**3. Results**

The results from the comprehensive confirmatory factor analysis based on the varimax rotation factors of the entire sample results, the sample results before COVID-19, and the sample results after COVID-19 can be viewed in Table 2. Although not shown, the covariance between stress and coping strategies was positive and significant for all the sample (covariance = 0.4; *p* < 0.001), both the sample results before (covariance = 0.28; *p* < 0.001) and after (covariance = 0.58; *p* < 0.001) COVID-19. When examining the entire sample responses factor loading show in Table 3, all factor loadings were above 0.40 [23].

**Table 3.** Unstandardized estimated for all-sample, before and after COVID-19.


Notes: LR test is the Wheaton et al. (1977) relative/normed chi-square (χ2/df), mc is the correlation between the dependent variable and its prediction, and mc2 = mcˆ2 is the Bentler-Raykov squared multiple correlation coefficient.

The overall average score of stress before COVID-19 was 1.32 (low stress) and 1.95 (moderate stress) during COVID-19 (See Table 4). Across all six stress categories, the average stress score was lower before COVID-19 than during COVID-19. The largest change was found in the stress category "lack of professional knowledge and skills" where the average stress score before COVID-19 was 0.95 (low stress) and 1.78 (moderate stress) during COVID-19 with a 0.83 change. The smallest change was found in the stress category "the environment" from an average stress level of 1.16 (low stress) before COVID-19 and 1.70 (moderate stress) during COVID-19. The overall average score of coping strategies before COVID-19 was 1.84 (moderate coping) and 2.17 (moderate coping) during COVID-19. Across all four coping strategies categories, the average coping strategies score is lower before COVID-19 than during COVID-19. The largest change was found in the coping strategy category "Transference" where the average coping strategy score before COVID-19 was 1.87 (moderate) and 12.41 (moderate) during COVID-19 with a 0.54 change. The smallest change was found in the coping strategy category "stay optimistic" from an average coping strategy level of 2.06 (low) before COVID-19 and 2.15 (moderate) during COVID-19.

**Table 4.** Means and std. deviation and T-test for subscales items of stress experienced by nursing students and coping strategies in their clinical practice before and during the COVID-19 pandemic.


\* *p*-value for Chi-squared test < 0.05.

The results from the T-tests (See Table 4) show that there are statistically significant differences in both average stress scores and average coping strategies before and during COVID-19 across the majority of the categories. This statistical difference shows that both stress and coping strategy scores were lower before COVID-19 and higher during COVID-19. However, there was no statistically significant difference in the coping strategy category "Problem-solving" and "Stay optimistic" with a before-COVID-19 average coping strategy score of 2.09 and 2.06, and during scores of 2.32 and 2.15, respectively.

#### **4. Discussion**

Through the development of this survey, we have built upon previous research indicating the importance of understanding nursing students' well-being through examining their stress levels and coping strategies. We have developed and tested a measurement scale that is reliable and accurately measures all identified in the Perceived Stress Scale (PSS) and the Coping Behavior Inventory (CBI) survey individually. However, our findings show that when the study is conducted on nurses in Saudi Arabia, there is not a strong reliable relationship between perceived stress and coping strategies (loading factor 0.4 and less) for the entire sample and the before COVID-19 sample. However, interestingly during COVID-19, there was a reliable and accurate relationship between stress and the use of coping strategies. A recent 2020 article regarding students' coping strategies during the COVID-19

pandemic found that approximately 35% of students experienced some level of anxiety and used four types of coping strategies: Seeking social support, avoidance/acceptance, mental disengagement, and humanitarian [24].

