Factors influencing the adjustment of pregnant nurses in continuing to provide nursing care: a qualitative content analysis

Abstract

Background

Nursing is a high-stress profession frequently marked by demanding workplace conditions. Pregnant nurses, in particular, face heightened pressure to balance work and family responsibilities while maintaining their professional obligations throughout pregnancy. Adjusting to the physical, emotional, and occupational challenges of pregnancy is a complex process with important implications for both maternal well-being and fetal development. This study aims to explore the factors that influence how pregnant nurses adjust to continuing to deliver nursing care during this critical period.

Methods

This study utilized the qualitative content analysis method proposed by Graneheim and Lundman. Eighteen participants were selected between May 2023 and August 2024 from healthcare centers affiliated with Semnan University of Medical Sciences, Iran, including fourteen pregnant nurses and four nursing managers (two head nurses and two supervisors). Based on the study’s central research question, data collection tools included in-depth semi-structured interviews, field observations, and field notes. To ensure rich and comprehensive data, the study aimed to achieve maximum variation in age, educational level, work departments, and different stages of pregnancy. Data management was conducted using MAXQDA software, version 2020.

Results

Data analysis yielded three themes, including “Health Concerns,” “Thoughts and Past Experiences,” and “Workplace Tensions in the Nursing Profession,” comprising seven categories and twenty-two subcategories.

Conclusion

Pregnant nurses’ adjustment is influenced not only by pregnancy-related factors such as workplace conditions, fetal health, and the physical and mental well-being of the mother, but also by past personal experiences. Identifying and understanding the factors affecting pregnant nurses’ adjustment and designing a mandatory training for all managers on Iranian pregnancy labor laws enables nursing managers to reduce occupational stressors. These programs could be directed toward creating a system of non-reciprocal behaviors, voluntary shift swaps for pregnant staff, and the reassignment of high-risk nurses with physical and psychological problems. Such initiatives may improve nurses’ adjustment during pregnancy, the quality of patient care, and the health of both mother and fetus.

Background

Pregnancy is a transformative period marked by hope, anticipation, and concern for women and their families [1]. Many women remain in the workforce during pregnancy [2]. Nurses constitute nearly 50% of the healthcare workforce [3]. In the United States, 90.4% of nurses are women, and approximately 49.2% are of reproductive age (18–49 years) [4]. Research indicates that in Tehran, Iran, 23.3% of employed pregnant women experience unintended pregnancies, and 12.5% of those with unintended pregnancies remain employed [5]. Pregnant women face unique challenges in the workplace, and many require sick leave during this period [6–8].

A comprehensive analysis of Iran’s population policies over the past seven decades demonstrates how demographic strategies have been shaped by sociopolitical and cultural contexts, driving shifts in social, political, economic, and demographic structures [9]. Iran has implemented a population policy to mitigate some of the challenges associated with transitioning to an older population characterized by slower growth. The policy goes beyond most policies in setting specific and clear population goals related to increasing fertility rates, reducing divorce rates, and lowering the age of marriage [10].

Pregnant nurses encounter distinct difficulties in balancing their professional responsibilities with the demands of pregnancy. Studies show that these nurses often experience “dual roles” dynamics as they strive to fulfill work obligations while prioritizing their own and their fetus’s health [11]. Over 86% of pregnant nurses prioritize maternal responsibilities over work-related duties [12]. Maintaining a balance between work and family obligations becomes increasingly challenging due to the physical demands of shift work, which may exacerbate fatigue and stress, potentially affecting maternal and fetal health [13, 14].

Their roles often involve tasks performed in environments considered high-risk for pregnant women, such as prolonged standing, heavy lifting, night shifts, long working hours, exposure to radiation, hazardous drugs, infectious diseases, and workplace violence [4, 15]. Factors such as pregnancy order, overtime work, awareness of protective regulations, managerial support, family support, and fetal prioritization—alongside self-management behaviors—have been associated with how pregnant nurses cope during pregnancy [15].

Adjustment refers to the process through which individuals regulate themselves when encountering a new environment or situation in order to manage, learn from, and adapt to changing conditions [16]. In this regard, psychological adjustment during the transition to parenthood appears to be closely related to a mother’s capacity to adjust to the multiple changes of this period and to accomplish the developmental tasks associated with this transition.

