‘All we've ever known is Covid’: A follow- up study with newly qualified nurses who worked as student nurses during the pandemic

Aims and Objectives: To explore the experiences of nursing students in England who had worked through the first wave and transitioned to qualification in the ongoing pandemic. Background: Experiences of health professionals and student nurses during the pan - demic are now well documented, but the transition of students to qualification is less well understood. In Summer 2020, we interviewed 16 student nurses who had worked as health care assistants on paid extended placements as part of the COVID- 19 re - sponse in the East of England, finding surprisingly positive experiences, including per - ceived heightened preparedness for qualification. A year later, we re- interviewed 12 participants from the


| INTRODUC TI ON
In March 2020, the English component of the United Kingdom's (UK) Nursing and Midwifery Council responded to the first wave of the COVID-19 pandemic by giving nursing students in the final year of their pre-registration degrees the option of completing their final extended placement as paid Health Care Assistants. In the Summer of 2020, we interviewed 16 student nurses across the four fields of nursing about their experiences of working in this novel role through the first wave of the pandemic . Participants reported surprisingly positive experiences, with one of our key findings being a perceived heightened preparedness for qualification.
Given these findings, and in response to calls to follow-up on the well-being of this cohort of students, we went back to those participants a year later to hear their experiences as they transitioned from students to newly qualified registrants with this unique experience.
Twelve of them agreed to be re-interviewed. This paper reports on the findings of the follow-up study.
The defining feature of participants' experiences a year on from the original study has been constant change; through the various waves of the pandemic, transitioning from being a student to a qualified nurse and from the unknown to the known. The participants also shared the impact of their experiences on their mental health and well-being, including coping strategies they used and support mechanisms they drew on. Through a reflective lens, participants outlined what they believed went well and provided suggestions about what could have been done differently to support them, both during their final placement and into their transition to newly qualified nurses. Our findings from this follow-up study provide important learning for our profession, including the need for ongoing support for this cohort of now qualified nurses, the strengthening of preceptorship programmes and careful consideration about how we prepare and support our students and newly qualified nurses in similar situations in the future.

| BACKG ROU N D
The experience of health professionals working through the pandemic has been the focus of a proliferation of research internationally. Commonalities relating specifically to experiences of nurses have been identified across the global scholarship, including unpredictable and challenging work practices; insufficient support; emotional, physical and psychological stress; and moral conflict (Joo & Liu, 2021;Zipf et al., 2021). Positive impacts have also been reported, including personal growth and a renewed sense of professional identify and calling (Joo & Liu, 2021;Zipf et al., 2021). For nursing students, the pandemic added additional pressures. They grappled with decisions about going into placement areas (where there were uncertain risks) so as not to lengthen their training, sometimes incentivised by payment and a sense of professional duty. They also faced challenging switches from face-to-face to online learning while embracing opportunities for learning and development in a unique clinical environment .
While research has documented nurses and nursing students' experiences, the experience of Newly Qualified Nurses (NQNs) is less well understood. Relevant studies included four undertaken in the United States of America (USA), one in Spain and one in the UK. American studies investigated the experience of transition for support add weight to calls for mandatory preceptorship programmes. While heightened resilience was evident, provision of ongoing mental health and well-being support is strongly recommended.

Relevance to Clinical Practice:
We need a partnership approach with nurse educators and practice colleagues which ensures preparation for qualified practice is appropriate. If we do not effectively prepare students for qualified nurse posts, patient care will almost certainly be compromised. -19, interviews, mental health, nursing graduate, nursing student, preceptorship, qualitative research, registered nurses What does this paper contribute to the wider global clinical community?

COVID
• New insights into the experience of newly qualified nurses in England who worked as health care assistants in the first wave of the COVID-19 pandemic and transitioned to newly qualified nurse during subsequent waves.
• Adds to the growing evidence base supporting the need for mandatory preceptorship programmes for newly qualified nurses in the UK.
• Provides further weight to calls for ongoing mental health and well-being support for this group of nurses.
NQNs generally (Crismon et al., 2021;Naylor et al., 2021;Sessions et al., 2021;Smith et al., 2021); García-Martín et al. (2021) focussed specifically on NQNs in Spanish emergency departments. These studies all reported similar findings, including the importance of support, organisational issues, feelings of vulnerability and uncertainty about preparedness for qualification arising from disruption to undergraduate programmes, particularly the quality of their clinical placements and stress impacting on mental health and well-being.
They were echoed in a recent UK survey which obtained the views of 5000 nurses and students specifically in relation to the accessibility and quality of preceptorship programmes for NQNs, something that is not currently mandatory in the UK (Mitchell, 2022). Eighty four percent of the respondents to that survey thought transitioning from student to NQN had become more challenging in the last 2 years. They cited workplace pressures and staff shortages as barriers to preceptorship, with a lack of support contributing to some leaving their jobs and others, the profession altogether.
When we disseminated the findings from our original study , we were encouraged by colleagues to carry out follow-up work, particularly because working as a student nurse during the first wave of the pandemic (between March and September 2020) had left participants feeling a heightened preparedness for qualification. This follow-up study therefore aimed to hear the experiences of nursing students who had worked on the frontline through the first wave of the pandemic but were now working as registered nurses in the UK context, offering key insights and important learnings from this group of nurses about how they adjusted to the responsibilities of being a registered nurse.