The current study aimed to analyze the impact of the COVID-19 pandemic on nursing students' stress levels and coping strategies. Through the combination of these two surveys, were have built upon previous research indicating the importance of stress and coping strategies among nursing students during unprecedented times. We have utilized a measurement scale that reliably and accurately measures stress and coping strategies before and during the COVID-19 pandemic. These findings can help inform nursing curricula developers on how to incorporate the needed skills and resources to prepare nurses for future infectious outbreaks. This is important as the Saudi Vision 2030 framework, released in 2017, has set a path to increase nurse graduates over the next 10 years and enhance the health delivery system to be community-focused. To meet this goal, Saudi Arabia has committed to increasing the nursing workforce by graduating and hiring 10,000 new nurses annually [25].

While multiple studies have reported on the psychological well-being of healthcare workers during COVID-19 [26–34], our study is one of the first to examine the influence of the pandemic by controlling for before the pandemic in nursing students in Saudi Arabia. Data collection occurred during the first wave of the pandemic in the country. The results of this study reflect an increased level of stress and coping strategies among nursing students during the continuing COVID-19 pandemic than before the pandemic. We found that, overall, across all subscales of stress there was a significant increase in stress relating to taking care of patients, teachers and nursing staff, assignments and workload, peers and daily life, lack of professional knowledge and skills, and the environment. These stressors can be attributed to multiple factors such as the unpreparedness to care for COVID-19 patients, increases in safety protocols in the clinical setting and decreases in safety personal protective equipment, relying heavily on simulation for training, and added assignments in an online learning environment to keep up with skill development. The stressful learning environment hinders student success. The completion of clinical practice and a precursor to licensure adds even more added pressure on students to complete an excessive workload to meet the non-direct care hours required [34].

According to previous research, even in normal circumstances, nursing students experience stress and must utilize several coping strategies to reduce both stress and anxiety. A study conducted in Bahrain found that almost all nursing students experience moderate to severe levels of stress while in their clinical practice [35]. Furthermore, another study found that over 99% of nursing students reported the level of perceived stress moderate or high. Several studies have revealed that the cause of clinical stress can be attributed to fear and uncertainty of unknown events, fear of medical errors, working with unfamiliar equipment, and gaps between theory and practice [36]. The additional increase in the level of stress among nursing students due to COVID-19 can have both internal and external consequences [37]. It can cause students to perform poorly and may lead to a withdraw from the program as self-doubt sets in, changes in mental and physical health, and can eventually affect the quality of care provided to patients. Several studies have shown that due to the demand and utilization of personal protective equipment across the globe, many direct care workers such as nurses and nursing students lacked the proper protective equipment, which increased their vulnerability to contracting COVID-19 [38,39]. As a result, many nurses have lost their lives to COVID-19, while others continue to fight against the deadly virus. Consequently, nurses perceive an increased risk of catching COVID-19 [40], which has increased turnover intentions [41]. However, a study conducted in China during the COVID-19 pandemic found that only 3% of their sample believed clinical nursing work to be "too dangerous to engage in" and have an increased intention of leaving the nursing profession [42].

The COVID-19 pandemic is currently the biggest threat to the lives and health of nurses and nursing students and has been shown to impact their emotional response and coping strategies. Our study shows that nursing students' use of Avoidance and Transference as coping strategies and overall coping strategies increased during the COVID-19 pandemic in comparison to before the pandemic. However, our study did not identify a statistical difference between nursing students' use of problem-solving or staying optimistic as coping strategies. This is in contradiction to a recent study that found that nursing students were more willing to use coping strategies that focused on problem-solving [8]. Our study findings can be explained by examining Gan and Liu's [43] study, which found that undergraduate students who regarded stressful events as controllable were more likely to apply problem-focused coping strategies; however, since COVID-related events were uncontrollable during the study period, students might have relied on emotion-focused coping strategies such as Avoidance and Transference, which contradict some priory studies [44,45]. A study conducted before the pandemic found that the most common coping behavior used by nursing students was transference, followed by staying optimistic and problem-solving, while the least used was Avoidance [46]. These findings are important for both nursing schools and hospitals, where they must focus on providing psychological support to nurses as well as training them in all available coping strategies to improve their ability to manage their emotions and effective coping tools to improve the lives of the nursing student, their families, and ultimately their patients.