Maternal adjustment—including adjustment to body image, physical symptoms, and the marital relationship—as well as maternal attitudes toward fetal gender, pregnancy, and the newborn, constitute essential components of women’s psychological adjustment during the transition to parenthood. Evidence indicates that somatic symptoms are significantly associated with maternal psychological adjustment both before and after childbirth.

Maternal adjustment and maternal attitudes are influenced by a variety of factors, with maternal age at pregnancy representing only one of these determinants. Other factors, such as partner support, socioeconomic status, educational level, and family lifestyle, have also been identified as important predictors of different dimensions of maternal adjustment and attitudes during pregnancy [17].

Adjusting to pregnancy-related challenges is a complex, multidimensional process with significant implications for both maternal health and fetal development. Research suggests that difficulty in adapting to pregnancy can lead to increased perinatal depression through mechanisms such as rumination and impaired maternal-fetal attachment [18]. Pregnancy presents a transformative physical, psychological, and social experience that significantly reshapes a woman’s daily life context. The adjustment process is influenced by various factors, including age, life plans, family and professional circumstances, and individual emotional resilience [1].

Given the growing participation of women in the nursing workforce in Iran and the limited availability of context-specific evidence, managers, occupational health leaders, and policymakers need to understand the occupational hazards and adjustment challenges faced by pregnant nurses [4]. While international studies have addressed pregnancy and work adjustment among nurses, these findings cannot be directly generalized to the Iranian healthcare system, which is shaped by distinct cultural expectations, organizational structures, staffing constraints, and socio-legal conditions affecting maternity protection and workplace accommodations. Notably, qualitative research exploring the lived experiences and adaptive processes of Iranian pregnant nurses as they continue to provide nursing care remains scarce. Considering the complex, multidimensional, and context-bound nature of this phenomenon—requiring in-depth interpretation of meaning, experiences, and behaviors—a qualitative approach using conventional content analysis is particularly appropriate to explore the factors influencing the adjustment process of pregnant nurses within the Iranian healthcare context.

Methods

Study design and approach

This qualitative study utilized conventional content analysis based on the approach of Graneheim and Lundman (2004), which reveals divergent perspectives and unresolved issues related to the data’s meanings, processes, and interpretations [19].

Participants and data collection

Eighteen participants were selected between May 2023 and August 2024 from healthcare centers affiliated with Semnan University of Medical Sciences, Iran, including fourteen pregnant nurses and four nursing managers (two head nurses and two supervisors). Purposeful sampling was employed to maximize variation across work units, gestational weeks, parity, and geographic location. Sampling continued until data saturation was achieved, when the main categories were sufficiently developed, and no new themes emerged.

Inclusion and exclusion criteria

Eligible participants were pregnant nurses willing to participate, preferably experiencing their first pregnancy. Participation was open from the moment the pregnancy was confirmed. All participants were required to be in good physical and mental health. Exclusion criteria included any sudden or severe change in health that impeded communication or voluntary withdrawal from the study.

The average ages of pregnant nurses and nurse managers participating in the study were 30.92 ± 3.66 and 40.25 ± 4.27 years, respectively. The mean gestational age among the pregnant nurses was 25 weeks. On average, interviews lasted 36.77 min, ranging from 20 to 55 min. The mean years of work experience were 7.5 ± 3.93 for pregnant nurses and 15.5 ± 1.73 for nurse managers. The nurses were employed across a variety of clinical settings, including Medical-Surgical, Emergency, Paraclinic, Critical Care, and Pediatric wards. Educational backgrounds also varied, encompassing a Bachelor of Science in Nursing (BScN), a Bachelor of Science in Anesthesia, and a Master of Science in Nursing (MScN). Table 1 summarizes the interview details.

Table 1.

