Journal of Qualitative Research in Health Sciences

Document Type : Original Article


1 Department of Nursing, Khalkhal University of Medical Sciences, Khalkhal, Iran

2 Student Research Committee, Khalkhal University of Medical Sciences, Khalkhal, Iran

3 Department of Nursing, School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran

4 Department of Nursing, Bam University of Medical Sciences, Bam, Iran

5 Student Research Committee, Tehran University of Social Welfare and Rehabilitation Sciences, Tehran, Iran



Background: Nurses are an important part of the health system, and the effectiveness of their clinical education has a significant impact on community health. The clinical environment is constantly changing, making student education very stressful. Due to the negative effects of stressors on education, the present study was conducted to explain the stressors in the clinical environment.
Methods: In this qualitative study (content analysis), the participants were selected using the purposive sampling method. In-depth semi-structured interviews were conducted with 16 nursing students who had completed at least one semester of internship in Khalkhal University of Medical Sciences until data saturation was achieved. The data were coded, the related codes were classified into categories, and the main themes were extracted.
Results: Four categories were obtained in this study: personal problems, the interaction between students and patients, patients’ families, instructors, and ward staff, executive planning, and clinical education environment. The most important source of stress was personal problems, including a lack of awareness and fear of following some clinical guidelines. The lower-semester students were reported to have more stress than last-semester students.
Conclusion: Due to the many clinical stressors, the related authorities should be required to promote students’ professional development by identifying the clinical environment stressors and providing appropriate solutions to reduce and control them. In this regard, considering the role of instructors in reducing stress and facilitating student learning, providing educational programs to train instructors in this area can be one of the main steps to reduce student stress.


Kobra Ghorbanzadeh (Google Scholar) (PubMed)

Nastaran Ilka (Google Scholar) (PubMed)

Maryam Khoshbakht Pishkhani (Google Scholar) (PubMed)

Mojtaba Jafari (Google Scholar) (PubMed)

Hajar Sadeghi (Google Scholar) (PubMed)


