Abstract
BACKGROUND:
Despite the prominent role of midwives in improving the health of women and families, limited studies have been conducted in the occupational and organizational field and their role on the performance of this group. The purpose of this research is to investigate the relationship between organizational health, burnout, and job stress among midwives working in hospitals affiliated to Shahrekord University of Medical Sciences.
MATERIALS AND METHODS:
The present study is a cross-sectional descriptive–analytical study, which was conducted with available sampling method on 159 midwives working in hospitals affiliated to Shahrekord University of Medical Sciences in 2020. Data collection tools were: Demographic Questionnaire, Modified Hoy and Feldman Organizational Health Questionnaire, Job Stress Questionnaire, Maslach Questionnaire to measure job burnout. Finally, the obtained data were analyzed with descriptive and analytical statistical tests (Pearson).
RESULTS:
The findings of the study showed that 70.4% of the participants had moderate to severe job stress and 70.4% of the participants had moderate level of organizational health and 79.9% suffered from job burnout. The results of structural equations showed that organizational health has an inverse and significant relationship with job stress (P < 0.001, β = −0.45) and job burnout (P = 0.002, β = −0.33).
CONCLUSION:
Organizational health has an inverse and significant relationship with job stress and job burnout. The findings of this study can be useful in planning and organizational policies for midwifery professionals. It also conveys the importance of extensive studies and planning to reduce stress and burnout and then improve organizational health. As a result, it can improve the performance and productivity, and as a result, improve the health of midwives and patients under their care and, consequently, the health of the society.
Keywords: Job burnout, job stress, midwife, organizational health
Introduction
Organizations related to health and treatment are considered one of the most important areas of sustainable development due to their importance in the health of people and society. In the new definitions, organizations are defined as living entities with an identity independent of the members of that organization. An identity can affect the performance and behavior of employees. The mentioned personality and identity can have organizational health or on the other spectrum have organizational disease.[1] A healthy organization is an organization that survives in its environment and develops and expands its ability to survive and adapt over time.[2] One of the important aspects of organizational climate is organizational health, which means the organization’s ability to effectively and efficiently perform tasks and continuously strive for growth and improvement.[3] Organizational health includes various parameters such as organizational efficiency, employee morale, employee well-being, resilience, cultural competence, and ability to adapt.[4] In a healthy organization, employees are committed, conscientious, spirited, successful, and have high performance, and they tend to work in the remaining organization and feel proud to be there.[5] A healthy and dynamic organization has a favorable atmosphere, provides motivation and interest in work among employees, and causes them to have more confidence and high morale, thereby increasing the effectiveness of the organization.[6] For managers, trying to ensure the health of the organization, maintaining and improving it is a priority over other activities and duties they are responsible for. But due to low awareness, when managers find themselves in an abnormal management situation, such as underwork, absenteeism, multiple requests for transfer, etc., they try to make the existing situation favorable by pressuring the employees, while the problem is another point called organizational health.[7] Organizations involved in the field of health, by improving and strengthening organizational health, in addition to improving the working conditions for the organization’s employees, can take a big step toward improving the health of patients.[4] Many factors affect the health and illness of the organization. The lack of job stress and consequently the reduction of job burnout are among the factors affecting organizational health.[8,9] Job stress is understood as a person’s reaction to the work environment and indicates a poor fit between the individual’s abilities and the person’s tasks. When employees do not feel supported by their managers and colleagues, or when they feel that they cannot cope with their work pressure, their stress increases.[10] In the healthcare system, midwives as a member of the health team provide a large part of healthcare services. Employees of this profession are one of the jobs that experience the highest stress due to the high responsibility they have for the health of their mothers and children.[9] Occupational stress can be associated with physical symptoms such as fatigue, headache, high blood pressure, pain in the back and shoulders, sleep disorders, appetite changes, digestive problems, and psychological symptoms (such as forgetfulness, concentration problems, anger, fear, depression, and complaining about others) as well.