**1. Introduction**

Nursing is a practice-based profession, in the sense that the performance of nursing students depends largely on their clinical practicum; therefore, the quality of clinical training practice is crucial to the nursing education and profession. Furthermore, nursing students' opinions regarding the quality of clinical training practices need to be strongly taken into consideration because of the demanding nature of the occupation. Nursing students are exposed to many sources of stress during clinical training and must handle stressful situations accordingly. Stressful situations can vary, including working with and handling breakout infections, where students assume an integral role in infection control measures and come into direct contact with infectious microorganisms. Becoming aware of and understanding students' clinical practice stressors and coping strategies during clinical training in different situations provides educators with valuable information to maximize their students' learning opportunities [1].

During a(n) pandemic/endemic, nursing students find themselves under additional stress factors such as the fear of being infected and infecting their close family members [2]. Two studies during the SARS (2003) and MERS outbreaks (2016) found that nursing students perceived themselves to be at a higher risk of infection and were reluctant to work in healthcare facilities due to inadequate safety and disease control measures [3,4].

**Citation:** Hamadi, H.Y.; Zakari, N.M.A.; Jibreel, E.; AL Nami, F.N.; Smida, J.A.S.; Ben Haddad, H.H. Stress and Coping Strategies among Nursing Students in Clinical Practice during COVID-19. *Nurs. Rep.* **2021**, *11*, 629–639. https://doi.org/ 10.3390/nursrep11030060

Academic Editors: Richard Gray and Sonia Udod

Received: 23 July 2021 Accepted: 7 August 2021 Published: 11 August 2021

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Increased stress levels during the 2003 MERS outbreak in South Korea were negatively linked with nursing students' intention to provide care to patients during future emerging infectious diseases [5].

Nursing students and staff are situated on the frontlines to combat infectious diseases and provide care and support to patients. They play a crucial role in providing effective infection control measures and ensuring the de-escalation of the spread of infectious microorganisms. Therefore, along with other medical staff and healthcare workers, nursing students and staff rushed to aid patients suffering from the most recent, fast-emerging, and rapidly spreading virus COVID-19 [6].

The COVID-19 pandemic spread to hospitals and nurses, putting them under enormous pressure in terms of workload and healthcare duties [7]. As a result, the lives and health of nurses and nursing students on the frontline, who are actively fighting the virus and are under great risk of contracting the disease, face dangerous repercussions [8]. COVID-19 studies and findings provide further evidence in regard to the anxiety experienced by nursing students and their response to treating this global pandemic [9].

Due to its extremely infectious and hazardous features, and the drastic lack of medication and treatment for the virus, COVID-19 has resulted in increased stress levels for nursing students and staff, which has consequently affected their coping strategies [8]. Therefore, understanding the relationship between stress levels and coping strategies of nursing students is critical. In non-pandemic times, the findings in Khater, Akhu-Zaheya [10], and Hamaideh [11] suggested that the most common coping behavior utilized by nursing students was problem-solving, followed by staying optimistic and transference.

It is essential to evaluate the quality of the clinical practices and identify stressors that arise from different clinical settings according to nursing students' perspectives. Therefore, this study aimed to examine nursing students' stress levels and their coping strategies in clinical practice before and during the COVID-19 pandemic.

#### *Theoretical Framework*

Stress has different definitions related to formulated theoretical models. It can be defined either as a stimulus, a response, or a combination of the two [12,13]. The definition of stress as a response was discovered by Selye (1976), who defines stress as the non-specific response of the body to any kind of demand [14,15]. On the other hand, Holmes and Rahes define stress as a stimulus without consideration to any response [16], stating that stress is: "an independent variable stimulus or load produced in an organism, creating discomfort, in such a way that whether tolerance limits are surpassed, stress becomes insufferable, appearing then psychological and physical problems".

The definition that is most relevant to and can be appropriately adopted in this study to explain the reality of nursing student's stress during clinical practice is Lazarus and Folkman's theoretical framework. Based on Lazarus' theory regarding the difficulty in differentiating between response and stimulus as the definition of stress, he conceptualizes an apparent stress definition that can reconcile differences between the separate theories of stress as a response or stress as a stimulus. He defines stress as "A particular relationship between the person and the environment that is appraised by the person as taxing and/or exceeding his or her resources and endangering his or her well-being" [17]. This is because it describes stress as a transactional relationship between the person and their surrounding environment [17]. Stress is not a singular facet, but rather arises due to influencing factors that affect the individual and, in turn, impact their response in such situations. For example, one of these stressful situations can occur during students' clinical practice once the students face a new environment and establish new relationships with staff nurses, patients, and an instructor and/or supervisor [18]. A study found that the most stressful clinical settings identified by the study were the intensive care unit followed by the emergency room, then the surgical units, while the area that was considered the least stressful was the medical units [19]. Therefore, this study uses this working definition of stress to examine nursing students' stress levels and their coping strategies in clinical practice before and during the COVID-19 pandemic.