  1. Jokar F, Haghani F. Nursing clinical education, the challenges facing: a review article. Iran J Med Educ. 2011;10(5):1153-60. [Persian].
  2. Williams LA. Nursing Candidates’ Perceptions of the Greatest Challenges to Becoming a Professional Nurse [dissertation]. Walden University; 2018.
  3. Nouhi E, Seyed Bagher Maddah S, Abbaszadeh A. Collaborative learning experiences of nursing students in the clinical learning setting: a qualitative study. J Qual Res Health Sci. 2021;10(1):300-11. doi: 22062/jqr.2021.91600. [Persian].
  4. Asadizaker M, Abed Saeedi Z, Abedi H. Development of clinical teaching process of the fundamentals of nursing with participatory approach: an action research. J Qual Res Health Sci. 2020;3(2):175-89. [Persian].
  5. Mohammed SFM, Ghaith R, Mohamed AI. Relation between stress and coping strategies as perceived by nursing students during clinical practice. Am J Nurs Res. 2017;5(6):250-9. doi: 12691/ajnr-5-6-8.
  6. Khosravi S, Pazargadi M, Ashktorab T. Nursing students’ viewpoints on challenges of student assessment in clinical settings: a qualitative study. Iran J Med Educ. 2012;11(7):735-49. [Persian].
  7. Moridi G, Valiee S, Khaledi S, Fathi M, Shafiean M, Gharibi F. Clinical education stressors from the perspective of students of nursing, midwifery, and operating room: a study in Kurdistan University of Medical Sciences. Iran J Med Educ. 2012;11(7):675-84. [Persian].
  8. Poorheidari M, Delvarian-Zadeh M, Yahyaee S, Montazeri A. Study of the stressful experiences of midwifery students during clinical education in the labor room. Res Med Educ. 2017;9(4):66-58. doi: 29252/rme.9.4.66. [Persian].
  9. Pourghane P. Nursing students’ experiences of clinical teaching: a qualitative study. J Holist Nurs Midwifery. 2013;23(2):16-26. [Persian].
  10. Rafiee G, Moattari M, Nikbakht Nasrabadi A, Kojuri J, Mousavinasab M. Problems and challenges of nursing students’ clinical evaluation: a qualitative study. Iran J Nurs Midwifery Res. 2014;19(1):41-9.
  11. Arkan B, Ordin Y, Yılmaz D. Undergraduate nursing students’ experience related to their clinical learning environment and factors affecting to their clinical learning process. Nurse Educ Pract. 2018;29:127-32. doi: 1016/j.nepr.2017.12.005.
  12. Suprapto S, Linggi EB, Arda D. Personality characteristics of nursing students with stress perception in clinical practice in the era COVID-19 pandemic. J Posit Psychol Wellbeing. 2022;6(1):534-8.
  13. Heydari M, Shahbazi S, Ali-Sheykhi R, Heydari K. Nursing students’ viewpoints about problems of clinical education. J Health Care. 2011;13(1):18-23. [Persian].
  14. Khan NA, Parveen S. Insights from clinics: stress among nursing students. Manag Econ Res J. 2020;6(2):9900004. doi: 18639/merj.2020.9900004.
  15. Darban F, Bagheri M, Behnam Vashani H, Hajiabadi F. Evaluation of stressors in clinical education from the perspective of nursing students of Mashhad school of nursing and midwifery. Horizons of Medical Education Development. 2020;11(1):64-78. doi: 22038/hmed.2020.50395.1058. [Persian].
  16. Lee MS, Lim HJ. The effects of job stress and emotional labor on perceptive health status of dental hygienist’s. The Journal of Korean Society for School & Community Health Education. 2019;20(3):43-52. doi: 35133/kssche.20191231.04.
  17. Parveen A, Inayat S. Evaluation of factors of stress among nursing students. Journal of Advanced Practices in Nursing. 2017;2(2):136. doi: 4172/2573-0347.1000136.
  18. Das Merces MC, Coelho JMF, Lua I, de Souza e Silva D, Gomes AMT, Erdmann AL, et al. Prevalence and factors associated with burnout syndrome among primary health care nursing professionals: a cross-sectional study. Int J Environ Res Public Health. 2020;17(2):474. doi: 3390/ijerph17020474.
  19. Rabiei M, Safarpour M. Assessment of dental environment stress and related factors in dental students. Res Med Educ. 2017;9(1):57-46. doi: 18869/acadpub.rme.9.1.57. [Persian].
  20. Dyrbye LN, Shanafelt TD, Johnson PO, Johnson LA, Satele D, West CP. A cross-sectional study exploring the relationship between burnout, absenteeism, and job performance among American nurses. BMC Nurs. 2019;18:57. doi: 1186/s12912-019-0382-7.
