The Impact of COVID-19 Pandemic on Nursing Education among Nursing Students: A Systematic Review

Introduction : Globally, the COVID-19 pandemic has had a significant impact on educational sections and is required to close down due to the transmission of the coronavirus. The newly developed online learning is the most reliable option to resume the education process by preventing the academic calendar from accumulating and minimizing learning loss. Objective : This systematic review aimed to search the available literature on the impact of the COVID-19 pandemic on nursing education. Methods : Searching the literature was systematically done using the PRISMA flow diagram, and the inclusion and exclusion criteria of the study were followed by the PICO/S framework. The quality assessment was conducted by using the CASP. Results & Discussion : 30 articles included in this systematic review. Three themes emerged in this review. Those are knowledge and perception of the nursing students towards COVID-19, experience and readiness of the nursing students towards E-learning, and the attitude and psychological impact on the nursing students towards COVID-19.


INTRODUCTION
A newly discovered disease, COVID-19, subsequently named SARS-CoV-2 emerged in Wuhan City, Hubei Province, China on 12 th December 2019 (Aida et. al, 2020).Since the first emersion of the disease, it has progressed to become a world pandemic.As reported by the World Health Organization (WHO), cases of COVID-19 have remained at approximately 4 million new cases, while new deaths have continued to increase to over 69 000.This brings the cumulative numbers to over 61.8 million reported cases and 1.4 million deaths globally since the start of the pandemic.
The worsening case happens when the disease affects the students' learning process, especially for critical courses such as medical students, pharmacy students, dentistry students, and nursing students.The face-to-face teaching and learning process is changed to the mode of virtual teaching and learning, which is new to the students.Even though studies have suggested that online learning is effective and that wisely using the internet can improve a person's career, there is a rising number of issues about the students' wellbeing that should be considered (Jamaludin et al., 2017;Jamaludin et al., 2018).
Moreover, some measures taken to combat the virus have disrupted the daily lives of many (Qiu et al., 2020;O'Sullivan et al., 2020).Based on a previous study, a few factors are identified that are related to the challenges faced by the students, such as technical problems, the home environment, and many more (Elsalem et.al., 2020).This COVID-19 pandemic can be described as a significant and life-changing experience, both a direct and an indirect threat to health and may have long-term implications at both local and global levels (Qiu et al., 2020).Nursing students have reported feeling more stressed during such crises, as the remote learning arrangements have compromised their learning (Aslan and Pekince, 2020).
According to Mirna and Ali (2021), students feel moderate anxiety and depression because of the heavy workload of assignments.
Besides, the period of confinement during the pandemic might affect their progress in study.(Li et.al., 2020).Students also have difficulty focusing on online learning compared to face-toface classes (Elsalem et al., 2020).Furthermore, financial and family support during COVID-19 affects the mental well-being of the students (Aslan, 2020).Even with the daily challenges of nursing, nurses make a difference in the lives of the many people they touch (Hasan, Nurumal, Firdaus & Jamaludin, 2021).Hence, it is recommended to have some solutions to solve it by helping the nursing student by addressing the issue that they face and helping them to learn through virtual learning effectively.Thus, this review focused on the common difficulties faced by university students, especially healthcare students, specifically nursing students, during this pandemic crisis.

METHOD
This study aimed to look for the available literature on psychosocial well-being as measured by the differences in levels and the outcome (sense of coherence, confidence level, knowledge and experience of the COVID-19 outbreak), stress, and coping mechanism of nursing students during the crisis.In this study, we used a systematic review approach.The reason for using this method was to maximize the inclusion of studies and to preserve the integrity of the findings of the different types of study findings (Harden, 2010;Jamaludin & Chan, 2019).

Search Strategies and Data sources
The search from databases Google Scholar, PubMed, and ScienceDirect by using the Boolean operators "AND" to find the articles with keywords of "COVID-19 pandemic" AND "nursing education" AND "undergraduates" from the first search on the 12 th November 2020 until the last search on 12 th December 2020.The keywords were searched in the titles and abstracts of the article.
The total articles found are 2799 from the described databases.The search was narrowed down by selecting the full text, peer-review, and published between 2019 and 2020, and it resulted in 100 articles.Seventy articles were excluded due to not being related to nursing education or related to the same field of study, and some of the articles did not have access to the full text.

