The results showed that more than half of the students reported their perceived stress at a severe level. The most common dimensions of educational stressors were “unpleasant emotions” and “humiliating experiences”. The highest stressors were included “feeling suffering due to seeing for patients with critical situation”, “instructor’s admonition in the presence of clinical staff” and “communication with instructor”. The “interest in the field of study” had a negative impact on perception of stressors in dimensions of “clinical practices” and “interpersonal communication”.
In considerable research the educational stress of nursing and midwifery students were reported at a moderate or severe level [14,18,21,30,31,32]. The study of Geraghty, Speelman & Bayes  showed that with the increase in the number and severity of stressors, adverse effects on midwives are increased, and their job commitment and job engagement diminish. Severe stress of the students may be due to more stressors in clinical education environment or because of the mental conditions of the students studied. The difference in the stress of students and their stressors in learning environment can vary according to the field of study, nationality and region .
Clinical training is the main part of midwifery curriculum . Since the clinical environment is one of the most stressful training environments , students experience a wide range of problems during the clinical learning . Fear of doing harm, fear of facing the first labor and fear of punishment are the factors enhancing the stress of midwifery students . These stresses have potentially a negative effect on students’ learning [11,12], cause poor clinical performance, and lead to physical and psychological problems [6,8]. Although midwives say midwifery is inherently stressful, mostly contextual and other environmental factors cause stress in midwifery .
Since health of midwives and midwifery students directly affects the quality of maternal care, these stresses must be adequately moderated by instructors’ support . The focus of instructors on the psychological complexities of midwifery role can be effective in adjusting and normalizing the inevitable tensions and inherent problems of this profession . It seems the best way forward would be education for clinical instructors in how better to support the clinical learning of future midwives.
In present study, there were no significant relationships between the perceived stress with individual and educational characteristics of the students. In some previous studies, perceived stress was not significantly associated with age , gender , and academic semester [21,31]. However, Smith & Yang showed that students in their final year reported the highest stress . Discrepancies in these findings can be due to differences in the field of study of the participants, clinical environment and characteristics of the subjects under study. However, stress is a recognized problem in the lives of nursing and midwifery students , which occurs mainly due to the stressful nature of educational environment in these professions. To provide a desirable environment for midwifery students, school managers and instructors should be aware of the facilitators and barriers to improving the clinical training environment . Counseling about managing stress, colleagues’ support, the families’ support and providing a supportive clinical environment may be useful in preventing stress and its negative consequences . Recognizing and enhancing coping skills in undergraduate nursing and midwifery students can help them to adapt to different stressors during their clinical training [17,30]. It is suggested that, before the outset of the clinical training course, students should be informed of the potential stresses during their course, and they would be supported properly by their instructors and other clinical staff.
The results showed there was no significant relationship between perceived stress and instructors’ characteristics. Although some previous studies reported that other characteristics of instructors have affected on the stress levels of students. In the study by Najafi Dolatabad et al., factors related to instructors showed a stronger relationship with stress compared to the individual characteristics of students . In another study the instructor’s supervision style and the number of students were effective on perceived stress . It seems that in the stressful environment of clinical training which the majority of the students have experienced a high level of stress, educational work experience and clinical work experience of the instructors had no modified the students’ stress level. Of course, this requires further research with larger sample. However mutual interaction and understanding and shared goals are essential for the positive experience of students in an optimal training environment . School managers need to assess and enhance the communication skills of midwifery instructors to reduce students’ stress .
The students reported the most stressors in the “unpleasant feelings” and “humiliating experiences” domains. In this regard factors such as “feeling suffering due to seeing patients with critical situation”, “instructor’s admonition in the presence of staff and doctors” and “communication with instructor” were reported as the highest stressors. Similarly, Poorheidari et al. reported that the highest domain of stressors was related to the “unpleasant feelings” domain, and “instructor’s admonition in the presence of the patient” and “lack of the instructor’s support” were the highest stressors . Rafati et al. indicated that one of the main areas inducing stress was ineffective communication between the instructor and midwifery students . Thunes et al. also reported that the most important factor affecting students’ well-being and learning is their relationships with their instructor . Anyway we have to say that academic, interpersonal and environmental stressors are direct stressors among midwifery students  which among them, interpersonal stressors make more students’ stress than other factors.
