key: cord-0889810-386z0dxg
authors: Sarnkhaowkhom, Chawapon; Promkanya, Anucha; Pomisrikeaw, Siriluk; Ritthapanya, Nutchaporn
title: “Novice nurse and novel coronavirus”—experiences of novice nurses caring for patients diagnosed with COVID‐19 in Thailand
date: 2021-07-21
journal: Nurs Open
DOI: 10.1002/nop2.996
sha: 7022e67926ad88a1b2c4ad896afd09ba3dab0297
doc_id: 889810
cord_uid: 386z0dxg

AIMS: To explore the experiences of novice nurses caring for patients diagnosed with COVID‐19 in Thailand. DESIGN: A qualitative descriptive research. METHODS: The experiences of twelve novice nurses were explored through in‐depth interviews, telephone and video conferencing interviews. All interviews were recorded, verbatim transcribed and analysed by thematic content analysis. RESULTS: The findings fell into five main themes as follows: from novice nurses to nurse who care for COVID‐19 patients; various learning methods focused on providing care to COVID‐19 patients; work experiences and confrontations with COVID‐19; various feelings that arise when being a nurse caring for patients with COVID‐19; the power of novice nurse to bring along positive changes. CONCLUSIONS: The study provides an understanding of novice nurses’ experiences when caring for COVID‐19 patients. It also highlights the stress, fear and anxiety of novice nurses during the pandemic and suggests novice nursing practice training systems to enhance their familiarity and confidence when dealing with situations during the pandemic. The novice nurses were found to demonstrate a large amount of self‐determination and possess several technological skills and innovative abilities to improve the nursing practice and quality of care.

2019 outside the People's Republic of China on 13 January 2020 (Ratnarathon, 2020; Regional Office for South-East Asia, 2020; World Health Organization, 2020) . After this, Thailand began monitoring people arriving from the People's Republic of China in February 2020. During this time, about 35 confirmed cases of the COVID-19 infection were found. Later, Thailand saw the confirmed cases of COVID-19 increase. Around March 2020, Thailand found that the cumulative number of confirmed cases had increased to 1,045 while four deaths were reported as well (Department of Disease Control Ministry of Public Health, 2020). The Thai government therefore declared a state of emergency on 26 March 2020 to control the spread of COVID-19 (Department of Disease Control Ministry of Public Health, 2020; Royal Thai Government, 2020) . During the pandemic situation, more pressure and work responsibilities were put on the medical and public health workers and there was a greater demand for medical resources and supplies (Andreu-Periz et al., 2020) . One of the issues was the allocation of manpower to care for patients infected with the COVID-19 during the pandemic, especially professional nurses who were seen as key personnel when having to offer patient care (Fawaz et al., 2020; Thobaity & Alshammari, 2020) .

Professional nurses normally take a long period of time to complete a Bachelor of Nursing Science program, and when a nursing student completes a bachelor degree, they are seen as professional nurses.

However, the start of being a professional nurse is considered a period of adjustment in the nursing profession as they need to learn how to cope with anxiety and stress once they are not nursing students anymore (Hussein et al., 2017; Kaihlanen et al., 2020; Woo & Newman, 2020; ) . This is mainly because these novice nurses are expected to have the knowledge, abilities and skills regarding the nursing practice after graduating with a bachelor degree (Woo & Newman, 2020) . However, novice nurses after studying for a period of 1-3 years still lack experience in the nursing profession and are still unable to apply the knowledge gained in their studies to real situations (Benner et al., 2010; Hezaveh et al., 2013) .

The levels of nurses according to Benner (1984) can be divided into five categories as follows: (a) The novice is a newly graduated nurse with 1-2 years of experience. Therefore, the novice does not have much work experience and may have never faced any problematic situations in actual practice; (b) Advanced Beginner refers to a nurse who has practised at the same location for 3-4 years and has learned the job by dealing with incidents. Therefore, this type of nurse is able to handle various situations under the supervision of a highly experienced nurse; (c) Competent refers to a nurse who has experience working in the same place for 5-7 years and is able to plan long-term patient care through the nurse's ability to analyse problems and make decisions to deal with emergency situations; (d) Proficient means a nurse who has 8-10 years of experience working at the same location, and who is able to holistically perceive all situations as this type of nurse can base his or her decisions on past experience since this experience gives these nurses a deeper understanding of the incident. As a result, abnormalities can be noticed, resulting in better decisions and greater accuracy when problem solving; (e) Expert means a nurse who has had experience in the same place for more than 10 years and who therefore possesses a deeper understanding of the situation and is able to foresee various situations that might occur. These expert nurses are also able to analyse stories or situations, which helps them make accompanying predictions of what might happen. This pushes them to make decisions and select solutions quickly and appropriately.