Selection criteria of the studies
In this study, the inclusion and exclusion criteria were used to specify and narrow down the search and ensure its relevance to the objective.Moreover, this study included all articles related to COVID-19, nursing education, or other healthcare students within the same field.The study also included the participants of undergraduates in nursing or healthcare related to the same area.The articles must be in English, and the search excluded the grey literature, unpublished articles, and articles that cannot be assessed for full text.The article selection was made systematically using the PRISMA framework, as shown in figure 1.A total of 30 articles were included in this review.
Furthermore, the review of clinical questions for this study was defined using the framework PICO for quantitative analyses and PICOS for qualitative studies, as shown in tables 1 and 2 (Miller, 2001;Amir-Behghadami & Janati, 2020).The study measures a sense of coherence, confidence level, knowledge, and experience of the COVID-19 outbreak.The study measures a sense of coherence, confidence level, knowledge, and experience of the COVID-19 outbreak.S (study design) The study used focus groups through semistructured, in-depth, and observation interviews.

Quality appraisal
Quality critical appraisal for the included studies has been carried out with the guideline from the critical appraisal skill program (CASP) tools according to the type of studies of articles selected (Critical Appraisal Skills Program, 2021).The rating score is represented by 1 point (strong), 2 points (moderate), and 3 points (weak).Additionally, the global rating for this paper is strong (no weak ratings), moderate (one weak rating), and weak (two or more weak ratings).Therefore, by assessing quantitative articles included in this review by eight criteria below: a) The selection bias is likely to the individual as representative of the target population.b) The randomized study design.c) Relevant confounders that were controlled.d) Participant blinding or not.e) The validity and reliability of data collection methods.f) Withdrawals and drop-outs.g) Consistency of Intervention integrity.h) The appropriate analysis.
For the qualitative studies, the following nine criteria were used in this review: a) The structured abstract and title.
b) The introduction and aims were clear.c) Clear method and data.d) Appropriate sampling targeted.e) Sufficient data analysis.f) Gained ethical approval and bias.g) Clear results.h) Transferability or generalizability to a wider population.i) Implications to policy and practice.
After accessing the quality of the selected articles, the following information from the articles was extracted, and the result is shown in table 3.

FINDINGS Data Synthesis and overall findings
From the process of analyzing the included studies, three themes were synthesized in this study.Those were knowledge and perceptions of the nursing students towards COVID-19, experience and readiness of the nursing students towards E-learning, and the attitude and psychological impact on the nursing students towards COVID-19.Finally, 30 articles were included in this review.There were two articles on a qualitative study, 25 articles on a quantitative study, and three articles on a mixed-method study.Among the 25 quantitative articles, there are 22 cross-sectional studies, two cohort studies, and one Quasi-experimental study.The following session explains the detailed findings of this study.The prevalence of psychological distress was 52.8%, with around 60% of respondents reporting disruption to their daily lives.Older (p = 0.015) and more senior students (p < 0.001) were less likely to be anxious than their younger and junior counterparts, respectively.A greater number of social support (three or more) was linked to a lower score of depression (p = 0.005) and stress (p = 0.045).
Undergraduates who received family support demonstrated lower depression scores (p = 0.037) and higher mental wellbeing (p = 0.020) compared to those without.Government support was independently associated with a lesser risk of depressive symptoms (Adjusted odds ratio, AOR 0.

Survey questionnaire
The response rate was about 75% (n=309).
The results' analysis revealed no gender differences in any of these domains.However, there were some variable responses among different educational levels.The average preparedness score was 32.8 ± 7.2 (Max 45), the average attitude score was 66.8 ± 16.6 (Max 105), and the average barrier score was 43.6 ± 12.0 (Max 75).There was statistical significance difference in both preparedness score and attitude scores between different professional years (P-value<0.5).However, there was no difference in barrier scores among all professional years.The results indicated that about 61.4% of the students agreed on that college of pharmacy was well-prepared and ready for the online education during the emerging COVID-19 pandemic with complete transition into online education.The results also indicated that 49.2% of the students showed positive attitude toward the provided online learning.The results indicated that about 34% of the students identify some barriers toward the provided online learning.Finally, there were strong association between the need for training on how to receive online courses and preparedness and barriers scores.

