*3.3. Main Findings*

Thirteen articles were selected and subjected to thematic analysis, showing different themes. The discussion used seven themes based on the information retrieved from them. Those seven themes fall into the broad categories of stressors and coping strategies. The first four themes are related to the nursing students' stressors, while the last three are related to the coping strategies employed by those students.

#### 3.3.1. Theme 1: Nursing Students' Stressors

Nine articles were concerned with studies on COVID-19-related stressors, from which four subthemes emerged. The first subtheme is "stress from distance learning", in which issues such as remote learning's psychological impacts are covered. The second subtheme is "stress from assignments and workload". The third subtheme is "stress from clinical training". The fourth subtheme is "fear of infection", and it covers issues such as feeling isolated and worrying about getting infected.

#### Stress from Distance Learning

Eight articles provided a link between the COVID-19 pandemic and nursing students' stress, with a focus on various stressors, including distance learning. During the COVID-19 pandemic, distance learning is a significant source of stress for nursing students. A cross-sectional study was conducted in 13 different nursing colleges in Nepal on 1116 participants [18]. The study aimed to assess the impact of E-learning during the COVID-19 pandemic among nursing students. The study found that many students suffered from the disruption of online classes related to the technological issues that occurred since higher learning institutions had moved to online classes. More than 63.2% of nursing students suffered from electricity problems, while 63.6% of nursing students suffered from internet problems, and only 64.4% of nursing students had internet access in the home for their online classes. Another cross-sectional study by [7] in Israel on 244 nursing students at Ashkelon Academic College assessed the levels of anxiety and coping strategies among nursing students during the COVID-19 pandemic. The study discovered that nursing students suffered significantly high levels of anxiety due to challenges presented by distance learning.

A qualitative study by [16] on 33 nursing students in Croatia explored how nursing students perceived the COVID-19 pandemic and their studying experience during the period. Distance learning presented many challenges to nursing students, including difficulties concentrating, as opposed to what they would do in a typical lecture room or face-to-face environment. The study also noted that nursing students found it difficult to remember and develop the motivation to undertake distance learning.

An observational and prospective study by [17] was on 142 nursing students in their second year in Murcia, Spain. The study's purpose was to assess the levels of stress among nursing students before and during the COVID-19 lockdown and its influence on taking online exams. The study established that levels of stress significantly increased among nursing students after lockdown. In addition, the study noted that the students who failed the online exam had higher levels of stress compared to those who passed.

The perceived stress levels and poor concentration emerged in another cross-sectional study by [19]. The study on 662 nursing students in Turkey evaluated nursing students' views on the COVID-19 pandemic and their perceived stress levels. The study proved that the nursing students suffered from moderate stress levels, but they had higher levels of stress than students assessed in the previous year. Nursing students expressed concerns about their clinical practice and inadequate clinical skills related to the interruption of education and moving to online learning during the pandemic.

Another cross-sectional descriptive study by [10] recruited 184 nursing students from universities in Nepal. The study assessed the factors associated with perceived stress, anxiety, and insomnia during the COVID-19 pandemic among nursing students. The study showed that 29.9% of the nursing students were afraid of delayed graduation, 36.4% suffered from costly mobile data and the necessity of spent money on mobile charging devices for their online classes, 17.4% had difficulties attending online access, 29.3% had difficulties concentrating, and 15.2% they were afraid of failure because they were unable to understand the online classes. The findings were confirmed in another study by [11], where they undertook a cross-sectional descriptive study on 244 nursing students in India. The authors assessed the perceived stress among nursing students during the COVID-19 lockdown. The study established that nursing students had moderate levels of stress related to a lack of resources and distance learning challenges.

Moreover, in a mixed-methods study by [12] that was conducted in Jordan on 335 nursing students, they analyzed the stress levels and sources of stressors related to distance learning and experienced by nursing students during the COVID-19 pandemic. It became evident that overall stress levels were higher among nursing students with low family income; 84.2% of the participants had a financial burden from paying for internet services. Furthermore, the Jordanian study found that distance learning has presented many stressors to nursing students, including difficulties concentrating because of distracting environments and no private areas for studying, limited resources, unorganized workloads, and a lack of strategies for standardized distance learning.

#### Stress from Assignments and Workload

Three articles reported that during the COVID-19 pandemic, assignments and workloads were a vital stress source for nursing students. One of these was the study conducted by [10], which reported that the global pandemic has affected university students in many ways. For nursing students working in a hospital, 44.4% suffered from long hours of duty, and 16.7% experienced increased workloads related to increased numbers of patients infected with the COVID-19 virus. Correspondingly, a study conducted by [7] reported that, in relation to the increase in the number of cases of the COVID-19 virus, there was a need to hire nursing students due to labor shortages in hospitals and in the community during the pandemic. Approximately 69% of the nursing students employed by hospitals had increased levels of anxiety. According to a descriptive study by [5], conducted in the United States among nursing students, learners showed difficulties in handling assignments, too. The study found that of the 84% of nursing students feeling anxious and overwhelmed, 62% had difficulty handling the academic workload, while 20% of nursing students had stress and difficulty writing assignments.