Interview data

Participant	Date	Interview duration (minutes)	Interview location
1	14/05/2023	42	Park
2	08/08/2023	55	Participant’s home
3	21/08/2023	51	Hospital
4	04/10/2023	31	Participant’s home
5	18/10/2023	22	Hospital
6	21/11/2023	40	Nursing faculty
7	24/02/2024	34	Participant’s home
8	28/03/2024	42	Participant’s home
9	18/04/2024	36	Participant’s home
10	12/05/2024	32	Hospital
11	28/05/2024	28	Hospital
12	15/06/2024	37	Participant’s home
13	16/06/2024	32	Hospital
14	30/06/2024	26	Hospital
15	03/08/2024	32	Participant’s home
16	07/08/2024	54	Participant’s home
17	09/08/2024	48	Hospital
18	09/09/2024	20	Hospital

In addition, some characteristics of participants are outlined in Table 2.

Table 2.

Characteristics of the pregnant nurses and managers participants

Characteristics		Frequency
Age groups (Nurses and managers)	21–25	1
	26–30	6
	31–35	7
	36–40	2
	41–45	2
Educational levels (Nurses and managers)	Bachelor of Science in Nursing	13
	Bachelor of Science in Anesthesia	2
	Master of Science in Nursing	3
Pregnancy trimesters (Nurses)	First	2
	Second	4
	Third	8

Data collection tools and procedure

Data were collected through semi-structured, in-depth interviews, direct observations, and field notes, all guided by the study’s central research question. The interviews were conducted by the first author, Mina Shayestefar, a Ph.D. candidate in Nursing. The average interview duration was 36.77 min. The researcher adopted a complete observer role, remaining present in the nurses’ workplace without intervening, and having established rapport before data collection. Data were managed and organized using MAXQDA software, version 2020. Based on participants’ responses and the interview guide, probing questions were asked, such as “What do you mean by that?” or “Can you elaborate?” At the end of each interview, participants were invited to share any additional comments they wished to make.

Data analysis

Data were analyzed following the five-step method of Graneheim and Lundman (2004). Analysis began immediately after the first interview. Transcriptions were verbatim, including non-verbal cues (e.g., tone, pauses, sighs). The first author (M.S., a nursing faculty member with experience in qualitative research) listened to recordings and reviewed transcripts multiple times to fully understand participants’ emotions and experiences.

In the second step, meaning units were identified word by word and sentence by sentence and coded accordingly. Interview transcripts, observational notes, and field notes were analyzed concurrently. In the third step, similar codes were grouped into preliminary categories. The entire research team reviewed and discussed these categories in the fourth step. Ambiguities were resolved through participant feedback and follow-up interviews (e.g., a second interview with the first participant). This ensured clear and accurate category definitions. Data collection continued until saturation was reached, at which point no new categories or insights emerged.

In the final step, extracted concepts were organized into three themes.

Rigor

Following Lincoln and Guba’s (1986) criteria for qualitative rigor—credibility, dependability, confirmability, and transferability [20]—the researcher ensured trustworthiness through multiple strategies. Credibility was enhanced by prolonged engagement with participants, attentive listening, and effective communication (e.g., selecting interview locations based on participants’ preferences), as well as the use of multiple data sources (interviews, observations, and field notes). In addition, member checking was performed by asking several participants to review their transcripts and extracted codes, and their feedback confirmed that the interpretations reflected their intended views. Dependability was addressed through an audit trail and regular reviews of data, codes, and categories by the research supervisor and advisory committee. Confirmability was ensured through peer checking (peer debriefing) in team meetings, where coding and interpretations were critically examined, and by keeping an explicit record of analytical decisions. Finally, transferability was supported through the use of maximum variation in participant selection, which provided a thick description of the research context, and by sharing the findings with nurses outside the sample, who confirmed their relevance to real-world settings.

The first author, a nursing faculty member, conducted all interviews and transcribed the data while serving as a complete observer during field observations, in which no intervention occurred. The researcher, who had prior familiarity with the participant, was present in the nurse’s workplace environment without influencing routine care. The observation lasted 150 min and was carried out in the intensive care unit (ICU). This observation was purposefully designed to enhance data collection and analysis, as emerging concepts related to the difficulty of providing nursing care in a critical care setting during pregnancy required a deeper understanding of the participants’ actual behaviors and interactions in the ICU context. Observational data were documented as detailed field notes and analyzed alongside interview data using qualitative content analysis.

To minimize the potential influence of her professional role on participants’ responses, she clarified her position, ensured that she had no supervisory or evaluative relationship with the participants, and created a safe and confidential environment. Reflexivity was maintained throughout the study through regular peer debriefing and team discussions on data collection and interpretation.