[11] While the midwife’s continuous emotional involvement with the mother and her family plays an essential role in the period of perinatal care, this relationship may lead to emotional exhaustion or even post-traumatic stress disorder. The pressure caused by such issues threatens not only the health of midwives but also their ability to take care of women and their families in the future.[8,9] The results of another study, Ahmadi et al.,[12] while investigating the effect of management style on organizational health and occupational stress, concluded that there is an inverse and significant relationship between organizational health variables and occupational stress. One of the consequences and problems of constant stress in nurses and midwives is the experience of “burnout syndrome,” which has negative effects not only on them, but also on the health of clients and patients.[13,14] Many researches indicate the relationship between occupational stress and organizational health. Lynde and colleagues reported in a research that occupational stress had a significant effect on organizational health.[15,16] Burnout is a well-known psychological syndrome that appears as a long-term response to chronic interpersonal pressures in jobs. Symptoms of burnout include feelings of emotional exhaustion, lack of identity, and decreased personal accomplishment at work. Job burnout is not the result of a sudden event, but the result of gradual processes and occurs as a result of the unbalanced interaction between people’s expectations and their ability to bear the burden.[17] The effective factors in the occurrence of job burnout include individual factors such as sex, age, level of endurance and commitment, level of self-esteem, nature of work, and professional beliefs, and the other group is related to the factors that cause the emergence of burnout syndrome. Situational factors such as time pressure, lack of social support, lack of independence, conflict, work intensity, lack of reciprocity, and hierarchy are observed.[18] The results of the studies indicate that burnout significantly affects the mood of employees, leads to their immobility, and reduces the quality of services.[18,19,20] The results of many researches show the inverse relationship between the two variables of organizational health and job burnout.[21,22] Based on the findings of Ghasemizad et al.’s study, an inverse and significant correlation was found between organizational health and job burnout of nurses. This means that the increase in organizational health will most likely lead to the reduction of job burnout of nurses, and for one unit of increase in organizational health, there is approximately a 60% increase in organizational productivity.[22,23,24,25] Which is in line with the results of Hojjatkhah et al.’s[26] study, which states that morale, respect, structuring, protection of interests, and organizational health have a negative correlation with job burnout. According to the review of existing literature and the lack of existing knowledge regarding the lack of a study on the state of organizational health, job stress, and burnout of midwives working in maternity hospitals and the importance of the impact that organizational health has on the health of any personnel, including midwifery personnel, this study was conducted with the aim of investigating the relationship between organizational health and burnout and job stress among midwives working in maternity hospitals affiliated to Shahrekord University of Medical Sciences.
Materials and Method
Study design and setting
This descriptive–analytical cross-sectional study was conducted on midwives working in hospitals affiliated to Shahrekord University of Medical Sciences in 2020.
Study participants and sampling
The sample size was determined based on the findings of the previous studies “investigating the relationship between job stress and innovative organizational climate with job burnout in hospital personnel”[23] with the help of med calc statistical software with a power of 80% and an error of 5%, 159 cases. The inclusion criteria were: employment in the maternity department of hospitals affiliated to Shahrekord University of Medical Sciences, consent to cooperate in the research and complete the questionnaire, having at least one year of work experience, not having a history of taking medication due to mental and physical illnesses in the past three months, absence of stressful events in the last 3 months (divorce, serious illness in oneself, children and spouse, death of a close relative, severe family dispute, etc.), lack of employment in hospitals that are Corona centers. The exclusion criteria were: incomplete completion of research tools, being on paid leave or sick at the time of distributing the questionnaires.
Data collection tool and technique
The data collection tools were: demographic questionnaire (including personal and midwifery information), organizational health questionnaire modified by Hoy and Feldman, ASIPO Job Stress Questionnaire, Maslach burnout questionnaire.
