**1. Introduction**

The COVID-19 pandemic and subsequent mandatory lockdown to suppress transmission of the SARS-CoV-2 virus have caused significant global disruption of the educational system. According to the United Nations Educational, Scientific and Cultural Organization (UNESCO), more than a billion students globally have experienced closures of educational institutions during the pandemic [1]. In California, USA, the state governor issued a statewide mandatory stay-at-home order on 19 March 2020, resulting in the shutdown of face-to-face education for students [2]. For college students, the rapid shift from inperson to online learning, as well as concerns over educational progress and future job opportunities, contributed greatly to increased levels of stress and anxiety [3,4].

Before the pandemic, a national survey of 26,181 college students in USA reported that about a half were either diagnosed or treated for anxiety, depression, or panic attacks

**Citation:** Kim, S.C.; Sloan, C.; Montejano, A.; Quiban, C. Impacts of Coping Mechanisms on Nursing Students' Mental Health during COVID-19 Lockdown: A Cross-Sectional Survey. *Nurs. Rep.* **2021**, *11*, 36–44. https://doi.org/ 10.3390/nursrep11010004

Received: 30 November 2020 Accepted: 5 January 2021 Published: 12 January 2021

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within the past year [5]. Nursing students experienced even higher levels of stress as they adjust to challenges of rigorous academic requirements as well as clinical demands, resulting in stress-related illnesses, depression, and sleep disturbances [6,7]. In China, the arrival of the COVID-19 pandemic has resulted in even higher levels of stress, anxiety, and depression among college students [8,9]. A study from Israel demonstrated that during the third week of COVID-19 lockdown, more than half of nursing students reported moderateto-severe anxiety symptoms [10]. The study findings showed that female gender, concerns of academic progress, and fear of infection correlated with higher anxiety.

In addition to the immediate impact of the pandemic, previous studies of earlier coronavirus outbreaks have indicated that quarantine or lockdown can result in long-term psychological consequences [11]. Anxiety symptoms and feelings of anger remained present four to six months following quarantine during the Middle East Respiratory Syndrome (MERS) outbreak in Korea [12]. Furthermore, long-term consequences of psychological distress and burnout among nurses persisted nearly two years after the original Severe Acute Respiratory Syndrome (SARS) outbreak in Canada [13].

In managing psychological distress during epidemics, various coping mechanisms appear to be effective [14]. For example, having a support group for college students quarantined at home during the earlier SARS outbreak was found to be helpful [15]. Similarly, the presence of parental support was associated with lower anxiety among college students during the COVID-19 outbreak [16]. Spiritual support also seems to be an effective coping mechanism. College students with high spiritual support had greater personal happiness and satisfaction with life, as well as better adjustment to college life [17–19]. Minority college students with high spiritual support employed more problemoriented coping behaviors, such as positive reinterpretation of adverse events, resulting in lower stress and better academic performance [20]. Resilience, another coping mechanism, refers to an individual's ability to bounce back from adversity and effectively respond to challenges [21]. Postgraduate nursing students exhibited a higher level of resilience than undergraduate nursing students, and the resilience was a positive predictor of perceived wellbeing [22]. Resilience was also positively associated with clinical communication ability and academic success [23,24]. During the COVID-19 pandemic, high resilience among nursing students was negatively associated with anxiety [10].

The psychological wellbeing of nursing students during the pandemic is critical for their academic success, and assessment of various coping mechanisms is necessary. However, there are limited studies on various coping mechanisms that enhance overall mental health of nursing students during the pandemic [10]. The aim of this study was to explore the influence of coping mechanisms as predictors of stress, anxiety, and depression among nursing students during the COVID-19 pandemic and subsequent lockdown.

#### **2. Methods**

## *2.1. Design and Sample*

This cross-sectional study was conducted using an online survey platform Qualtrics XM (Provo, UT, USA) during the COVID-19 pandemic lockdown. All undergraduate and graduate nursing students enrolled in the spring semester 2020 at a private university in Southern California, USA were eligible to participate in the study.

#### *2.2. Study Questionnaire*

The study survey included valid and reliable instruments that measure resilience, spiritual support, family functioning, stress, anxiety, and depression. The respondents were asked to assess their current mental health status as well as to estimate their pre-lockdown mental health. Demographic information, including age, gender, ethnicity, and nursing program enrollment, was also collected.

The Connor–Davidson Resilience Scale (CD-RISC)-10 asks respondents to assess their adaptability in challenging situations and the ability to bounce back [25]. The response options on a 5-point Likert scale range from 0 (not true at all) to 4 (true all the time). The possible maximal score is 40, with a higher score indicating higher resilience. The Cronbach's alpha was previously reported as 0.92 and was 0.83 in this study.

The 12-item Spirituality Support Scale evaluates respondents' perceived spiritual support from a higher power, religious faith, or beliefs on a 4-point Likert scale ranging from 1 (strongly disagree) to 4 (strongly agree) [26]. The summation scores range from 12 to 48, with a higher score indicating higher spiritual support. The Cronbach's alpha was previously reported as 0.97 and was 0.96 in this study.

The Family APGAR questionnaire measures satisfaction with support from family members [27]. It includes five indicators of family functioning: adaptation, partnership, growth, affection, and resolve, on a 3-point Likert scale ranging from 0 (hardly ever) to 2 (almost always). Scores of 8–10 indicate a highly functional family, while scores of 4–7 and 0–3 indicate moderate and severely dysfunctional families, respectively. The inter-item correlation coefficients were reported to be 0.63 to 0.71.

The Perceived Stress Scale (PSS) assesses respondents' perception of stress by eliciting thoughts and feelings during the past month [28]. It consists of 10 items in two subscales, including 6-item positive and 4-item negative factors on a 5-point Likert scale ranging from 0 (never) to 4 (very often). The responses of four items in the negative factor were reversed with possible total scores ranging from 0 to 40. Scores of 0–13, 14–26, and 27–40 were assessed as low, moderate, and high stress, respectively. Cronbach's alpha was previously reported as 0.83, and was 0.85 in this study.

The General Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) are widely used tools that assess the symptoms of anxiety and depression, respectively [29]. The response options range from 0 (not at all) to 3 (nearly every day). Scores ≥10 are considered moderate-to-severe anxiety or depression that potentially warrant further follow-up. The sensitivity and specificity of the GAD-7 for anxiety disorder were 72% and 80%, respectively. Similarly, the sensitivity and specificity of the PHQ-9 for the major depressive disorder were 88% and 88%, respectively.