Knowledge and perception of the nursing students toward COVID-19
According to Li et al., (2020), in a study from five nursing colleges with 362 students in China, "the SAS anxiety score was (33.64 ± 6.17) higher than the norm of anxiety symptoms in Chinese normal people (29.78 ± 10.07, n = 1158)".They concluded that the awareness knowledge was significantly associated with self-preventive behaviours, while there was no association with the SAS anxiety of the nursing students (Li et al., 2020).Another study also found that "students described the spread of misinformation on social networks and the risky behaviour of the population" (Lovrić et al., 2020).There are 19 participants worried about the well-being of family members, especially the elderly.Five participants reported the spread of diseases through an aeroplane and disinfection cell phones.The author concluded the 23 participants realised their responsibility and importance to the community in the nursing profession (Fawaz et al., 2020).
A study done in Almeria, Spain, found that the participant's feedback supported the simulated video consultation as they enjoy the practice and can adapt well during clinical simulation sessions (Diana et al., 2020).From simulated videos, the students will have chances to learn from their mistakes and apply them in a real situation.Students claimed to be calm when staying at home by feeling safe when conducting the simulated scenario.
To acquire the same goals as face-to-face consultations, the skills in simulated scenarios need to be increased to acquire the same goals as face-to-face consultations.The students felt the technical problems and skills were an obstacle in their study as they could not carry out the physical exams and clinical procedures (Diana et al., 2020).
A study done in Universitas Indonesia found that in year one, students preferred distance learning over other years as the majority of the students chose the synchronized learning sessions (Elsalem et al., 2020).The challenges during distance learning were external factors, for example, unstable internet coverage and financial burden for the internet costs.The advantages of distance classrooms were providing more time for students and flexibility.Meanwhile, the disadvantages were: distraction during online class, the complicated technology, limited interaction with instructors, unable to stay focused during the course, unstable internet coverage, and a financial burden (Kecojevic et al., 2020).Diana et al. (2020) found that nursing students expressed high satisfaction and positive perceptions as they were pleased with the simulated experience to transfer it to clinical practice.The improvement in communication, active learning, and teamwork skills through the simulated video consultation and prevention of anxiety from face-to-face class.A study done in Nepal found that more than half of the students were satisfied with online learning (Sharma et al., 2020).Among the healthcare students, such as medicine, dentistry, pharmacy, and allied medical sciences reported having a lower level of satisfaction as they preferred traditional learning.The satisfaction of the students was affected by the lack of a technology system as they needed to learn the usage of it.

Experience and readiness of the nursing students towards E-learning
According to Lovrić et al., (2020), "negative experiences" with public transportation and residence in the student dorm.The fear of possible infection in the classroom is not significant.However, students fear the clinical settings.Some students reported difficulty concentrating and learning, while all praised teacher support and faculty work in this crisis.For safeguard measures, the participants avoided using public transport.The participants felt unsafe in the dormitory, as they felt afraid during classroom lectures and clinical settings.Some participants faced difficulty in learning as they lacked motivation and disturbed concentration and memory.Self-reflection and critical thinking would affect each other.However, their study sample was a group of nursing students carrying out a nursing practicum just before their graduation among first-year students nursing students in Taiwan (Cheng et al., 2020).
A cross-sectional study among medical students in North Jordan started to join online lectures consisting of a hybrid teaching method, live classes, and recorded classes using the Zoom platform.48.7% and 57% of clinical and basic students express their interaction as bad, while the others had good and excellent interaction (Elsalem et al., 2020).According to the authors, the main obstruction of online lectures was a poor internet connection, and timing from joining the classes, as one-third of the students assumed that attendance was unimportant.The clinical students portrayed the interaction with lecturers were poor because they were unable to access the natural clinical setting compared to the basic students who expressed their satisfaction with their interaction with the lecturers directly during live classes and discussion forums.
The study on the radiology program by Higgins, Murphy & Hogg (2020) found that students claimed the learning experience through the online version to be positive.The advantages of using an online learning platform outnumbered the barriers as the majority of them preferred online presentation to face-to-face presentation.The students show high self-efficacy to experience the potential failure as a motivation for their future attitudes in practice.The students claimed social interaction was decreased with student-student interaction and student-instructor interaction.The barriers to online learning were practice in interacting with the technology and time spent constructing material for online learning.
Despite the classes being interactive and non-disturbing, 162 (77.51%) of respondents rated that the online classes were ineffective (Tuladhar et al., 2020).The majority of the students claimed the level of understanding to be moderate and pointed out the training to be taken by the teachers in online classes.The participants pointed out that they needed to recap the online classes once the physical classes started but to continue with the online learning during the pandemic.Some students cannot attend the classes because the location at outskirts area has internet problems and also been affected by the electricity problem.
According to Shawaqfeh et al et al. (2020), in their study among pharmacy students, half of them revealed that they had experienced online learning before the pandemic.The second-year students showed the lowest readiness and attitude due to increased work assignments in the year of study compared to the fourth-year who showed the highest level.The students proposed the need for training on online courses, but the majority rejected the proposal as they assumed it was unnecessary.Through online learning, the students experience a lack of motivation and boredom during the online classes, and some of them need time to adjust to online learning tools.