The situation of the coronavirus disease 2019 outbreak, which is a major global crisis, has made healthcare providers and professional nurses face more stress, pressure and exhaustion from work . Moreover, for novice nurses who have been working during the COVID-19 pandemic, the pressure and the difficulty of adapting to both the nursing practice and the COVID-19 epidemic crisis are even greater (García-Martín et al., 2020; International Council of Nurses, 2020) . Studies on the performance of healthcare providers during the COVID-19 pandemic found that healthcare providers who worked during the COVID-19 pandemic all act with the highest responsibility to ensure the well-being of the patients . Both normal and non-normal situations need to be handled in difficult situations, which basically represents the challenge of working during COVID-19. This creates an overwhelming and exhausting workload especially when combined with a lack of protective equipment. Then, there is also a lot of fear and confusion as nurses need to cope with uncertainty and fear of infection and transmission to others as well as to professional nurses. These lack of resources, fatigue and stress are all issues novice nurses dealing with patients with the COVID-19 need to be able to handle (García-Martín et al., 2020; Hu et al., 2020; Kackin et al., 2020; Sadati et al., 2020) .

A review of the literature reveals mainly that professional nurses with practical experience in the nursing profession when caring for patients infected with the COVID-19 are all faced with stressful conditions, a feeling of overwhelmingness, an exhausting workload and a lack of protective equipment. In addition to this, they also have to face uncertainty and fear of infection and transmission to others (Fernandez et al., 2020; Liu et al., 2020; LoGuidice & Bartos, 2021) .

However, there is not much research on novice nurses and their experiences. Therefore, the current situation has made it important to conduct research among novice nurses caring for patients infected with COVID-19 as well to gain a rich understanding of perspectives and experiences of novice nurse when caring for patients during the COVID-19 pandemic phenomenon. Although some of their issues might be similar to those of professional nurses, some may face a wide variety of different problems apart from the normal circumstances described above. The researchers would like to focus on novice nurses as the researchers recognize the importance of developing an in-depth understanding of all of the organization's personnel as they are valuable human resources and very important to the organization (Kareem, 2019; Uddin et al., 2016) . In particular, a great comprehension is hoping to be gained regarding the novice nurses' experiences when caring for patients during the COVID-19 period by using a qualitative descriptive approach. This approach focuses on discovering the information from responses of informants to open-ended and probing questions of person's direct experiences or stories that have occurred to the informants to understand the experience of novice nurses more when they care for patients diagnosed with COVID-19 (Colorafi & Evans, 2016) . Moreover, by looking at the research results, the researchers can also offer recommendations for the development of the nursing profession. In particular, the ideas focused on the development of novice nurses during the pandemic of COVID-19 may be adapted to the nursing profession with regards to dealing with this crisis. Therefore, this research aimed to explore the experiences of novice nurses caring for patients diagnosed with COVID-19 in Thailand and sought to answer a main question: what is the experience of novice nurses caring for patients diagnosed with coronavirus disease 2019?

This qualitative research employed qualitative descriptive approach to gather the information from responses to open-ended and probing questions from the novice nurses (Colorafi & Evans, 2016) . This research method was applied to explore and describe the experiences of novice nurses caring for patients diagnosed with in Thailand. The data collection method was performed by using indepth interviews of novice nurses through face-to-face interviews with physical distancing, telephone interviews and interviews by video conferencing platforms, such as Google Hangouts Meet and Microsoft Teams. The data analysis was simultaneous performed with in-depth interviews by applying a thematic analysis method, which included data familiarization, data coding, themes seeking, themes reviewing, themes naming and defining and producing a rapport of themes.

The sample selection of this qualitative research was begun based on purposive sampling. The snowball sampling strategy was also supplemented conducting to identify the key informants for each interview. The inclusion criteria for the participants were as follows: (a) Registered Nurse (RN) who had graduated with a Bachelor's degree in Nursing Science (B.N.S.) with less than three years of experience;

(b) current or active Registered Nurse license; (c) living permanently in Thailand and speaking Thai; (d) working in a hospital setting as a Registered Nurse and must have taken care of patients diagnosed with COVID-19 at least once during the pandemic; and (e) willing to participate in this research. A total of 12 novice nurses who met the inclusion criteria were interviewed. All participants were female Registered Nurses. Their ages ranged from 22-26 years old, and their minimum amount of working experience was 2 months while their maximum amount of working experience was 2 years and 5 months.