The modified Hoy and Feldman organizational health questionnaire has 44 items, which are scored on a four-point scale (always = 4, often = 3, sometimes = 2, rarely = 1). In this organizational health questionnaire, questions 3, 4, 5, 6, 7, 12, 30 are scored in reverse. The interpretation of the scores is as follows: 170–220 points: very high organizational health, 132–169 points: high organizational health, 131–88 points: normal organizational health, 44–88 points: low organizational health. The validity and reliability of this tool has been confirmed in various studies. In internal studies (Abedi and Darfesh), Cronbach’s alpha has been calculated from 0.82 to 0.89.[27]
Esipo job stress questionnaire was designed by Esipo in 1987 to assess individual stress. This questionnaire contains 60 questions. The scoring of the ASIPO job stress questionnaire is based on a 5-point Likert scale (never = 1, sometimes = 2, often = 3, usually = 4, most often = 5). The range of scores of this questionnaire is between 60 and 300. Higher scores of the subject in this questionnaire indicate a high level of stress. Also, the level of overall stress is divided into four categories as follows: low stress 50 to 99 points, low to moderate stress 100 to 149 points, moderate to severe stress 150 to 199 points, severe stress 200 to 250 points. The validity and reliability of this tool has been confirmed in the study of Sharifian and colleagues.[28]
The Maslach burnout questionnaire was created by Maslach in 1985. This questionnaire has 22 questions that measures emotional exhaustion, depersonalization, and individual performance. Questions 1, 2, 3, 6, 8, 13, 14, 16, and 20 represent the subscale of emotional exhaustion, questions 5, 10, 11, 15, and 22 represent the subscale of depersonalization, and questions 4, 7, 9, 12, 17, 18, 19, and 21 represent the individual performance subscale. The range of each question’s score changes from (0) to (6), each of the numbers, respectively, representing the options (never, very little, little, sometimes, average, much, and always). In the emotional exhaustion subscale, a score higher than 30 indicates “high emotional exhaustion,” a score between 18 and 29 indicates “moderate emotional exhaustion,” and a score less than 17 indicates “low emotional exhaustion.” In the depersonalization subscale, a score higher than 12 indicates “high depersonalization,” a score between 6 and 11 indicates “moderate depersonalization,” and a score less than 6 indicates “low depersonalization.” In the individual performance subscale, a score higher than 40 represents “high individual performance,” a score between 34 and 39 represents “average individual performance,” and a score less than 33 represents “low individual performance.” In the end, if a person is at a high level in terms of emotional exhaustion or depersonalization and at a low level in terms of individual performance, it means having job burnout. In Malahadi’s study, the Cronbach’s alpha of this tool was reported as 0.79.[29]
In order to conduct the study, the researcher first obtained the necessary permits and the code of ethics from the research vice-chancellor of Ahvaz University of Medical Sciences. After sending a letter by the research vice-chancellor of Ahvaz University of Medical Sciences to the research vice-chancellor of Shahrekord University of Medical Sciences to conduct research in this province, the researcher with an introduction letter went to the research environment which was the hospitals affiliated to Shahrekord University of Medical Sciences. After explaining the study process and the research objectives, the consent and cooperation of the relevant authorities was obtained and the sampling was started. The research population included midwives working in hospitals affiliated to Shahrekord University of Medical Sciences, who were working in the maternity ward according to the inclusion criteria. Available sampling method was used for sampling. Due to the Corona situation, consent forms and questionnaires were provided to the participants virtually and with the knowledge that participation in the research is optional. The participants were assured that the information in the questionnaires would remain confidential. The participants were given one week to complete the questionnaire, and during this interval, a short text message was sent to them as a reminder. Finally, after collecting the data, their analysis was done with SPSS version 22 statistical software as well as STATA version 14 software and descriptive and inferential statistical tests. A significance level of 0.05 was considered. Also, before each test, the normality of the distribution of each of the quantitative variables was checked using the Shapiro–Wilk test, which indicated the normal distribution of the variables.
Ethical consideration
The code of ethics under the number IR.AJUMS.REC.1400.073 was obtained from the Research Deputy of the Ethics Committee of Jundishapur University of Medical Sciences, Ahvaz. Informed consent was obtained from all participants. Research objectives and working methods were explained to the study participants. The participants were assured that their information would remain confidential.
