*4.2. Limitations*

There are several limitations to this study. Because this was a cross-sectional study, the resilience, family functioning, and spiritual support as predictors of mental health should not be taken as a cause-and-effect relationship. Such a causal relationship can be determined only through interventional studies. Second, less than 40% of the enrolled students completed the survey, which is not unusual for an online survey. However, this may have introduced a selection bias. Third, the self-reported data collection method could have over- or underestimated the symptoms of stress, anxiety, and depression. Fourth, pre-lockdown data were collected retrospectively, which may have introduced recall bias. Fifth, this study was conducted in spring 2020 during the initial wave of the COVID-19

pandemic in the US. Thereafter, the pandemic has evolved rapidly with subsequent case spikes, as well as the advent of improved treatments and vaccines. Therefore, the study findings may be most applicable to the initial phase of such pandemics. Finally, the study findings are based on a relatively small sample size from a single institution and may not be broadly generalizable. Future interventional studies are needed to confirm these study findings as well as to determine the effectiveness of fostering coping mechanisms among nursing students.