The characteristics of these participants can be found summarized in Table 1 .

In-depth interviews of novice nurses through face-to-face interviews with physical distancing, telephone interviews and interviews by video conferencing platforms, such as Google Hangouts Meet and Microsoft Teams were performed to gain a richer understanding of experiences that novice nurses had undergone caring for patients diagnosed with COVID-19 in Thailand. The doing of observations and note-taking were also applied during the in-depth interviews of novice nurses, and the fieldwork was completed when enough data were collected. Before each interview, participants were informed by principal investigator (PI) about the purpose and method of the study, and all participants were asked permission if their data could be collected in both oral and written form. The data were ethically collected by two members of the research team, who had experience in the in-depth interviews were: "Please tell me a little bit about yourself, and when did you start working in the nursing profession?", "When did you start caring for patients diagnosed with COVID-19?", "Could you describe how you prepare yourself before caring for patients diagnosed with COVID-19?", "Could you please tell me how you felt when caring for patients diagnosed with COVID-19 for the first time?" and "Please, tell me more about your experiences of dealing with the outbreak or caring for COVID-19 patients. How did it go?". The interviews took 45 to 60 min each time and a transcribed verbatim was provided within a day after the interviews. After the verbatim transcript was completed, the transcript was sent to the informants so that they could review and agree on the content or provide the informants the opportunity to modify any of it. The transcript was sent back to researchers after the informants had reviewed and agreed on the content. Afterwards, all of informants had agreed with no modification of any contents in the transcription. Throughout this whole process, the research team was committed to keeping the informants' information, data and anonymity confidential. E.040/2563). The researchers always showed concern about the ethical considerations and conducted this research after approval of the ethical reviews. Informed consent was obtained from all participants both orally and in writing prior to participation in this research.

The purpose and methods were explained thoroughly to participants by principal investigator (PI) before starting each interview or collecting data. In addition, the research team was committed to keeping the any participant' information anonymous, and confidential while they also offered the participants the possibility to withdraw from the research at any time.

All collected data were analysed simultaneously after the in-depth interviews and verbatim transcripts was created within a day after the in-depth interviews. After this, the transcripts were sent to the informants so that they could review the transcript and modify any data that they did not agree with. The data analysis of this research was based on the thematic analytical method designed by van Manen (1990), which helped summarize the major themes and sub-themes regarding the experiences of the novice nurses, which included a clear reflection and description of the phenomena (Streubert & Carpenter, 2011) . The researchers followed the six steps of van Manen (1990) thematic analytical method to analyse the experiences of novice nurses when caring for patients diagnosed with COVID-19 by (a) turning to a phenomenon or lived experience of interest, (b) investigating experiences, (c) reflecting on the essential themes that reflect the interesting phenomenon, (d) describing the interesting phenomenon by using the art of writing and re-writing, (e) maintaining a strong and oriented relation to experiences and (f) balancing the context of research through partial and whole consideration (van Manen, 1990) . Once these steps were completed, the researchers would scrutinize the trustworthiness of the transcripts while carrying on with the data analysis.

The rigour of this research was guaranteed by reassuring people and building trust in the findings through an approach by Guba and Lincoln (1994) , which focused on the following criteria: (a) credibility-the verbatim transcript was performed within a day after the in-depth interviews, and then the researchers sent the transcripts to all participants so that they could modify any parts they did not agree with and reach agreement from the participants. Moreover, the analysis of findings was undertaken by three experts in the nursing fields for peer debriefing and minor suggestions from experts were offered to make the analysis of findings more fulfilling after revision;

(b) transferability-the researchers had no intention to transfer the results of the study to other people, but instead they intended to provide detailed and reliable information on insightful phenomena while at the same time providing comprehensive coverage of these phenomena. Therefore, the researchers carefully fulfilled an analysis of the findings by analysing all the data and information to gain a thorough understanding of the experiences novice nurses had had when caring for patients diagnosed with COVID-19 in Thailand; (c) dependability-the researchers used several instruments and tools for data collection, such as field note-taking forms, demographic data forms, interview guidelines and a voice recorder to ensure that all data were collected and recorded; and (d) conformability-the researchers performed a systematic data collection and analysis, and the data were checked and compared as part of establishing an audit trail throughout this research.