Results
The results of the data analysis showed that the majority of the studied subjects were married (73%) and had a bachelor’s degree (95%). The income level of most of the participants (67.9%) was 6 to 8 million Tomans [Table 1].
Table 1.
Frequency distribution of demographic variables of the research subjects
| Variable | Cumulative percentage | Percentage | Number |
|---|---|---|---|
| Marital status | |||
| Single | 0/27 | 0/27 | 43 |
| Married | 0/100 | 0/73 | 116 |
| Education | |||
| Associate degree | 5/2 | 5/2 | 4 |
| Masters | 5/97 | 0/95 | 151 |
| MSc | 0/100 | 5/2 | 4 |
| Number of children | |||
| 0 | 9/50 | 9/50 | 81 |
| 1 | 9/72 | 0/22 | 35 |
| 2 | 2/96 | 3/23 | 37 |
| 3 | 0/100 | 8/3 | 6 |
| Income | |||
| 6-8 million | 9/67 | 9/67 | 108 |
| 8-10 million | 2/61 | 3/23 | 37 |
| 10-12 million | 0/100 | 8/8 | 14 |
| Organizational position | |||
| Obstetrics department manager | 8/3 | 8/3 | 6 |
| Midwife | 0/100 | 2/96 | 153 |
| Shift type | |||
| Rotating shift | 9/96 | 9/96 | 154 |
| Working day | 0/100 | 1/3 | 5 |
| Type of employment | |||
| Official | 6/12 | 6/12 | 20 |
| Official test | 6/22 | 1/10 | 16 |
| A treaty | 1/42 | 5/19 | 31 |
| Contractual | 2/57 | 1/15 | 24 |
| Corporate | 4/70 | 2/13 | 21 |
| A plan | 0/100 | 6/29 | 47 |
Also, the results showed that the average age of the participants was 31.45 ± 6.37 years and the average service experience was 6.25 ± 5.50 years. The maximum age of the participants was 53 years and the maximum service experience was 28 years [Table 2].
Table 2.
Descriptive characteristics of quantitative demographic variables of the research subjects
| Variable | Domain | Middle | Average |
|---|---|---|---|
| Age | (53-22) | 0/30 | 37/6±45/31 |
| Years of service | (1-28) | 0/5 | 50/5±25/6 |
| Average number of personnel per shift | (2-6) | 0/3 | 70/1±70/3 |
| Average number of patients under care per shift | (9-2) | 0/4 | 50/1±34/4 |
According to Table 3, Pearson’s correlation coefficient test showed that although the relationship of some cases is significant, but according to the reported correlation coefficient, the intensity of the relationship is weak and relatively weak. Overall organizational health and overall job stress have no significant relationship in this test. The highest intensity of the relationship is related to the overall organizational health and role duality dimension (P < 0.001, r = 0.426).
Table 3.