| ME THODS
A qualitative approach was adopted as this provides an opportunity to gain understanding of the experiences of participants (Grove & Gray, 2018) from their perspective (Morse, 2010). Qualitative research involves the asking of 'open questions about phenomena as they occur in context' (Carter & Little, 2007: 1316 and involves the generation and analysis of data that leads to enhanced understanding (Aspers & Corte, 2019). Qualitative research draws on a range of data collection methods, including interviews (Denzin & Lincoln, 2005), a semi-structured approach being used for this study. The questions were designed to reflect the research aim (DiCicco-Bloom & Crabtree, 2006), but also allowed the participants to have a degree of flexibility and control in the interview (Holloway & Galvin, 2016). The study was designed in accordance with the COREQ (COnsolidated criteria for REporting Qualitative research) guidelines (Tong et al., 2007) (See File S1).

| Recruitment
Purposive sampling was used to facilitate the recruitment of participants who possessed the characteristics required to meet the research aim (Nieswiadomy, 2013). Sixteen nurses who completed their BSc Hons Nursing or pre-registration MSc Nursing programme in 2020/beginning of 2021 were invited in July 2021 via email to take part in the research; a participant information sheet was attached providing full details of the study. All 16 who had been involved in our previous research  had agreed to be contacted to potentially participate in this study. Twelve responded positively with representation being achieved across all four fields of nursing (5-Adult; 3-Children's; 2-Learning Disability; 2-Mental Health).

| Data collection
The interviews were conducted via Zoom™, an online audio and web conferencing platform; Zoom is an effective mechanism for collecting qualitative data within a healthcare context because of its low-cost user-friendliness, levels of security and in-built data managing strategies (Archibald et al., 2019). Using Zoom™ allowed the interviews to be easily arranged with the participants at mutually convenient dates and times, taking place between July and November 2021. All the interviews and associated consent were recorded via the audio system integral to Zoom™; this data were then sent securely for professional transcription. Interviews lasted between 24 and 62 min and were conducted by experienced female academics RG, LW, CA and YN.
Initial demographic data were gathered (

| Participants and setting
Participants that consented to be contacted again from the original study were sent an email inviting them to take part in the follow up study. Twelve (of 16) agreed to be re-interviewed for this followup work. Of those that agreed to participate, all graduated from a University in the East of England at similar times and were working as newly qualified nurses in a variety of clinical settings. They were all female, from a mix of ethnic backgrounds and from across all four fields of nursing. At the time of interview, five were working as staff nurses in the same area in which they undertook their final extended placement as students, others were in the same placement organisation, but different clinical areas (see Table 1).

| Ethical considerations
Ethical approval was obtained from the University's ethics committee (protocol number aHSK/SF/UH/04184(2)). Particular attention was given to the emotional well-being of participants. As this was a follow-up interview, and to optimise the relationship that had already been established, most participants were interviewed by the same researcher as in the first study. Confidentiality was maintained through pseudonymisation and careful reporting of findings to avoid possible identification through specific events unique to individual participants. To the best of our knowledge, no other persons were present at the time of the interviews, but this was left to the discretion of participants. We had a protocol in place should any participants become distressed, and information was provided to them all about potential sources of ongoing support. Debrief opportunities were offered from within the research team in the event of any distress arising from interviews, however, this was not required.

| Data analysis
To analyse the data, Braun and Clarke's reflexive thematic analysis was used: a 'method for developing, analysing and interpreting patterns across a qualitative dataset' (Braun & Clarke, 2022, p. 4).
It is a 6-step process which centralises the role of researchers in interpreting and making meaning from the data, requiring ongoing reflexivity: 'a disciplined practice of critically interrogating what we do, how and why we do it, and the impacts and influences of this on our research' (p. 5). An experienced researcher (RG) undertook the first 3 phases and step 4 was carried out by another team member (LW). Using a collaborative approach (RG and LW), themes were defined and named (stage 5) and the findings written up (stage 6).
See views and open discussions about influences on data analysis (Braun & Clarke, 2022). As this was a follow-up study carried out by the same researchers, we were particularly attuned to any influences from carrying out the original research. For more information on the process, see Table 2. To ensure confidentiality, pseudonyms have been used and participants' fields of nursing identified as follows: Adult-Ad; Child-Ch; Mental Health-MH; Learning Disability-LD.