The attitude and psychological impact on the nursing students toward COVID-19
A study conducted by Savitsky et al. (2020) among the nursing students in the Ashkelon Academic College, Southern District, Israel, found that moderate and severe anxiety levels were 42.8% and 13.1%.Higher anxiety level was significantly associated with gender, lack of PPE, and fear of infection, and at the same time, the study's continuation will be affected.Elsalem et al. (2020) conducted a crosssectional study among Medical Sciences students in Jordan and reported that students were more stressed with remote E-exams.The stress factors were associated with exam duration, navigation mode, and technical problems in 78%, 76%, and >60%.The author concluded in the study that the E-exam is more stressful than the on-campus exam.
A study from Egypt found that negative attitudes toward e-learning as a high obstacle, especially in the first year (67.6%) and the fourth year (55.7%) of nursing students (Gehan et al., 2020).The most obstacles to e-learning were infrastructure and technology, technical and management support, and instructors' characteristics in 87.1%, 85.2%, and 82.9%.Besides, a study from India found that female students showed a positive attitude towards online classes compared to male students, even more than 76% of the participants (Gaur et al., 2020).
According to Sallam et al. (2020), anxiety levels among students at the University of Jordan, higher anxiety levels among participants who felt the pandemic was very dangerous.Most of the participants portrayed a positive attitude towards quarantine as the minority.They broke the quarantine in need to buy groceries or emergency cases.Higher anxiety levels of female students for being worried and overthinking.As the lower monthly income has higher anxiety level.
Another study discovered that male students had more perceived stress scores (22.73) than female students (21.86).The majority of participants were between 21-25 years.The maximum mean perceived stress score (22.56) was observed in the fourth-year students, and the least mean perceived stress score (20.20) was found in the second-year students.On the whole, the maximum mean coping score (78.45) was found among first-year and the least coping score (71.23) was found among fourth-year BSc Nursing students (Sheroun et al., 2020).The way they cope with the stress of staying with relatives rather than family or dormitory, the students' behavior with frequent hand washing or disinfecting and avoiding crowded places such as events, public transportations, and grouping.
According to Lea et al. (2020) found that the prevalence of psychological distress was 52.8%, with around 60% of respondents reporting disruption to their daily lives.The author concluded the MCO was associated with the incline level of psychological distress among students as it affects the mental well-being of the students.Social support was not associated with stress and anxiety experienced by the students.High anxiety is affected by the clinical posting in the hospital for nursing and medical students.As for the nursing students, the DASS-21 higher mean score as they interact by giving direct care to the patient frequently.As reported, the stress score is higher in Malay students than Chinese students.Lea et al. (2020) conducted a study on confidence scores of fourth-year medical students throughout the United States.The pre-session confidence scores show less than 10% of students feeling confident about self-reported knowledge.The scores were the highest in teaching medical students; 55% of students felt confident and comfortable.Most students prefer the virtual format to the in-person session, but in the clinical setting, the students choose the in-person session.
A study conducted among undergraduate students in New Jersey stated students with a high level of mental distress were affected by their academic and everyday difficulties during COVID-19 (Sheroun et al., 2020).The graduation students showed a high level of anxiety as they worried about the impact of the pandemic compared to first-year students as they might lose employment.Students with a high level of anxiety correlated with a significant amount of time spent searching for COVID-19 information.Searching for information for COVID-19 is an adaptive coping strategy for students with high anxiety.