Examining the relationship between different dimensions of organizational health questionnaire with occupational stress and different dimensions
| Variable | Role loading | Role incompetence | Dual role | Role scope | Responsibility | Physical environment | Total job stress score |
|---|---|---|---|---|---|---|---|
| Institutional unity | |||||||
| Correlation coefficient | -0/151 | 0/169 | 0/234 | -0/137 | -0/081 | -0/189 | -0/022 |
| P | 0/057 | 0/034 | 0/003 | 0/085 | 0/310 | 0/017 | 0/783 |
| Manager influence | |||||||
| Correlation coefficient | -0/129 | 0/152 | 0/183 | 0/033 | 0/036 | -0/149 | 0/038 |
| P | 0/106 | 0/056 | 0/021 | 0/677 | 0/657 | 0/061 | 0/635 |
| Considerateness | |||||||
| Correlation coefficient | -0/344 | 0/152 | 0/255 | 0/025 | -0/059 | -0/053 | 0/002 |
| P | < 0/001 | 0/056 | 0/001 | 0/753 | 0/462 | 0/504 | 0/979 |
| Duty oriented | |||||||
| Correlation coefficient | -0/096 | 0/219 | 0/326 | 0/062 | -0/010 | -0/072 | 0/124 |
| P | 0/227 | 0/005 | < 0/001 | 0/439 | 0/904 | 0/365 | 0/121 |
| Resource support | |||||||
| Correlation coefficient | -0/161 | 0/258 | 0/298 | 0/097 | -0/030 | -0/065 | 0/114 |
| P | 0/043 | 0/001 | < 0/001 | 0/222 | 0/707 | 0/417 | 0/153 |
| Spirit | |||||||
| Correlation coefficient | -0/221 | 0/367 | 0/339 | 0/056 | -0/048 | -0/295 | 0/067 |
| P | 0/005 | < 0/001 | < 0/001 | 0/484 | 0/552 | < 0/001 | 0/403 |
| Scientific emphasis | |||||||
| Correlation coefficient | -0/178 | 0/300 | 0/308 | 0/154 | 0/116 | -0/096 | 0/162 |
| P | 0/025 | < 0/001 | < 0/001 | 0/053 | 0/144 | 0/228 | 0/041 |
| Scientific emphasis | |||||||
| Correlation coefficient | -0/283 | 0/364 | 0/426 | 0/062 | -0/018 | -0/212 | 0/105 |
| P | <0/001 | <0/001 | <0/001 | 0/434 | 0/825 | 0/007 | 0/188 |
According to Table 4, the results of the Pearson correlation coefficient test showed that although the relationship of some cases is significant, but according to the reported correlation coefficient, the intensity of the relationship is weak and relatively weak. Overall organizational health and its dimensions have an inverse relationship with the two dimensions of emotional exhaustion and depersonalization in significant cases and a direct relationship with the individual performance dimension. The highest intensity of the relationship is related to the overall organizational health and the dimension of emotional exhaustion (P < 0.001, r = 0.470).
Table 4.
Examining the relationship between different dimensions of the organizational health questionnaire and the burnout dimensions of the research subjects
| Variable | Individual performance | Disfigurement | Emotional exhaustion |
|---|---|---|---|
| Institutional unity | |||
| Correlation coefficient | 0/114 | -0/227 | -0/262 |
| P | 0/153 | 0/004 | 0/001 |
| Manager influence | |||
| Correlation coefficient | 0/054 | -0/203 | -0/212 |
| P | 0/497 | 0/010 | 0/007 |
| Considerateness | |||
| Correlation coefficient | 0/155 | -0/233 | -0/397 |
| P | 0/050 | 0/003 | < 0/001 |
| Duty oriented | |||
| Correlation coefficient | 0/209 | -0/173 | -0/264 |
| P | 0/008 | 0/030 | 0/001 |
| Resource support | |||
| Correlation coefficient | 0/120 | -0/087 | -0/261 |
| P | 0/132 | 0/273 | 0/001 |
| Spirit | |||
| Correlation coefficient | 0/123 | -0/237 | -0/399 |
| P | 0/121 | 0/003 | < 0/001 |
| Scientific emphasis | |||
| Correlation coefficient | 0/044 | -0/137 | -0/327 |
| P | 0/581 | 0/086 | < 0/001 |
| Scientific emphasis | |||
| Correlation coefficient | 0/173 | -0/281 | -0/470 |
| P | 0/029 | <0/001 | <0/001 |
Discussion
The results showed that organizational health had a significant relationship with different dimensions of job burnout (P < 0.05). In this regard, Sabancı et al.’s[30] research showed that organizational health has a significant relationship with job burnout in different dimensions. In another study on nurses, organizational health had a significant relationship with job burnout.[22] In this regard, in the study of Shalani et al.,[31] innovative organizational climate showed a significant negative correlation with job burnout, which is similar to the results obtained from several other studies.[23,32] It seems that health in the organization where a person works causes people to work with a sense of belonging to the organization and to feel a respectful relationship between them. Employees in these organizations can easily comment on problems and feel less burnout due to high self-efficacy.[33,34] In line with the results obtained in this research, Jin et al.[35] also showed that organizational justice has a significant relationship with job burnout. In a study, the results showed that insufficient manpower and the lack of leadership and support for nurses cause an increase in emotional fatigue and depersonalization in the participants. They also reported that organizational factors including sufficient human resources, ability to manage and lead and support employees play an important role in predicting job burnout.