a competent nurse. Experiences shared by the nurses in this study express the complexity and depth of being a new nurse complicated during a pandemic which is consistent with the intended understanding to be gained from a study exploring the phenomenology of practice (Errasti-Ibarrondo et al., 2018). Consistent with qualitative methods, the findings may not be applicable beyond the context of graduate nurses and practice during a pandemic. The familiarity of the three researchers may be viewed as both a strength and limitation. The researchers were familiar with the challenges of transition to practice for graduate nurses and the participants were accustomed to sharing their experiences with the GNR Program Coordinator during monthly check in sessions. The nurses all work in a level one safety-net hospital providing care to a unique demographic population of a large urban city which may have influenced the practice experiences shared by the participants. The COVID-19 pandemic created unprecedented disruption for all nurses. Challenges associated with being a nurse during this healthcare crisis were amplified for the nurse new to practice. Graduate nurses in this study experienced rapid fire progression in their transition to practice. While participants described moving through the stages of doing, being, and knowing (Duschshcer, 2008), the progression was not sequential. For the nurses that started practice at the height of the pandemic, the early honeymoon phase described by Kramer (1974) was absent. GNR programs have been designed to facilitate success for the nurse new to practice at the organization and in the profession (Goode, Ponte & Havens, 2016; Van Camp & Chappy, 2017) . Experiences shared by the participants in this study highlighted additional challenges for understanding knowledge the nurse new to practice possesses about practice during a pandemic and opportunities moving forward for organizations to reinforce this knowledge applied to practice. Participants spoke to the benefit of continuous learning associated with being a graduate nurse. This characteristic of rapid learning was a benefit in that the participants were used to taking in new information, however, the lack of consistency in practice and frequent changes resulted in significant stress. Structure in practice facilitates learning (Russell, 2006) , but findings from this study demonstrated a need for flexible learning that accommodates constant change. Findings from this phenomenological study describing the experiences of nurses new to practice during a pandemic can ideally prompt nurse leaders and nurse educators to better prepare and support graduate nurses' successful transition to practice. The importance of retaining social connections, maintaining a classroom structure, a focus on resiliency, and being nimble were critical, especially during a stressful period in healthcare such as a pandemic. 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