According to Mirna and Ali (2021), "learning through online platforms has given rise to depression and anxiety disorders among undergraduate university students, where there was a significant correlation between student satisfaction and prevalence of depression, anxiety, and stress."Learning experience affected with technological difficulties proven to have low average and connection of telecommunication infrastructure during class where students faced the loss of data, re-log into sessions and power outage as students unable to join their classes or exam.Symptoms of moderate anxiety and depression among students shown through the dissatisfaction with online learning and stress on students who needed to submit their work on time due to system crash contributed to more stress.Li et al. (2020), in his study in China, mental health was observed before quarantine and after 15-17 days after the start of quarantine.The students' mental health after two weeks showed more severe results of anxiety and depression.Some of the students assumed e-learning reduces the quality of knowledge and is an ineffective way of teaching.A study among undergraduate medicine and nursing students at Makerere University, Uganda, stated that 60% of the participants required extra training to utilize elearning effectively and up to 75% preferred blended method of teaching delivery; moreover majority of the students agreed that e-learning could be used for sharing learning material, lectures, revisions, and discussions (Olum et al., 2020).Most students revealed bad behaviour towards e-learning, while students who received money and owned a laptop showed good behaviours towards e-learning because the internet charge and poor coverage were the major problems.Students who are deficient in technology such as cell phones and laptops face difficulties in e-learning.
According to Puljak et al. (2020) found that the percentage of e-learning revealed by the participants was good at 39.6% while worse with 24.9%, and the other results were neutral.Students were worried about being unable to complete their work and academic year for their final with the current pandemic affecting their graduation time.There was the majority of students preferred to blend e-learning and classic classroom learning, while the remaining students of them preferred only classic classroom learning and only e-learning after the pandemic.
A study from King Saud University (KSU), Riyadh, Saudi Arabia has shown that the frequency of high stress in female medical students than in male students, and the highest was in 3 rd -year medical students.The most effective coping during mild stress by students were "regular exercise, watching an online movie, playing online games, online fun with family and friends, religious activities and learning to the line in current COVID situation and accept it.(Abdulghani et al., 2020).
Another study conducted in China by Wang et al., (2020) found that a higher risk for psychological distress was the active clinical duties.Furthermore, the negative mental impacts from the academic pressure, workload, and financial burden added to the mental weakness of the trainees in addition to high exposure to COVID-19.
Social determinants of health such as seclusion, environmental hazards, and healthseeking behaviours carried over and compounded the effects of the outbreak on the placement communities and clinical sites (Tuladhar et al., 2020).The stressors for most Canadians were deficient, increased prices supply chains, and panic buying.
According Islam et al., (2020) in their study among Bangladeshi university students found that students were to have mild to severe depression and anxiety symptoms.Male students had high depression symptoms compared to female students.No physical exercise and academic lag were current depressive symptoms while living with family reported having high depressive symptoms.The majority of the students found they are getting depressed as the academics lagged behind and the closure of universities even online learning cannot counteract.
A study by Li et al., (2020) in Wuhan stated the students were adjusting to online learning progressively.The sense of self-efficacy of lecturers was high and coherent signifying the positive ability to teach students.The correct teaching methods for the students to learn efficiently throughout the online classes.The student reported the low score for item 15 and item 16 was because of the quizzes.The confidence level of the students was affected as they are unable to concentrate on online learning.The anxiety and depressive symptoms were shown through eating and sleeping habits as a major concern.Social stigma is an obstacle for the students to attending counselling sessions or other support.