[36] The relationship between job burnout and organizational health can be explained using social exchange theory. People who feel that organizational benefits facilitate their work process and work in a supportive environment where they may achieve their personal goals, reciprocally perform the tasks they are responsible for in the organization in a way that facilitates organizational affairs and achieves organizational goals.[37] Lower levels of job resources and higher levels of job demands predict higher burnout.[38] Also, the results showed that some dimensions of stress (role workload, role incompetence, role duality, and physical environment) have a significant relationship with the total score of organizational health. Several studies have clearly identified job-related factors that cause stress, including organizational health in various dimensions. In line with the results obtained from the present study, in the study of Lan et al.,[39] there was also an inverse relationship between organizational climate and job stress, which is similar to the results reported by Shalani et al.’s study[31] and several other studies.[40,41] In this regard, similar results were reported in another study conducted on nurses working in hospitals in Chinese Taipei.[39] In a study on midwives, organizational behavior had a significant and inverse relationship with job stress,[42] which was in line with another study that studied midwives.[43] Human power is the most important asset of the organization. A stressful job due to workload, high-risk work, communication problems with colleagues, and inability to manage family life causes social problems and dissatisfaction among employees.[44] However, in some studies, they did not mention the results of the existence of a relationship between the mentioned variables. In this regard, in a study conducted by Nasurdin et al.[45] in Malaysia, there was no significant relationship between organizational climate and job stress. In explaining the observed difference between the results of this study and the current research, it is possible to mention the population and occupation of the people studied, who were examined in the mentioned study as store salesmen. The organization related to health and treatment and its activities can be associated with special features and stresses in which organizational factors, including organizational health, play a prominent role. Finally, it seems that health in the organization can be associated with an increase in self-efficacy in employees and an improvement in the level of job satisfaction in individuals.[46] High stress leads to negative work environments that destroy employee morale and enthusiasm for their jobs. Low job satisfaction in people is empirically associated with chronic absenteeism, decreased morale, decreased job performance, and job burnout.[47] A supportive work environment may help improve stress and thus reduce burnout.[48] Theoretical and experimental studies show that the key driver of attracting and retaining the workforce is job satisfaction and quality of care, health and favorable atmosphere in the organization. Since midwives are working in stressful work conditions that can lead them to burnout, health in the organization followed by reducing stress and burnout leads to improved birth outcomes and women’s satisfaction with their birth experience through psychological and physiological mechanisms.[49,50,51]
Limitations and recommendation
The impact of job stress and burnout and its relationship with organizational health is usually the result of a long process; however, this study implemented a cross-sectional design. For this purpose, it is recommended to carry out further studies on midwives at multiple times so that the results can be more generalizable.
Conclusion
Organizational health has an inverse and significant relationship with job stress and job burnout. The findings of this study can be useful in planning and organizational policies for midwifery professionals. It also conveys the importance of extensive studies and planning to reduce stress and burnout and then improve organizational health. In addition, it can improve performance and productivity, and as a result, improve the health of midwives and clients under their care, and consequently the health of society.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Ahvaz Jundishapur University of Medical Sciences.
Conflicts of interest
There are no conflicts of interest.
Acknowledgments
The present study is the results of the master’s thesis in midwifery approved by Jundishapur University of Medical Sciences, Ahvaz, with code IR.AJUMS.REC.1400.073. For this purpose, we express our appreciation and thanks to the research vice-chancellor of Ahvaz Jundishapur University of Medical Sciences and the participants in the research.
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