Midwifery students experience problems during their academic and clinical courses, which leading to uncertainty, dissatisfaction, and lack of adaptation to their profession . Most problems are related to a wide range of potential sources of clinical training environment and events that can lead to stress. While midwifery students usually have a good knowledge, they lack sufficient clinical skills, and they are unsuccessful in applying their theoretical knowledge in a stressful environment. This problem can be resolved with a lot of support and using a simulated environment [39,40]. Mutual interaction, common understanding, and shared objectives are essential to students’ experiences in a learning environment . Considering the nature of midwifery, there is a need for more focusing on orientation of students and instructors about clinical stressors .
It can be said although midwives say midwifery is inherently stressful, contextual and other environmental factors cause stress in midwives . The students’ relationship with instructors and different aspects of the learning environment can be the most stress-inducing . Iranian midwifery students have a little chance of acquiring independent experiences in clinical training. This leads to unpleasant fears and experiences, and stress . The clinical learning is vital factor for the development of competence and confidence of the students, and support through instructors and clinical staff is essential for positive learning experiences .
When students are been publicly criticized by their clinical instructor, this situation causes fear and increased their stress. This issue sometimes occurs for the Iranian students, and the clinical instructors do not pay enough attention to this issue [8,13]. An effective clinical instructor should be able to create an appropriate communication and a calm emotional climate to produce a favorable environment for learning [5,27]. Education process should not making distress for the learner, especially humiliating and disrespecting a student . Experienced instructors are aware of how to communicate effectively with students and they do the punishment and advisement in the right time and right place. If the clinical instructor notifies to the students these matters publicly, it can damage students’ self-confidence and personality [4,27]. The gap between theory and practice, and the midwives’ negative view to clinical educators, may also be one of the causes of ineffective clinical education. This issue can also make educational stress for students. Lukasse et al. believe that many midwives have a negative view to midwifery instructors who have not been in clinical practice for many years or who are not up-to-date in clinical practice. Old and outdated teaching methods lead to a gap between theory and practice .
Making a stressful relationship between the instructors and the Iranian students may be due to large number of students in clinical setting, or the use of inexperienced instructors who are not familiar with communication skills [4,6]. It seems that the clinical environment do not provide enough support for the students studied. Although education in midwifery is associated with the experience of invasive, risky and stressful clinical work, it seems that the unpleasant feelings and humiliating experiences due to student-instructor communication seem to have caused more stress in Iranian students. This can also highlights the need to preparation and support given to clinical instructors in similar cultures in other countries.
In present study, the students who were interested in midwifery perceived the lower level of stressors in “clinical practices” and “interpersonal communication”. Mansouri et al.  and Alizadeh and Sigarchian  showed that the students’ interest in their field impacts on their academic success. Midwifery students face a high level of stress in their clinical training that can affect their mental health and academic achievement . Therefore, practices which promote students’ interest could lead to improved academic outcomes . Awareness of these issues and the factors influencing students’ choice are important for curriculum planners as well as nursing and midwifery educators .
Today midwifery students also begin their midwifery programs with differing expectations and beliefs about maternity care which may be leads to increasing of their interest in the field of study at the beginning of their course. Since in most cases, enrolment in the bachelor of midwifery program is the student’s first exposure to university and hospital systems, the students have no enough knowledge about the realities and difficulties of midwifery profession. This situation causes increasing to new concerns, including difficulties with transition and poor student support . These difficulties may leads to declines in students’ interest in the field of study and increasing their stress level during their course.
It seems that students who are interested in their field of study are more focused on learning clinical activities, and they may expect to earn more academic achievement and so experienced less stress. In addition, it seems that the higher interest in their study field in these students lead to improved their mental health and may therefore have experienced less stress in interpersonal communication. Enrolling students who are more interested in their field of study may contribute in experiencing of less stress during the clinical learning.