Indian Journal of Continuing Nursing Education

: 2019  |  Volume : 20  |  Issue : 1  |  Page : 65--68

Factors causing stress in midwifery students

Anne Jarone, Ebenezer E Benjamin 
 College of Nursing, CMC, Vellore, Tamil Nadu, India

Correspondence Address:
Mrs. Anne Jarone
College of Nursing, CMC, Vellore, Tamil Nadu


Stress is an emotional and physical strain caused by our response to pressure from the outside world. It is a specific response by the body to a stimulus that disturbs normal functioning. Students are subjected to different kinds of stressors such as the pressure of academics with an obligation to succeed. Students also face social, emotional, physical and family problems. Stress results from the interaction between stressors. Nursing students are likely to experience more stress than their friends and colleagues enrolled in other programmes. This study was conducted among the midwifery students enrolled in the diploma nursing and BSc nursing courses. A self-administered stress questionnaire prepared by the investigator was used to assess the factor causing stress among midwifery students. The study revealed that majority of midwifery students of both diploma and BSc nursing reported high stress related to clinical experience and interpersonal reasons.

How to cite this article:
Jarone A, Benjamin EE. Factors causing stress in midwifery students.Indian J Cont Nsg Edn 2019;20:65-68

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Jarone A, Benjamin EE. Factors causing stress in midwifery students. Indian J Cont Nsg Edn [serial online] 2019 [cited 2021 May 8 ];20:65-68
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Stress is the emotional and physical strain caused by our response to pressure from the outside world.[1] It is a specific response by the body to a stimulus that disturbs normal functioning. It is impossible to live without some stress, but if stress gets out of control, it may harm health, the relationships and ones' enjoyment of life. Stress results from the interaction between stressors.[1] The amount of stress experienced may be influenced by the individual's ability to effectively cope with stressful events. The higher the level of stress, the higher is the level of physiological symptoms. Students are subjected to different kinds of stressors such as the pressure of academics with an obligation to succeed. Students also face social, emotional, physical and family problems. Nursing students, however, are likely to experience even more stress than their friends and colleagues enrolled in other programmes. Researchers have documented that perceived stress levels are high among nursing students.[2] Nursing students frequently complain of being stressed out and overwhelmed during their time in nursing colleges or school. Nursing students, regardless of the year of study, experience higher levels of stress and higher levels of physiological symptoms than students in other health fields.[3] The research has indicated that stress can cause higher dropout rates in student nurses.[4] The previous studies have identified that the sources of stress to nursing students are academic load, clinical problems or personal problems and test anxiety.[2],[5]

As there are less studies on the factors that cause stress in midwifery students, this research focussed on midwifery students. This study will be beneficial to identify factors for which intervention could be designed to alleviate the negative effects of stress in midwifery students.

The objectives of the study were to:

Determine the level of stress in midwifery studentsIdentify the factors causing stress in midwifery studentsCompare the stress between the BSc and the diploma nursing students.


A descriptive design was adopted for this study. The participants of the study were recruited by convenience sampling. A total of 178 students participated in the study. The investigator developed a stress questionnaire that was appropriate for measuring stress in midwifery students. The instrument consisted of four sections: clinical experience in the maternity wards with ten statements, midwifery theory classes with six statements, interpersonal factors with five statements and intrapersonal factors with three statements. The scoring was done using a 5-point Likert scale to obtain a quantifiable result. Content validity was done by two experts. The content validity score was 90.3%. The reliability of the instrument was checked during a pilot study done with a senior batch of students.

Before conducting the study, approval from the Research Board of the College of Nursing was obtained. The study was explained in detail to the students, and queries were clarified. The stress questionnaire was distributed after the consent forms were signed. The students were requested to fill the questionnaire to the best of their ability recollecting their experience in their clinical area (maternity wards), their maternity classes and their experience in the hostel and home. The BSc nursing students filled the questionnaire on 1 day, and the diploma nursing students filled the questionnaire on the next day.


A total of 178 midwifery students participated in the study. All the ninety diploma nursing students and 88 of 96 BSc nursing students consented to participate in the study. Of the 178 midwifery students, 170 (95.51%) were female students and 8 (4.49%) were male students, 88 students (49.44%) were in the BSc nursing course and 90 (50.56%) students were in the diploma nursing course. The mean age of the 178 students who participated in the study was 21.3 years.