A total of twelve novice nurses who met the criteria were interviewed, and the data were collected through face-to-face interviews with physical distancing, telephone interviews, note-taking and interviews by video conferencing and analysed simultaneously. All of the participants were female novice nurses. Their ages ranged from 22-26 years old, and the minimum amount of work experience they had was 2 months while the maximum amount of work experiences was 2 years and 5 months. Most of the novice nurses were working in private hospitals, and the original wards they worked on before having to care for patients with COVID-19 were the medicine and medicine/surgery wards following by the paediatric, intensive care unit and cardiology wards, respectively.

Overall, the experiences of novice nurses caring for patients diagnosed with COVID-19 were divided into five main themes and 17

sub-themes as shown in Table 2 

Novice nurses faced challenges in their work and often needed to work by themselves as soon as possible, so that the team could function properly and that the care for the patients was not compromised. For instance, they had to learn and practice by themselves how to use PPE. They also had to confine themselves in the hospital while working for the safety of those around them. 

When the novice nurses took care of COVID-19 patients, the novice nurses showed various feelings during their duties. They involved stressed, discouraged, fearful and proud feelings when taking care of COVID-19 patients.

When being selected by the head of the department or supervisors and left to face difficult working situations, novice nurses wonder why they have to be in this role even though they are novice nurses. 

The novice nurses were part of the young generation of the nursing organization and key drivers of change by contributing to the betterment of nursing practices in the future through their use of technology, embracing of innovations and creative skills.

Novice nurses had high technological capabilities and skills and applied their abilities and knowledge to their work to assist their team with effectively caring for patients.

An example of how these technological skills from novice students were used is given below: Novice nurses become nurses who take care of COVID-19 patients come in the following two ways: first, they can volunteer to do this duty due to a shortage of nurses providing care to hospitalized COVID-19 think that it is a learning opportunity and a challenge.

They are also still young, so they do not carry the burden of family responsibilities like senior nurses. Moreover, some nurses might decide to perform such duties since nurses are taught to provide ethical patient care and follow professional ethics which gives them a sense of duty and determination when taking care of patients (Fernandez et al., 2020; Galehdar et al., 2020; Sarabia-Cobo et al., 2020) . Another way for novice nurses to become nurses caring for COVID-19 patients is supervisors recruiting nurses who are required to take care of COVID-19 patients due to staff shortages.

The supervisors specifically look out for the ability and potential of novice nurses to learn jobs and then select novice nurses to join the team to work during the COVID-19 pandemic situation (Poortaghi et al., 2021) .

Working among COVID-19 patients is a completely new experience for novice nurses as it forces the novice nurses to perform their duties independently as soon as possible. Consequently, novice nurses are trained in a variety of ways. Each department where novice nurses work now provides COVID-19 nursing care training to novice nurses using online learning through both smartphone applications and social media (Waddell et al., 2020) . Online learning is combined with these platforms to keep the healthcare staff safe from the spread through social distancing based on government policy (Royal Thai Government, 2020). In addition, another effective way to train nurses and other staff during the pandemic is related to a study of Liu et al. (2020) which suggested that the hospital should offer learning, counselling and psychological support by using online platforms. Moreover, on-the-job training (OJT) also allows novice nurses to gain practical experience of real situations while working on COVID wards and learning from multidisciplinary teams caring for COVID-19 patients by attending conferences with physicians, participating in knowledge sharing, doing research and following practice guidelines based on new practices from a multidisciplinary team . Also, novice nurses also took part in self-learning to answer questions they had themselves and to learn the principles of caring for patients with COVID-19 by using various methods such as searching Google and watching YouTube video clips (Fernandez et al., 2020) . The learning or training methods of these novice nurses or healthcare providers met the new staff orientation requirements that were covered when they started their practical work or profession (Marks et al., 2020; Pertiwi & Hariyati, 2019) .

However, novice nurses caring for patients with COVID-19 face a variety of situations and practical challenges. Therefore, novice nurses dealing with COVID-19 patients must learn how to adapt themselves to the nursing practice, resolve impromptu situations, constantly confront uncertainty and adjust themselves consistently to be able to face any situation during the COVID-19 pandemic (García-Martín et al., 2020; Liu et al., 2020) . Moreover, when caring for COVID-19 patients, all healthcare providers are required to use PPE for patient care on the ward. Consequently, novice nurses need to learn the correct method of how to wear and remove PPE gowns and also quickly learn how to perform any tasks independently while wearing PPE. If the novice nurses are unable to work independently, this could lead to PPE sets being wasted, which will prove costly and put the staff members that need to help at risk as well. However, as novice nurses are personnel members who have just graduated from nursing school with little experience, they must rely on the knowledge learned at nursing school to take care of the sick, which can lead to a lot of stress among novice nurses (García-Martín et al., 2020; Thilo et al., 2020) . Fundamental nursing and holistic care principles were the key concepts to enable them to work effectively when caring for COVID-19 patients . Another issue is that novice nurses caring for COVID-19 patients need to go into isolation to prevent the spread of infection. Therefore, the novice nurses are often found in hospital confinement for the safety of everyone, which makes them feel lonely and distant due to a lack of social interaction (Fernandez et al., 2020; García-Martín et al., 2020) . Benner (1984) who argued that novice nurses with 1-2 years of experience did have not much experience of working and may have never faced any problem situations in actual practice, so they might become stressed and show fear when dealing with the stage of grief or the stage of anger. Benner (1984) reported that this leads to novice nurses beginning to feel frustrated and questioning themselves in a way of "Why me?" "It's not fair" etc.