Ethical considerations

The study was approved by the Ethics Committee of Semnan University of Medical Sciences (Ethics Code: IR.SEMUMS.REC.1401.320). The researcher introduced herself to the participants, explained the study’s aims, and obtained written informed consent. Participants were assured that all information would remain confidential and anonymous. Participation was entirely voluntary, and participants could withdraw at any time. They were also informed that multiple interviews might be needed. The study findings were shared with both participants and affiliated hospitals.

Results

The average age of the participants was 35.58, with pregnant nurses averaging 30.92 and nursing managers 40.25 years. The average gestational age was 25 weeks, and the average interview duration was 36.77 min (ranging from 20 to 55 min).

Three themes, categories, and 22 subcategories were extracted after the data analysis. The themes included [1] Health Concerns [2], Thoughts and Past Experiences, and [3] Workplace Tensions in the Nursing Profession (Table 3).

Table 3.

Themes, categories, and subcategories of factors influencing the adjustment of pregnant nurses in providing nursing care

Themes	Categories	Subcategories
Health Concerns	Physical and Psychological Changes	Physical problems during pregnancy
		Psychological challenges during pregnancy
		Pregnancy-related limitations
	Risk to Maternal and Fetal Health	High-risk pregnancy
		Increasing anxiety about fetal harm
		Concerns about personal and fetal health
Thoughts and Past Experiences	Distressing Thoughts	Specific conditions for becoming pregnant
		Fear of recurrent abortion
	Pregnancy Experience	Previous pregnancy experience
		Lack of understanding from colleagues and supervisors without pregnancy experience
Workplace Tensions in the Nursing Profession	Systemic Neglect	Structural problems and staff shortages
		Lack of awareness regarding job conditions and pregnancy-related regulations
		Mistreatment of novice nurses
		Inadequate workplace support
	Situational and Reciprocal Support	Comprehensive support from family and close ones
		Partial support and reciprocal responses from others
	Inherent Demanding Nature of Nursing	Intrinsic difficulties of the nursing profession
		Obligation to be present and fulfill caregiving duties
		The necessity of disclosing the pregnancy
		Stress and anxiety in providing care
		Fear of being judged or misunderstood by others
		Conflict between nursing responsibilities and pregnancy

Theme 1: health concerns

This theme reflects the anxiety and distress that pregnant nurses experience regarding their health and that of their fetuses. It includes two categories:

• 1.1. Physical and psychological changes

Participants reported a range of pregnancy-related physical symptoms such as shortness of breath, weight heaviness, dizziness, fatigue, nausea, musculoskeletal pain, and sensitivity to smells. These changes created limitations in performing nursing tasks—e.g., difficulty bending, walking quickly, or repeated sitting and standing. Psychological symptoms included stress from reduced concentration, irritability, anxiety due to placenta previa, and depression from an unplanned pregnancy.

Regarding the occurrence of physical and psychological changes, a 39-year-old nurse in the 29th week of pregnancy referred to experiencing shortness of breath, and subsequently described the problems it caused as follows:

“Standing for extended periods placed pressure on my legs and abdomen, causing shortness of breath and significant discomfort.” (Participant 2, Scopy Ward)

Nausea and sensitivity to odors are also common physical issues during pregnancy, particularly in the first trimester, and often significantly affect the performance of pregnant women. A 32-year-old nurse in the 35th week of pregnancy described her experience with nausea and olfactory sensitivity triggered by providing nursing care in the intensive care unit, such as suctioning, gavage, and dressing changes, and noted that due to the severity of the nausea, she was unable to continue delivering care. She stated:

“While working in the ICU, tasks such as suctioning, gavage, or wound dressing would make me so nauseated that I often had to step away, unable to continue.” (Participant 3, Surgical Ward)

• 1.2. Risk to maternal and fetal health

Many participants described high-risk pregnancies or feared complications like miscarriage, preeclampsia, preterm labor, or cervical insufficiency, mainly due to physically demanding tasks like prolonged standing or stress from emergencies.