| FINDING S
Three main themes were identified from the interview data: • constant change/transitions • mental health and well-being • reflecting on the past to learn for the future.
Whilst participants had had many negative experiences, they were also keen to voice positive impacts and share their recommendations for future practice.

| Theme 1: constant change/transitions
The key defining feature of participants' experiences since qualification was change; with the consequences of the pandemic being ongoing. This specifically related to the sub-themes of either direct delivery and organisation of nursing care or their transition from student to newly qualified nurse throughout the various waves of the pandemic.

| Direct delivery and organisation of nursing care
Participants were experiencing changes in their clinical environments and associated procedures daily. They talked of having to con- Guidance on what to expect on qualification both from the University and practice areas. Missing key training and struggling to get necessary skills signed off was seen as a barrier to their development, although some participants expressed gratitude for opportunities to attend sessions virtually instead of face to face.
In terms of preceptorship, we have a book that the Trust want us to complete but there was just never a time to do it….It's just like, I haven't got it completed, it's nearly coming up to a year and it's…stress.
(Beth, Ch) Because of increased levels of patient acuity and poor staffing, many participants felt as though they had been 'thrown in at the deep end'. They felt they had been required to take on higher levels of responsibility than would have otherwise been the case, often having to step up and be shift leaders when they did not feel ready; a situation described by one participant as 'petrifying'. They also felt higher expectations on them linked directly to being student nurses on the special extended paid placement in the first wave of the pandemic.

| Theme 2: mental health and well-being
Capturing the impact of participants' experiences on their mental health and well-being was a central goal of this study and vivid descriptions were provided of what they had been through, how this had affected their mental health (both positively as well as negatively), the coping strategies they had used and the sources of support that they drew on. There was a general sense across the interviews that participants had been through something momentous and were coming out the other side. This was aided by feelings of inner personal strength which were related to survival and an enhanced sense of teamwork.
My current team are really supportive…Yeah, they are right there…They're very, very supportive.

(Brook, LD)
A big source of stress was the uncertainty of what they were walking into each day, for example, if they would be short staffed, have very sick patients, changes in protocols, reconfiguring or shutting of wards.
The relentless busyness of the work environment took its toll on wellbeing, particularly during the very early stages of qualification. They talked of being out of their depth and feeling a sheer weight of pressure at the responsibility and immensity of the workload they were having to deal with.
You come away thinking, oh my God, did that just happen….We've had days that are just so, so busy, everyone is just overwhelmed, and it doesn't matter how many staff you have…. there is just too much going on.

(Daksha, Ad)
There was also sadness expressed by participants; about the number of deaths they witnessed, the acuity of the patients and having to deal with constant high-level anxieties of patients, their relatives and colleagues, as well as their own families. There was also sadness about what they had missed out on because of the pandemic, such as graduation and that they had known no other ways of working. A mechanism that all participants appreciated while they were students on extended placement were regular check-ins, someone from either the University or the work organisation asking if they were alright. This was an initiative continued by some areas after qualification; one participant explained that she was not offered this but felt that it could have helped: What they could have done….for the newly qualified nurses was put on little group sessions just to offload and talk about things if you wanted to. I think that would have helped.
(Daksha, Ad) Follow-up by the University after qualification was mixed. Some had received ongoing contact by personal tutors to enquire how they were coping with the transition and this ongoing support was really appreciated. Where this did not happen, participants expressed feelings of being abandoned. One participant noted that other than receiving information about alumni events and graduate MSc programmes, they received nothing that acknowledged their qualification at such a difficult time and would have appreciated some kind of follow-up and signposting for ongoing support.
Maybe just a follow-up email or phone call from the uni to find out, 'Did you manage to find employment' was it the job you were looking for, is there anything that we can do in terms of not just careers but emotional support as well maybe and well-being?
(Brook, LD) Initiatives suggested to ease transition included ongoing emotional support, such as groups where NQNs could discuss their fears and anxieties, new starter booklets and strategies such as ensuring that if their preceptor were away from work, another would be provided; small changes that could have a big impact. One suggestion was for final year students to be given a realistic picture about what to expect, perhaps a talk from an NQN, who could share their experiences and signpost them to help and advice: I think highlighting that times will be hard, times will be challenging, but there are options to help you with that.