DISCUSSION
Based on this review's findings, a few aspects can be taken into consideration as critical indicators to reduce the stress and increase the coping mechanism of nursing students during the pandemic crisis.The following sessions will describe further discussion on the impact of the COVID-19 pandemic on nursing education among nursing students:

Knowledge and perception of the nursing students towards COVID-19
There are six articles related to this theme.The findings regarding the knowledge and perception of the students towards COVID-19 are different in their conclusions.Firstly, the majority perception of the studied participants towards COVID-19 is the concern of the older family members who are the most vulnerable to the disease because of the age factor (Daoust, 2020).Age is the most important factor in diminishing one's chances of surviving COVID-19, especially after 65 years.This finding is supported by the results in the article, "all participants indicate a sense of concern for older members of their family" (Deepika et al., 2020) and "19 participants are suffering from an intense fear of infection, with great concern for older members of their families" (Gehan et al., 2020) Both of the articles agreed that the participants show concern for elderly.
Secondly, the satisfaction of the participants with the simulated consultation video.They show a high level of satisfaction in the study, supported by the results in the article, "high satisfaction with simulated video consultations (97.8%) supported by the students' comments" (Diana et al., 2020) and "high level of satisfaction and the positive perceptions expressed by nursing students about simulated nursing video consultations were also congruent with different studies that employed face-to-face clinical simulation methodologies" (Diana et al., 2020) The positive aspects of the simulated consultation video.
Third, the authors agreed with the technical problems related to internet connectivity during online classes.As supported by the articles, "technical problems during simulated video consultations, and these problems were aggravated by the internet connection overload during the COVID-19 confinement, as both teleworking and online classrooms were widespread" and "the majority of the problems were categorized as external factors such as unstable internet connection and extra financial burden for internet quota" and "two negative categories were identified (ordered by frequency of mention): technical issues and technical skills development" The problem might affect the effectiveness and smoothness of the online class (Diana et al., 2020& Gehan et al., 2020).

The attitude and psychological impact on the nursing students toward COVID
There is a total of four articles under this theme.The first discussion on the findings is the disagreement on online learning based on the participant's experience.The two different opinions and results supported the article, which gives positive feedback and negative feedback on online learning.There are two articles with positive feedback.The first article "total scores of self-reflection and critical thinking had a significantly positive correlation (p < 0.001)" and "the participants' self-reflection and critical thinking improved after taking the ELP" (Cheng et al., 2020).
While the article with negative feedback, "lack of the motivation, feeling board during an online class, and that some of them took them a long time to adapt to online learning tools" (Jamaludin et al., 2018) This is affected by the preparedness of the study toward online learning, according to Jackman et al., (2020) "students were not prepared for a complete online experience while social issues and lecturer issues affect students' intentions to study online."The poor technical problems faced by the students are supported by two articles "bad internet connection and inappropriate timing to be the main obstacle, that prevents them from attending (Elsalem et al., 2020& Tuladhar et al., 2020) The interaction in the online class between the student and student or student and lecturer.According to Elsalem et al. (2020), "Student lecturer interaction revealed that the majority interacted directly during live lectures, while the E-Mail and university E-learning massages were used less frequently.Student-instructor interaction for asynchronous classes was through E-learning massages, University E-mail, or discussion forums on e-learning platforms in an equal manner.These findings showed an interaction between the student and their lecturers.According to Higgins, Murphy & Hogg (2020), "online platforms such as Blackboard Collaborate Ultra and Microsoft Teams also helped to facilitate and encourage discussions, which allowed the students to ask questions and receive support (student-instructor interaction)."