Concerning the risk of preterm labor, which is considered a high-risk condition during pregnancy and childbirth for both the mother and the fetus, a 26-year-old nurse in the 29th week of pregnancy stated:

“Due to my contractions, I was informed of the risk of preterm labor and was advised to take the final week off.” (Participant 4, Medical Ward)

Another nurse described her emotional trauma from a previous miscarriage due to amniotic fluid loss during the height of the COVID-19 pandemic:

“Everything was progressing normally until, within a single week, the amniotic fluid dropped to zero, and I tragically lost the baby.” (Participant 2, Scopy Ward)

Fears were also expressed about physical trauma at work, such as being kicked by pediatric patients or jostled during ambulance transfers. One nurse at 36 weeks stated:

“I was constantly worried that one of the children might kick my abdomen—it was incredibly stressful.” (Participant 6, Pediatric Ward)

A 29-year-old pregnant nurse in the 38th week of pregnancy, who was employed at a hospital near the provincial capital and was required to accompany and transfer a patient by ambulance, expressed concern about potential harm to the fetus due to the excessive movements of the ambulance and its associated risks. She stated:

“After being involved in an ambulance transfer early in my pregnancy, I was so shaken that I asked to be excluded from any future transfers.” (Participant 9, ICU Ward)

Lack of proper nutrition due to the demanding work schedule was also a source of concern:

“There were times when I couldn’t even find a moment to drink a glass of water, let alone eat a proper meal—and it really affected me.” (Participant 7, Pediatric Ward)

Theme 2: thoughts and past experiences

This theme highlights how a pregnant nurse’s mental state, shaped by previous pregnancies, current life circumstances, and personal or professional memories, influences her ability to adapt. It includes two categories:

• 2.1. Distressing thoughts

Participants described mental struggles stemming from the context of the current pregnancy. Themes included unplanned pregnancies, living far from family, advanced maternal age, inherited health concerns, and fears of miscarriage due to prior abortion or perceived work-related causes.

A 29-year-old nurse in the 28th week of pregnancy expressed her feelings of discomfort and loneliness due to being away from her family during pregnancy as follows:

“My husband doesn’t work here, and my family isn’t nearby. I deeply wished my mother could be with me during this time—I felt completely alone.” (Participant 17, Medical Wrad)

From another perspective, a 30-year-old nurse in the 16th week of pregnancy shared her concerns about being pregnant at an advanced maternal age and having a background of hereditary health issues. She stated:

“I realized I was getting older and that pregnancy could become riskier with time. Given our family history of early hysterectomies, I decided it was best to try now.” (Participant 5, ICU Wrad)

• 2.2. Pregnancy experience

Participants and managers alike described how personal experiences of pregnancy—whether positive or negative—shaped their empathy and behavior toward pregnant staff. Those who had experienced complicated pregnancies or had never been pregnant were sometimes perceived as less understanding.

A 42-year-old head nurse, referring to her own pregnancy experience, expressed her understanding of and support for pregnant nurses as follows:

“I understand what they’re going through—I was once pregnant while working in this same ward. I want the staff to leave with better memories of this place than I had.” (Participant 13, ICU Ward)

Additionally, a 39-year-old supervisor described how her personal experience with pregnancy influenced her behavior toward pregnant nurses. She stated:

“I remember working night shifts until I was eight months pregnant, trying to rest on hard stretchers between exhausting shifts. It’s no surprise we’re mentally drained—how could that not affect our babies?” (Participant 18)

These recollections influenced how managers supported (or failed to support) pregnant nurses and shaped the workplace dynamics.

Theme 3: workplace tensions in the nursing profession

Pregnant nurses often face heightened workplace stress due to systemic limitations, inconsistent support, and the demanding nature of nursing itself. This category includes three categories:

• 3.1. Systemic neglect

Participants frequently reported feeling overlooked by the healthcare system. This neglect was associated with structural issues (e.g., staff shortages, outdated equipment), lack of knowledge about pregnancy-related work policies, mistreatment of junior staff, and insufficient institutional support.