  21. Zhang Y, Zhao Y, Mao S, Li G, Yuan Y. Investigation of health anxiety and its related factors in nursing students. Neuropsychiatr Dis Treat. 2014;10:1223-34. doi: 2147/ndt.s61568.
  22. Shahrokhi A, Tayebi Miyaneh Z. Comparison of stressful factors in clinical practices of nursing students: causes and solutions. Res Med Educ. 2012;4(1):26-33. [Persian].
  23. Pulido-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(1):15-25. doi: 1111/j.1466-7657.2011.00939.x.
  24. Velando-Soriano A, Ortega-Campos E, Gómez-Urquiza JL, Ramírez-Baena L, De La Fuente EI, Cañadas-De La Fuente GA. Impact of social support in preventing burnout syndrome in nurses: a systematic review. Jpn J Nurs Sci. 2020;17(1):e12269. doi: 1111/jjns.12269.
  25. Raji M, Firozbakht M, Bahrami S, Madmoli Y, Bahrami N. Assessment of clinical stressful factors among academic students of nursing and operating room of Dezful University of Medical Sciences (2015). Community Health. 2016;3(2):111-8. [Persian].
  26. Graneheim UH, Lundman B. Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105-12. doi: 1016/j.nedt.2003.10.001.
  27. Elo S, Kääriäinen M, Kanste O, Pölkki T, Utriainen K, Kyngäs H. Qualitative content analysis: a focus on trustworthiness. Sage Open. 2014;4(1):2158244014522633. doi: 1177/2158244014522633.
  28. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107-15. doi: 1111/j.1365-2648.2007.04569.x.
  29. Seyedamini B, Mahmoudifar Y, Esmaeillou Y. Effective stressors in clinical education. Int Arch Health Sci. 2018;5(3):104-9. doi: 4103/iahs.iahs_40_17.
  30. Labrague LJ, McEnroe-Petitte DM, Gloe D, Thomas L, Papathanasiou IV, Tsaras K. A literature review on stress and coping strategies in nursing students. J Ment Health. 2017;26(5):471-80. doi: 1080/09638237.2016.1244721.
  31. Onovo GN. Fundamentals of nursing practice and the culturally diverse ESL nursing students: the students’ perspectives for teaching and learning in nursing. Teach Learn Nurs. 2019;14(4):238-45. doi: 1016/j.teln.2019.03.003.
  32. Miri S, Bahramnejad A, Rashidinejad M. The effect of life skills education on emotional, think, behavior in situational and different times of Bam nursing school students. J Qual Res Health Sci. 2020;10(20):47-53. [Persian].
  33. Goliroshan S, Hoseinzadeh H, Poorhosein Fookolaee S, Aziznejadroshan P, Khafri S. Investigating the educational needs of nursing students before and after learning. Sleep Hypn. 2019;21(2):101-7. doi: 5350/Sleep.Hypn.2019.21.0177.
  34. Alimohamadi Y, Taghdir M, Sepandi M, Kalhor L, Abedini F. Prevalence of needlestick injuries among health-care workers in Iranian hospitals: an updated systematic review and meta-analysis. Arch Trauma Res. 2020;9(2):47-55. doi: 4103/atr.atr_91_19.
  35. Cornine A. Reducing nursing student anxiety in the clinical setting: an integrative review. Nurs Educ Perspect. 2020;41(4):229-34. doi: 1097/01.nep.0000000000000633.
  36. Aliafsari Mamaghani M, Zamanzadeh V. Nursing clinical education challenges. J Med Educ Dev. 2017;10(25):68-82. [Persian].
  37. Bhurtun HD, Azimirad M, Saaranen T, Turunen H. Stress and coping among nursing students during clinical training: an integrative review. J Nurs Educ. 2019;58(5):266-72. doi: 3928/01484834-20190422-04.
  38. He FX, Turnbull B, Kirshbaum MN, Phillips B, Klainin-Yobas P. Assessing stress, protective factors and psychological well-being among undergraduate nursing students. Nurse Educ Today. 2018;68:4-12. doi: 1016/j.nedt.2018.05.013.
  39. Abu Salah A, Aljerjawy M, Salama A. Gap between theory and practice in the nursing education: the role of clinical setting. JOJ Nurs Health Care. 2018;7(2):555707. doi: 19080/jojnhc.2018.07.555707.
  40. Yekefallah L, Dehghankar L, Shafaee M, Mohamadi S, Moradi M. ICU students’ experiences of an effective clinical instructor: a phenomenological study. J Qual Res Health Sci. 2021;10(2):124-33. doi: 22062/jqr.2021.193588.0. [Persian].
  41. Nakayama N, Ejiri H, Arakawa N, Makino T. Stress and anxiety in nursing students between individual and peer simulations. Nurs Open. 2021;8(2):776-83. doi: 1002/nop2.680.
  42. Abbaszadeh A, Borhani F, Sabzevari S. Nursing teachers’ perception of the challenges of clinical education and solutions: a qualitative study. J Qual Res Health Sci. 2020;2(2):134-45. [Persian].