Overall stress

Overall, majority of midwifery students (60.1%) reported high stress and 6% of the students reported no stress [Figure 1].{Figure 1}

Stress related to clinical experience

Stress related to clinical experience was the predominant source of high stress for most students (67.4%) [Figure 2]. As far as clinical requirements were concerned, attending a woman in labor and conducting the delivery was considered highly stressful by 65.33% of students. Majority of the students (65.33%) also found the peer competition in completing procedures to be of highly stressful. The major cause of high stress for most students (75.81%) was the expectations from the staff nurses working in the labor room and the wards. Getting help from clinical instructors and performing a clinical procedure for the first time in front of the clinical instructor was found to be stressful for half the proportion of students (51.11% and 52.02%). The number of clinical requirements and the time limit to complete the requirements was the next highly stressful events for 46.32% and 47.75% of the students, respectively.{Figure 2}

Stress related to theory classes

The midwifery classes did not cause much stress to most of the students except for 30.9% who reported high stress [Figure 2]. With regard to the theory classes, class assignments caused mild stress for 30.34%, and the examination or tests caused high stress for 16.29% of the students. Only 14.02% of the students were highly stressful about failing the examination. The class environment, the language and the teaching methods were not stressful (51.2% and 67.42%) or caused only mild stress (28.65% and 25.28%) for most of the students.

Interpersonal factors and stress

Only 33.1% of the students reported high stress related to interpersonal factors [Figure 2]. Among the intrapersonal factors, extracurricular activities and responsibilities were the common causes of high stress in 27.53% of the students. Mild stress was reported by 21.9% regarding the lack of cooperation among classmates. Interpersonal relationship issues among students caused mild stress in 37.26% of the students.

Intrapersonal factors and stress

Next to the clinical experience, intrapersonal stress was reported as high for majority of the students (62.4%) [Figure 2]. Majority of the students (50.3%) had high stress due to financial problems at home and the others had mild (18.39%) or no economic stress (29.31%). Death of a family member was the cause of high stress for 48.26% of the students, and declining personal health was projected as a cause of high stress by 44.32% of the students.

Stress between BSc and diploma nursing students was compared. Clinical area and theory classes caused significantly more stress in the BSc nursing students than the diploma nursing students. Doing procedure for the first time and patients' attitude towards them and staff expectation from the students caused significantly more stress in the male midwifery students than the female midwifery nursing students among the diploma nursing students.


The curriculum for nursing students in India covers midwifery also as an essential requirement to complete the nursing degree or diploma programme. Midwifery course is planned and provided during the final year of the nursing programme. The students who enter into the midwifery course have already been exposed to patient care in various clinical settings and have completed many academic and clinical requirements related to adult, pediatric and community health nursing courses. They have also gone through multiple theory and practical examinations. However, midwifery course poses unique challenges and causes different types of stress in nursing students. This study was carried out with an aim to identify the sources of stress for final-year students who were doing midwifery as part of the academic requirement.

High stress was reported by majority of the nursing students which replicates what is already evident in the literature.[2] Stress related to clinical experience was also high in most students. The main causes of stress in the midwifery students in the clinical area were conducting delivery and not being able to meet the expectation of the staff in the clinical area. Conducting a delivery is one of the most challenging as well as mandatory procedures in midwifery. Monitoring the well-being of the foetus until safe birth and taking care of the woman and the baby in the post-partum period is a responsibility that can understandably cause stress in young students. As a 4th year student, they realize their true potential to be responsible for a life and this realization often causes pressure and stress for nursing students. Although this stress is high during the initial period of clinical experience in midwifery, experiential reports from clinical faculty suggest that students become fairly confident and less stressed by the time they complete their requirement of twenty deliveries based on the supervision and support they receive from faculty/clinical instructor in the clinical area.

Staff expectation from the students caused high stress in 136 (75.81%) students. As the midwifery students are final-year students, the unit staff expect them to take complete responsibility for the care of women and their newborns assigned to them in the obstetric wards, but the students may find it difficult to take up complete responsibility as they need to complete their clinical requirements along with the patient care. This could have been the cause of high stress in most students. Patient assignments and clinical requirements for students should be balanced, and the unit staff should be explained about the students' level of participation in care.

Help received to complete the requirements and showing procedure for the first time caused high stress in >50% of the students as there were invariably many skills to complete in a limited time period. The clinical and academic requirements in nursing are arranged and organised in a rigorous manner in the clinical settings. Such rigour in itself may cause stress to students as they cannot afford to lose time.[6] Students also perceived the number of clinical requirements, the time available to complete the requirements and the competitions in completing procedures highly stressful. Students in midwifery are expected to complete numerous requirements in addition to conducting twenty deliveries with supervision. Furthermore, they have to compete with not only their own classmates but also their counterparts from medical college to complete their clinical requirements. Such a competitive environment is not seen in other clinical areas. These reasons can be attributed to the stress that the nursing students expressed. These findings are similar to the findings of the study done by Deary et al.[7] Their study showed that clinical sources including unfamiliar situations, making errors with patients and learning to apply clinical procedures were more stressful for nursing students. The study done by Jimenez et al.[8] also revealed that nursing students report perceiving higher levels of stress than other students in conjunction with elevated external stressors, including increased clinical responsibilities and course requirements. Planning clinical posting, considering the number of students posted and providing supervision and support to all students will help in reducing this stress. The use of simulation before the clinical practice can be one method of reducing stress related to conducting delivery and completing clinical requirements. Scenario-based simulation exercises will help the students to assimilate to clinical situations which, in turn, will reduce stress.[2]