One nurse explained how the system complicated sick leave payments:

“I’m a contract nurse, and if we take more than three days of leave, we must get it approved by Social Security. Otherwise, the university won’t pay us. We have to break up our leave just to get paid fully.” (Participant 6, Pediatric Ward)

Another nurse described the impact of staff shortages:

“There was a 16-year-old patient in the Emergency ward. It was 3:30 a.m., no anesthesiologist on call, and I was told to intubate her myself. It was terrifying.” (Participant 9, ICU Ward)

Another issue that contributes to nurses feeling neglected by the healthcare system is the inadequacy of physical infrastructure and equipment to meet the needs of pregnant nurses. In this regard, a 28-year-old nurse in the 36th week of pregnancy stated:

“The hospital elevator is always broken—we have to use the stairs. Imagine being heavily pregnant and climbing three floors every shift.” (Participant 6, Pediatric Ward)

• 3.2. Situational and reciprocal support

Support during pregnancy came from two primary sources: personal networks (e.g., family, spouse) and professional networks (e.g., coworkers, supervisors). However, support at work was often conditional, based on past behavior or perceived reciprocity.

A nurse shared how her family supported her at home:

“Mostly, they helped with meals—lunch and dinner were always ready. When I felt unwell, someone would come over to help.” (Participant 6, Pediatric Ward)

A 29-year-old nurse in the 38th week of pregnancy referred to the support received from colleagues, noting that it was often conditional upon reciprocal compensation. She stated:

“People looked out for me, but nobody was willing to give up their off days or work long shifts for me—unless I agreed to return the favor later. Everything was conditional.” (Participant 9, ICU Ward).

• 3.3. The inherent demanding nature of nursing

Nursing itself was described as physically, emotionally, and ethically demanding. Tasks required constant monitoring of patients, minimal rest, and repeated walking or standing—all of which became more difficult during pregnancy.

Nursing care involves a high level of physical activity, which can be accompanied by stress, fatigue, and discomfort for pregnant nurses. A 29-year-old nurse in the 28th week of pregnancy described the challenges and heavy responsibilities of patient care as follows:

“If I were assigned a critical patient, I had to manage everything—from treatments to documentation. It was exhausting during pregnancy.” (Participant 17, Medical Wrad)

Another reflected on the legal and ethical responsibilities:

“I was responsible for everything—from signing documents to patient care. There was no one else to share the load.” (Participant 2, Scopy Wrad)

Due to limited staffing, many nurses felt compelled to work even when physically unwell. A participant recalled:

“My blood pressure and sugar were dropping, but I still worked two weeks straight. Colleagues were upset, telling me to rest—but I couldn’t.” (Participant 8, Medical Wrad)

Even high-risk pregnancies didn’t always excuse nurses from work:

“One nurse had IVF, and a week later, she was back at work. We couldn’t afford to give her time off just to see if the pregnancy held.” (Participant 14, Supervisor)

Pregnant nurses also feared being perceived as lazy or taking advantage of their condition. This fear often led them to hide discomfort or continue working through severe symptoms:

“Someone told me, ‘Why should you skip night shifts? Are you any different from the others?’ They thought I was trying to get out of work.” (Participant 8, Medical Wrad)

Finally, several nurses questioned the compatibility of pregnancy with the realities of nursing:

“We all want to have children, but the conditions in nursing just aren’t supportive—the workload is overwhelming, the pay doesn’t reflect what we do, and there’s never enough time. The demands just keep piling up.” (Participant 9, ICU Ward)

Discussion

This study identified three themes that influence pregnant nurses’ adjustment to continuing to provide care: health concerns, thoughts and past experiences, and workplace tensions within the nursing profession.

The first theme, health concerns, included both physical and psychological changes as well as threats to maternal and fetal health. These findings align with existing literature. Natalia et al. (2022) and Rahmawati and Wulandari (2019) noted that pregnant women commonly experience physical changes such as breast enlargement, abdominal growth, and weight gain, accompanied by discomforts like nausea and fatigue. Many also report intense emotional shifts—anxiety, fear, and mood swings—especially in the first trimester [21, 22]. Similarly, Hino et al. (2024) observed that pregnant nurses often face the dilemma of fulfilling their duties while prioritizing maternal-fetal health [11]. Alex (2011) noted that nurses are exposed to occupational hazards, including radiation, infectious agents, and teratogenic chemicals, which may prompt requests for work modifications [23]. Despite these physical and psychological challenges, many pregnant nurses remain committed to their caregiving roles while striving to protect their health and that of their fetus.