Experience and readiness of the nursing students towards E-learning
There are 20 articles related to this theme.The first discussion on findings of high anxiety levels related to different causes.Some articles agreed on the high anxiety level of fear of getting infected because of insufficient medical supplies during the pandemic (Savitsky et al., 2020) and supported by the other article about medical supplies, according to Sallam et al., (2020), "The shortage of sanitizers, medical supply, the overwhelming and sensational news headlines, and erroneous news reports have also added to anxiety and fear."In contrast, the other findings claimed the high anxiety level because of financial burden, "Participants with a lower monthly income had a higher anxiety level" (Sallam et al., 2020).In addition, the anxiety level affects the clinical undergraduates who need practice in the hospital, but with the current pandemic, their concern is on direct contact with the patient.(Aida et al., 2020).The impact of Covid-19 on their study plan might increase the level of anxiety in participants, "higher levels of anxiety explanation for this could be that students in upper classes may be more concerned about the impact of the pandemic on their postgraduation plans and the economy" (Kecojevic et al., 2020).The E-exam is more stressful than the in-campus exam, as stated in the articles by Elsalem et al., (2020) As the students preferred the in-campus exam rather than the E-exam.
As for the other articles which stated on the issues of psychological impact on students such as the psychological distress on the participants, "the author hypothesized that the MCO is associated with an increased level of psychological distress among our students and is linked to poorer mental wellbeing" (Aida et al., 2020) Poorer mental wellbeing as inadequately received support from the family, friend and others.
The obstacle faced by the participants during the online learning on the technical problem can lead to stress.According to Elsalem et al., (2020), the main factors of stress are exam duration, navigation mode, and technical problems.This statement is supported by the other author.In his study, he stated, "the most obstacle faced by nursing students were infrastructure and technology, technical and management support, and instructors' characteristics" (Gehan et al., 2020) Both authors agreed that technical problems faced by the students can lead to stress.
Moreover, some of the authors reported the coping strategies or mechanisms the participants perform when they were stressed or anxious.According to Bella et al., (2020), "the coping strategies resilience has the lowest anxiety level, mental disengagement is associated with a higher level of anxiety as the coping strategies might affect or worsen the student's conditions.
A recent study also found that nursing students faced psychological roadblocks to online education and developing resilience despite adversities, and online education: what worked and what did not for them during the pandemic crisis (Kunaviktikul et al, 2022).Another study also found that although most students felt that their education was compromised, they have positive levels of psychosocial well-being (Shorey et al, 2022).The nursing students' sense of coherence was positively correlated with their psychosocial well-being and negatively correlated with stress levels.

LIMITATION AND RECOMMENDATION
This review has several limitations.This study only focuses on the result that measures the level of the student's anxiety, knowledge and perception.The study reported the overall findings on the student's well-being without observing the students as a whole.The finding of this study strongly proposed conducting a research study by using qualitative or quantitative methods with a bigger sample size to get the generalization of the result.

CONCLUSION
The global pandemic, COVID-19 growing concern among university students including nursing students.The teaching process throughout the quarantine via virtual mode affects the student's behaviours, well-being and health.Despite everything that happened throughout the pandemic, a limited number of studies had been identified to address the problems faced by the students.For future studies, the study should explore the student's adoption of virtual teaching.the effectiveness of online classes for undergraduate medical and dental students of Gandaki Medical College during COVID 19 pandemic period in Nepal.Orthodontic Journal of Nepal, 10(2), 36-40.https://doi.org/10.3126/ojn.v10i2.31146. Wang, Y., Li, Y., Jiang, J., Feng, Y., Lu, D., Zhang, W., & Song, H. (2020).COVID-19 outbreakrelated psychological distress among healthcare trainees: a cross-sectional study in China.BMJ Open, 10(10), 1-10.https://doi.org/10.1136/bmjopen-2020-041671.

Figure 1 .
Figure 1.Systematic Literature Search Flow

Table 2 . PICOS framework for the qualitative study PICOS element Inclusion Criteria for review
P (population) Nursing and healthcare-related students I (Intervention) The study examines students' psycho-social well-being, stress, and coping mechanisms during the COVID-19 crisis.C (comparison) The study examines students' psychosocial well-being, stress, and coping mechanisms.O (outcome)

Table 3 . ……………………………. (Continued)
Male students had more perceived stress score (22.73) than female students (21.86).Majority of participants were between 21-25 years.The maximum mean perceived stress score (22.56) was observed in 4 th year students, and least mean perceived stress score (20.20) was found in 2 nd year students.On the whole the maximum mean coping score (78.45) was found among 1st years and least coping score (71.23) was found among 4 th year BSc Nursing students

Table 3 .
…………………………….(Continued) Students tend to use and trust the official sources and have changed their behaviors in accordance with public health recommendations (i.e., increased hand washing, wearing mask).However, students reported a number of academic and everyday difficulties and high levels of mental health distress.High levels of depression were associated with difficulties in focusing on academic work and with employment losses, while higher levels of anxiety were more likely to be reported by students other than freshmen and those who spend more than one hour per day looking for information on COVID-19.Inability to focus on academic work and an elevated concern with COVID-19 were more likely to be associated with higher levels of somatization, while trusting news sources was associated with lower levels of somatization.Those with higher levels of perceived stress were more likely to be females, unable to focus on academic work, and report difficulties in obtaining medications and cleaning supplies.