Classroom teaching caused mild or no stress for majority of the students. Environment in the midwifery classes, assignment in midwifery classes, midwifery examination/tests, fear of failing in midwifery examination, difficulty to understand the language of midwifery teachers and competition from peer in academics were not stressful or mildly stressful for >50% of midwifery students. Understandably, some students were highly stressed about tests which were also projected by Turner and McCarthy.[2] Midwifery classes are taken by a single faculty who consistently takes charge of the specific group of students for the whole course and also for the whole year of the study. This could have been the cause of less stress related to classes as the teachers are generally available and approachable, and their expectation in the class is less when compared to the clinical requirements. Students are given short tests after every 15–20 h of midwifery class; thus, a small portion is evaluated at a given time which may also be the reason for less class-related stress. This is in contrast with the study done in another college of nursing in South India where 82.5% of nursing students had moderate stress due to academics.[9]

Participating in extracurricular activities was reported by many as a cause of high stress in the intrapersonal level. The stress caused by extracurricular activity was higher in students who took leadership positions in various capacities in the Student Nurses Association as well as in those who were representatives of their class. Generally, as senior students in the final year of college many of these students are expected to take up additional responsibilities in their student associations and student welfare committees. Demand on time, communicating with junior students at different levels and balancing study and the additional responsibilities could have aggravated the stress in intrapersonal domain. Consideration for time for extra responsibilities should be planned by faculty to reduce stress for those who have these responsibilities. Working with others and interpersonal issues were not projected as sources of high stress in this study. Seyedfatemi et al.[10] conducted a study done among undergraduate nursing students, on the contrary, found that interpersonal stressors (e.g., finding new friends) and environmental stressors (e.g., working with unfamiliar people) were the most common causes of stress among nursing students.

Intrapersonal reasons have been reported as a source of high stress by the most students in this study. Students in this study had reported financial problems as a cause of high personal stress. Nursing students from low economic status not receiving monetary help through scholarships may have high stress. This factor has to be considered by faculty and assistance to get financial help need to be arranged when necessary. Death in the family was found to cause high stress in significant number for this group of students. As a number of days of leave from clinical or theory hours are generally restricted in nursing to avoid delay in completing academic and clinical requirements, students may not take much leave in the event of personal loss and may not get adequate time to grieve. Counselling and support sessions have to be arranged for such students who experience loss. Some students reporting declining personal health as a cause of high stress is of concern and need further investigation. It is known that stress itself causes a decline in personal health. However, what they perceive as the decline has to be explored further.

Although the proportion of male students in this study was much smaller, it is worth mentioning that the patients' attitude towards them caused high stress. This may be attributed to the gender preferences for health-care team members by most women. In India, most women find it difficult to accept personal care from male nurses, especially in the labor and delivery rooms and the maternity wards.


Stress is a global phenomenon and affects everyone. The incidence of stress among midwifery students can have serious and negative effects on their health and studies. Knowledge of the stressors and their severity among midwifery students in the nursing colleges can be helpful in effective management and counselling of students on how to cope and adapt to stressors. Policies related to clinical placement and number of students posted in each clinical area have to be clearly established. As senior students, they should be empowered to practice independently with the supervision and guidance of faculty. Faculty in the clinical area should build a good rapport with the students so that students will be able to ventilate their interpersonal and intrapersonal problems and will receive help to cope better with their problems. The faculty, instructor and staff need to give continuous support and positive feedback to enhance stress-reduced learning.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Feldman RS. Understanding Psychology. New York: McGraw-Hill Education; 2014.
2Turner K, McCarthy VL. Stress and anxiety among nursing students: A review of intervention strategies in literature between 2009 and 2015. Nurse Educ Pract 2017;22:21-9.
3Beck DL, Hackett MB, Srivastava R, McKim E, Rockwell B. Perceived level and sources of stress in university professional schools. J Nurs Educ 1997;36:180-6.
4O'Regan P. Student nurses are coming under increasing levels of financial and personal stress in today's environment. World Irish Nurs Midwifery 2005;13:16.
5Pulido-Martos M, Augusto-Landa JM, Lopez-Zafra E. Sources of stress in nursing students: A systematic review of quantitative studies. Int Nurs Rev 2012;59:15-25.
6Tagher CG, Robinson EM. Critical aspects of stress in a high-stakes testing environment: A phenomenographical approach. J Nurs Educ 2016;55:160-3.
7Deary IJ, Watson R, Hogston R. A longitudinal cohort study of burnout and attrition in nursing students. J Adv Nurs 2003;43:71-81.
8Jimenez C, Navia-Osorio PM, Diaz CV. Stress and health in novice and experienced nursing students. J Adv Nurs 2010;66:442-55.
9Joy CL, Anchala M, Hemamalini M. A descriptive study to assess the academic stress among nursing students at SRM college of nursing, Kattankulathur. Int Educ Res J 2016;4:85-7.
10Seyedfatemi N, Tafreshi M, Hagani H. Experienced stressors and coping strategies among Iranian nursing students. BMC Nurs 2007;6:11.