The second theme, thoughts, and past experiences, is related to the circumstances of conception and prior pregnancy experiences. Chamberlain et al. (2019) emphasized that women often recall previous reproductive experiences during subsequent pregnancies, which may influence current emotional responses [24]. Positive memories about previous pregnancy and positive thoughts can facilitate adjustment, while distressing experiences, such as abortion, may complicate it.

Unwanted pregnancy, loneliness, and advanced maternal age with associated genetic risks were among the distressing factors described by participants. Iwamoto et al. (2010) identified unplanned pregnancy, the perception of “early” pregnancy, and pregnancies following infertility treatments as key contributors to depressive symptoms during late pregnancy and up to four months postpartum. These findings underscore the need to consider a woman’s reproductive context during prenatal care [25]. One possible reason for the rise in unintended pregnancies at the community level may be linked to the country’s macro-level policies. As Nejhaddadgar et al. (2025) stated, the prohibition of family planning services in Iran has led to a shift toward traditional methods of contraception, an increase in unintended pregnancies, and a rise in unsafe abortions. This highlights the need for targeted interventions by health policymakers [26]. For pregnant nurses, these stressors are intensified by the physical and emotional demands of nursing work and limited organizational support, increasing vulnerability to psychological distress. This highlights the need for prenatal care that integrates psychosocial assessment and workplace accommodations. At the policy level, restrictive reproductive health measures may add further strain on working women, emphasizing the importance of aligning national policies with women’s occupational and reproductive realities.

The third theme, workplace tensions in the nursing profession, included systemic neglect, situational and reciprocal support, and the inherent demanding nature of nursing. Structural problems and staffing shortages were key elements of systemic neglect. Danquah and Asiamah (2022) found that the physical work environment has a significant impact on nurses’ presence and well-being, and that workplace health support can moderate this relationship [27]. For pregnant nurses, systemic neglect and staff shortages heighten workload and feelings of vulnerability, while support from colleagues only partly offsets these pressures. This highlights the importance of organizational policies that ensure sufficient staffing and address the unique needs of pregnant employees.

One of the subcategories of the third theme was “lack of awareness of working conditions and pregnancy-related regulations.” At the national level, this factor was linked to the lack of clarity in the “Family Protection and Youthful Population Law” regarding pregnant nurses, which influenced how managers managed, perceived, and interacted with their pregnant staff. Due to the considerable ambiguity of this law for employed pregnant nurses, managerial practices often became discretionary, preventing nurses from benefiting from its specific provisions and leaving them with limited awareness in this regard. Although no direct or explicit regulations were observed in the clinical settings studied, all managers acknowledged the existence of this law and emphasized the need to pay attention to and respect pregnant mothers. As stated in the Silva-Fernández study, one of the main variables of the study is the level of women’s awareness of their rights related to maternal health care, and the higher the awareness of women about their rights, the more positive the realization and experience of maternal rights has been reported. The perception of the realization of maternal rights depends on the socio-cultural context, the health system, the history of midwifery, and support resources [28]. In addition, Sahebi-Rizi et al. (2024) stated that, despite the existence of various policies and guidelines at both micro and macro levels regarding population and related issues, there is no consensus in the implementation of these policies [29]. Overall, the realization of maternity rights—both in the Iranian context and in other countries—appears to depend on the clarity of legal frameworks, women’s awareness of their rights, the socio-cultural context, the health care system, and the availability of supportive resources.

Although Gietel-Basten et al. (2024) about reframing policy responses to population aging in Iran mentioned that the policy measures aimed at women’s economic empowerment, productivity gains through education, and institutional reforms in critical sectors such as the pension system and labor market are more effective than population-centric interventions, including fertility promotion, lowering the legal age of marriage, or restricting family planning services. Accordingly, adopting a multidimensional strategy centered on human capital development and women’s engagement in the labor market provides a more robust and sustainable framework for addressing the challenges posed by population aging in Iran [10]. In contrast, population policies in Iran, including the Youthful Population Law, have primarily focused on fertility promotion. However, insufficient attention to women’s occupational, psychosocial, and adjustment needs—particularly among employed pregnant women—may undermine the long-term effectiveness of these policies.