| DISCUSS ION
The effective transition of students into qualified nurses has been the focus for international scholarship in recent years, reporting substantially increased attrition rates for this group secondary to high levels of stress and burnout, feeling unsafe and demands of unreasonable workloads (Alghamdi & Baker, 2020) all of which are compounded by the potential for reality shock (Ho et al., 2021). Our study adds to this literature, demonstrating how these effects have been amplified by the pandemic, supporting calls for mandatory preceptor programmes for all NQNs in the UK. Preceptorship is a 'structured start for newly registered nurses' which helps them develop in confidence and apply their knowledge to practice (NMC, 2020). Healthy work environments are influential in reducing reality shock for the transition to NQN (Kramer et al., 2011). While this study found that NQNs felt supported in their workplace as they transitioned, this was usually in relation to personal issues arising out of the pandemic (such as a need to shield or taking extended bereavement leave following the loss of a close relative) rather than any formal, structured preceptor programme. Any dedicated supernumerary time usually given at the start of a NQNs transition was impossible and, in keeping with the findings of a UK survey (UNISON Health, 2021), preceptorship was detrimentally impacted by staff shortages, extreme busyness and work intensification in clinical environments.
Pre-pandemic evidence demonstrates that if organisations fail to provide adequate support or reduce stress levels, NQNs are more like to leave nursing within 2 years of qualification (Taylor et al., 2019).
This study confirms that the pandemic has further challenged already inconsistent preceptorship provision (Taylor et al., 2019), of particular concern given the results of a recent employment survey of UK nurses, where more than half respondents reported considering leaving their job because of feeling undervalued and under too much pressure (RCN, 2021a, p. 6). A direct link has been made between the theory practice gap that NQN's experience and patient safety concerns, with transition programmes having an important role to play in bridging the gap (Murray et al., 2018). Among the positive findings of the original study were heightened feelings of preparedness for qualification resulting directly from working through the pandemic as student nurses and being paid as health care assistants . This follow-up study confirmed those predictions, and whilst existing problems with preceptorship programmes were magnified, this seemed to be mitigated somewhat by increased confidence and skills acquired from experiences as students on extended placement throughout the first wave of the pandemic, including management, leadership and delegation. These findings are in direct contrast with research carried out with NQNs before the pandemic which identified a decreased sense of competence and confidence relating to transition shock and a lack of connectedness to workplace environments (Ho et al., 2021). Most of our participants had stayed in the same clinical environment, if not the same organisation, and because they had already experienced the shock of being 'thrown in at the deep end' on their extended placement, any effects of transition shock seem to have been reduced.
The findings from this study further illuminate the impact of the unique social and clinical environments of the pandemic, particularly in relation to professional calling and pride, improved teamworking and making a meaningful contribution at a time of global crisis (Jun & Rosemberg, 2022). This has been understood using the sociological Weberian concept of communities of fate which 'denotes the purposeful collective action that may be attained by a group of people facing a common crisis' (Montgomery et al., 2021, p. 9). Participants expressed feelings of camaraderie, pride in what they were doing, and being battle hardened having 'survived' working through the pandemic which meant they felt able to cope with anything. One American study found that NQNs felt a sense of lost opportunities because they transitioned during the pandemic (Crismon et al., 2021). In contrast, this study's findings indicate that while mentally and emotionally challenged, the NQNs embraced the unique learning and developmental opportunities which arose.
Pre-pandemic research shows that as NQNs become more familiar with their role, their confidence grows and anxiety lessens (Jenkins et al., 2021).  terviews a year after the original study, the participants were still very much in the pandemic and coping with its effects. Support was crucial and came from a variety of sources, including friends, family, colleagues, the organisations where they worked and for some, the University. Simply having a nurse manager or practice educator check on how they were made a huge difference and talking with those going through similar experiences was particularly important.
The mental health effects on those working through the pandemic are yet to be fully realised, but a resolute commitment to provide ongoing support for all those who contributed at a time of national crisis is needed. While resilience, strength and professional pride grew, our findings show how important support mechanisms initiated by organisations were, such as the professional psychological support, wobble rooms and yoga sessions. Many of these have now been withdrawn, to the potential detriment of those still working in challenging clinical environments. A recent report from the Kings Fund has called for positive change and renewal in the provision of health services already under pressure from poor resourcing and chronic staff shortages exacerbated the pandemic (Charles & Ewbank, 2021). Their foremost recommendation is to prioritise the well-being of staff, proposing that those who worked through the pandemic be given 'time, space and resources to recover' and to address the drivers of poor staff experience and chronic excessive workloads. We now have an opportunity to harness some of the innovations that were successful during the pandemic, for example the positive potential for online preceptorship peer support (Jenkins et al., 2021). The switch to online teaching as well as the use of social media to provide both peer and professional support as part of preceptorship for NQNs was highly valued, supporting the need for the ongoing use of these approaches.