when they are faced with unfamiliar situations. This is due to them having to face situations that the novice nurses did not want to happen or did not expect. Also, novice nurses who care for COVID-19

patients feel stressed and face fearful situations similar to experienced professional nurses who work during the COVID-19 pandemic.

Moreover, novice nurses are also worried that they will not be able to do their jobs due to them having little experience, which causes them to become discouraged and cry cause of the stress and anxiety they face (García-Martín et al., 2020; Karimi et al., 2020) . In addition, when working during the COVID-19 pandemic, healthcare providers find it difficult to work with heavy protective equipment, as it makes it difficult for them to move their body and conduct various procedures, which is the same as professional nurses who experience difficulties in performing their tasks during the COVID-19 pandemic as well (Galehdar et al., 2020; Thobaity & Alshammari, 2020 

There were some limitations to this study that should be considered when interpreting the data. First, due to the pandemic of COVID-19, the researchers recruited and interviewed some participants through the telephone, which led to potential limitations. Although the researchers attempted to interview and record participants' views through face-to-face or video call interviews, with some of the participants it was unavoidable that telephone interviews had to be used. This might have had an effect on the data interpretation as the researchers could not observe the feelings, non-verbal actions and expressions during the interviewing of some participants through telephone interviews. Second, all of the participants in this study were female nurses due to the limited number of male nurses working in the general context of the nursing practice and the low number of male nurses on COVID-19 wards. Finally, only a small number of novice nurses who work in public hospital were included in this study, which would have had an influence on the results obtained with regard to getting a clear picture of work experiences and perspectives of novice nurses. However, this study also provides interesting findings that help gain a clearer understanding of novice nurses' experiences while caring for COVID-19 patients, which may contribute to the improvement of the nursing practice, nursing orientation, training and the quality of care given by novice nurses during the pandemic of COVID-19.

The experiences of novice nurses caring for patients diagnosed with COVID-19 offer some interesting insights that people can learn from. The results showed various learning methods used by novice nurses during the pandemic such as nursing department or hospital training, on-the-job training, self-study through online platforms and multidisciplinary team learning. These are believed to be able to contribute to the learning styles and processes of the nursing training program in the future. Additionally, working during the pandemic mostly generates stress, fear and anxiety because of unfamiliarity, lack of experiences, overwhelmingness and work overload. These issues should be considered and covered during training periods by nurse experts, shadowing periods with preceptors, orientation programmes and simulation training sessions to ensure the novice nurses become familiar and confident when they provide COVID-19

care. Furthermore, the findings also showed that novice nurses possess the self-determination to accomplish any task because of the accountability they feel towards their team and duties as well as their pride with regards to being on the frontline of the COVID-19 response team and being able to use their technological skills to improve their work and come up with innovations to improve the quality of care. Therefore, it is believed that novice nurses should be supported and encouraged to be the future of the nursing profession. It is also believed that the abilities and capabilities of the young generation should be used to enhance the patient care and nursing practice quality and strengthen the standing of the nursing profession.

The authors are grateful to all participants in this research and profusely thank to Saint Louis College for financial and any kind of support.

There were no conflicts of interests according to the authors of this study.

Chawapon Sarnkhaowkhom, principle investigator and corresponding author, conceptualization of the idea of research, research design, data collection and data analysis, initial drafting of the manuscript and manuscript revision. Anucha Promkanya, co-researcher, research design, data collection and data analysis, essentially intellectual contributor. Siriluk Pomisrikeaw, co-researcher, data collection and data analysis. Nutchaporn Ritthapanya, co-researcher, research design and data collection.

The supported data of this research are available from the corresponding author, Chawapon Sarnkhaowkhom, upon request reasonably. The data are not publicly available due to ethical restrictions. 

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