Table 4 Reported stress management recommendations for nursing students, nursing faculty and educators, and nursing institutions in Middle East and North Africa (MENA) countries

▪ Establish a student support system through which the students can be equipped with effective coping strategies [64, 65, 115, 116]. This includes the following:

 ◦ A structured mentorship program to effectively reduce psychological stress and enhance nursing students' sense of self-confidence and psychological sense of belonging [63, 67, 86, 117, 118] and to adequately manage and regulate the academic and clinical practice stressor [69].

 ◦ Trainings on self-efficacy [69], stress management, time management, counseling, and coping skills enhancement [63, 64, 67, 69, 118,119,120].

 ◦ A structured orientation by nursing school administrators [69, 86, 100].

 ◦ Stress interventions which are theory-driven such as relaxation and cognitive appraisal techniques [67, 69].

 ◦ The use of multifaceted strategies such as peer and staff mentorship, provision of social support and professional networks, creating a caring learning environment, positive faculty role modeling utilizing positive coping, and proactive learning [67, 121].

 ◦ Follow-through to nurses in the profession to incorporate methods to cope with stress and develop effective coping strategies. Hospital administrators and other stakeholders may benefit with the continued process from nursing education to entry and beyond for the nurse [69].

▪ Emphasize regular training sessions and workshops for nurse educators aiming to enhance their communication, social, and interpersonal skills to assist in dealing with students [69] and enable them to work effectively with students [65, 97, 122, 123].

▪ Linking specific coping strategies to nursing school stressors is helpful to better prepare nursing students, while managing stress effectively [63, 112, 124]. This will allow teachers to support their students more effectively, which in turn may result in improving clinical nursing education [65, 124].

▪ Hospital administrators should promote policies that facilitate a training environment in which students are supported and inspired while they engage in clinical practice [125] and develop continuous professional education programs for their staff so they can learn how to appropriately deal with students [64, 126].

▪ Utilization of positive coping mechanisms reduces stress levels in nursing students and can impact the effects of stress on their physiological and psychological well-being [67].

▪ Nursing students should be aware of the significance of using problem-solving approaches, as well as understand that combination of problem-solving techniques can alleviate stress levels [67].

▪ Establishment of a social support unit/centre such as family, friends, and relatives would be an asset to counter the adverse effects of stress [69, 127, 128].

▪ Mentor students to develop and strengthen problem-based, rather than emotion-based behavior to cope with stress [65].

▪ Provide a supportive clinical learning environment and strengthen positive-coping mechanisms in students, to better deal with stressors and maximize clinical learning [63, 69, 119, 129,130,131].

▪ Formulate custom-tailored coping strategies and interventions by identifying coping factors/predictors to lessen, reduce and prevent stress in order to facilitate maximum learning both in the theoretical and clinical setting [63].

▪ Pay more attention to nursing students with high stress levels and offer adequate support as this is critical for their successful completion of the courses [67].

▪ Address students’ need to handle stressors effectively. Give more attention to clinical training, minimize the required paper work, prepare all professionals involved in training nursing students adequately, and offer simulation practice to enable the students to provide patient care prior to entering the actual clinical context [97].

▪ Encourage students to discuss their feelings and stressors in order to provide appropriate interventions [64, 132].

▪ Include video films about clinical settings, invite expert guest speakers and host frequent field visits (during orientation period) to decrease initial clinical stress [64, 132].

▪ Plan strategies to prevent stress recurrence among nursing students during clinical training while keeping them driven to achieve maximum knowledge [63].