| Limitations
This was a small qualitative study carried out with a particular cohort from the East of England, therefore, the views may not be wholly representative of others in a similar situation. Whilst we were not able to recruit all participants from the original study, we did have a representative mix across the four fields of nursing. The insights from the initial research intentionally influenced the design of this followup study, particularly when matching interviewers for the comfort of participants. However, there is potential that the same researchers could have had an 'insider' perspective that may have had an influence on the study; this was recognised and a range of strategies to enhance trustworthiness were employed (such as regular research team meetings, the integration of a reflexive approach and the documentation of an audit trail). In the original study, we focussed on students who had undertaken the extended paid placement; as a follow-up study, findings relate to this group of NQNs and we recognise that NQNs who did not undertake the paid extended placement may have had different experiences. Further research is recommended to document and compare their perspectives with our participant group. Despite these limitations, our findings provide unique and important insights which add to the evidence base in this area.

| CON CLUS ION
The aim of our study was to follow-up on a group of students, now qualified, who had been through a unique transition experience which we can all learn from. We were particularly interested to see if the perceived heightened preparedness for qualification that students who had worked on an extended, paid placement during the first wave of the pandemic had become a reality. We also wanted to hear about the ongoing impact of working through subsequent waves of the pandemic had on mental health and well-being. We found that participants predictions that they were well equipped for qualification were confirmed, which ameliorated some of the documented usual effects of transition to NQN. However, other pressures arose such as increased expectations and added responsibilities in extremely busy, constantly fluctuating clinical environments with considerably less support than usual. Our study adds weight to calls for mandatory preceptorship programmes to optimise transition to qualified practice and reduce potential impacts on patient safety, which can be effectively supported with the use of online technologies. To lessen feelings of abandonment, the profession would benefit from close consideration of how it can support the transition for future student nurses into qualified practice, for example, by harnessing innovative approaches used during the pandemic, such as social media and online support groups. In keeping with the scholarship in this area, participants demonstrated heightened resilience resulting from their experiences with key sources of support such as friends, families, colleagues and managers who had encountered similar challenges. Organisational support strategies, put in place during subsequent waves of the pandemic, were sorely missed when discontinued and we strongly recommend the provision of ongoing mental health and well-being support for this group of nurses as well as all those who have worked through the pandemic, the ongoing impact of which may never be fully realised.

| RELE VAN CE TO CLINI C AL PR AC TI CE
The delivery of safe and effective care for patients/service-users is at the heart of the UK's Nursing and Midwifery Council's code, however, the challenges of COVID-19 meant that, sadly, in some cases, this care was compromised. We need to learn from these experiences to ensure that, going forward, everyone receives high quality nursing care. This study has demonstrated the benefits for students of having additional clinical experience as well as added responsibility, in this case, enabled by the pandemic. We are now in a situation where many services have been reconfigured and are operating very differently; placement capacity is therefore tight, and students are having increased clinical simulation time.
As a result, preparation for qualified practice is changing, yet the demands in terms of patient care are, in many instances, becoming more challenging (for example, more acutely and chronically ill patients are being cared for at home; patients in hospital are there for shorter stays and can be critically ill whilst hospitalised). We therefore need a partnership approach with practice colleagues to ensure that preparation for qualified practice is adequate, including the acquisition of clinical skills (such as venepuncture) as well as providing opportunities for final year students to develop self-confidence and the attributes that underpin management and leadership. The nursing workforce has changed; so student nurses will qualify and will be expected to support learners as well as more junior staff (such as Nursing Associates). If we do not appropriately prepare students for qualified nurse posts, we will continue to lose NQNs from the nursing workforce and patient care will almost certainly be compromised.

ACK N OWLED G EM ENTS
The authors wish to express their sincere thanks to the nurses who participated in this study.

FU N D I N G I N FO R M ATI O N
This study was unfunded.

CO N FLI C T O F I NTE R E S T
The authors declare that there was no conflict of interest.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data available on request from the authors.

N O PATI E NT O R PU B LI C CO NTR I B UTI O N
As this is a follow-up study with qualified nurses who worked as students during the first wave of the pandemic.