The inherently demanding nature of the category was characterized by high patient loads, unpredictable shifts, and emotionally taxing responsibilities. Alenezi et al. (2022) emphasized that nursing-related stress is heavily influenced by workload, conflict with coworkers, and lack of managerial support. These factors vary between hospitals and primary care settings but consistently affect performance and care quality [30]. For pregnant nurses, heavy workloads and irregular shifts intensify both physical and emotional strain, thereby increasing risks to their well-being and patient safety. Therefore, supportive staffing and flexible scheduling are essential.

The category situational and reciprocal support highlighted that while supportive environments can empower nurses and enhance job satisfaction, such support is often inconsistent. Sheffield (2018) emphasized the importance of a safe environment, open communication, and strong relationships to empower nurses [31]. Dijkshoorn-Albrecht et al. (2024) also confirmed that colleague support reduces stress and promotes job satisfaction, especially among novice nurses [32]. While support networks are essential, including family, coworkers, and managers, constraints within hospital systems often limit the continuity and scope of support, making it highly conditional.

The final subcategory, nursing’s professional responsibility, captured the conflict between personal health needs and professional obligations. Ooshige et al. (2024) reported that pregnant nurses are challenged by the physical demands of shift work and the risk of pregnancy complications, navigating a dual burden of physical strain and professional duty [14].

Limitations

One of the primary limitations of this study was the challenge in securing participant availability, largely due to the demanding nature of clinical work, the sensitivity surrounding pregnancy, and frequent medical leave among participants. These factors contributed to an extended data collection period. Additionally, the study did not include the perspectives of nurses who had experienced miscarriage—a significant group whose experiences merit further exploration in future research.

Although the first author’s personal and professional experiences may have influenced the interpretation of the data, efforts were made to minimize bias by applying Lincoln and Guba’s trustworthiness criteria. These included prolonged engagement with participants, methodological triangulation, and external audits to enhance credibility and dependability.

Conclusion

The findings of this study indicate that the adjustment of pregnant nurses is influenced not only by pregnancy-related factors, such as working conditions, fetal health, and the physical and psychological state of the expectant mother, but also by their previous experiences. Pregnant nurses face numerous challenges in providing quality care within high-risk, high-stress healthcare environments, all while managing concerns for their well-being and that of their unborn child.

Understanding and identifying the factors affecting the pregnant nurses’ adjustment and designing mandatory training for all managers on Iranian pregnancy labor laws can empower healthcare managers to design support strategies that reduce occupational stressors in clinical settings. These programs could be directed toward creating a system of non-reciprocal behaviors, voluntary shift swaps for pregnant staff, and the reassignment of high-risk nurses with physical and psychological problems, particularly for nurses with a history of miscarriage in the hospital to lower-risk clinical settings. Such interventions may enhance pregnant nurses’ ability to adjust during pregnancy, improve the quality of patient care, and safeguard the health of both the mother and the fetus. Since head nurses maintain the closest relationship with staff nurses, their psychological support can be highly effective in facilitating these nurses’ adjustment process.

Authors’ contributions

All authors (MS, HB, SJ, and MRA) have participated in the conception and design of the study. MS Study conception/design contributed to the data collection, analysis, interpretation of the data, and manuscript drafting. HB Study conception/design, data collection/analysis, manuscript drafting, critical revisions for important intellectual content, supervision, Administrative/technical, and Final revision. HB and MRA critically revised and closely checked the proposal, the analysis and interpretation of the data, and the article’s design. SJ has been involved in critically revising the manuscript. All authors read and approved the final manuscript.

Funding

This study was funded by the Research and Technology Deputy of Semnan University of Medical Sciences, Semnan, Iran (Grant no: 2098).

Data availability

The data supporting this study’s findings are available on request from the corresponding author. However, the data are not publicly available due to privacy or ethical limits.

Declarations

Ethics approval and consent to participate

Under the guidance of the principles of the World Medical Association Declaration of Helsinki, it was first considered to respect participants’ rights and protect their health and rights. The Semnan University of Medical Sciences Ethics Committee, Semnan, Iran, approved this study (IR.SEMUMS.REC.1401.320). Participants were provided information about data confidentiality, voluntary participation, and freedom to withdraw from the study. Then, written informed consent for participation was obtained from all of them.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.