The Relationship between Observance of Midwifery Ethics Codes and Organizational Commitment
Banafshe Riahipour1, Nahid Javadifar2*, Mohammad Hosein Haghighizadeh3
1 Department of Midwifery, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
2 Reproductive Health Promotion Research Centre, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
3Department of Biostatistics and Epidemiology, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran.
Introduction: Midwifery care is associated with providing ethical practice, and one of the factors affecting professional ethics is organizational commitment, which can improve the quality of services provided. The aim of this study was evaluating the relationship between observing the midwifery ethics codes and organizational commitment. Methodology: This was a descriptive-correlational study conducted in 2018. The participants were all 261 midwives working in Ahwaz and maternity hospitals of four cities, selected randomly from the north, south, east and west of the province. The inclusion criterion was having at least one year of employment. The data were collected by three questionnaires including demographic, midwifery professional ethics, and Allen and Meyer's organizational commitment. The data were analyzed with descriptive and inferential statistics. Results: The mean score of observance of ethics codes and organizational commitment were 288.33± 41.33 and 108.82 ± 18.72; respectively. The results of the Pearson correlation test showed a positive and significant relationship between the level of observing the professional ethics codes and organizational commitment and all dimensions (r =0.328 P< 0.001). Conclusion: According to the findings of this study, it was suggested that managers and policymakers provide appropriate conditions for improving and enhancing the quality of cares and midwifery services.
Key Words: Midwifery Ethics Codes, Observance, Organizational Commitment.
Midwifery is one of the fields of medical sciences that is as old as human history, and its task is empowering and providing care for women and their families. Midwives meet one of the basic needs of women, which is protecting and improving maternal, child and community health . Due to the provision of diverse services in the wide range of reproductive health, midwives should use the common principles and values reflecting their professional commitment to the community, and improve the quality and standard of the cares by observing them .
Professional ethics is a set of principles and standards defining the behavior of individuals and groups, and professional ethics codes are a set of accepted actions and reactions determined by professional communities and organizations to provide the most favorable social relationships among the members in performing the professional duties . In the midwifery profession, midwifery ethics codes were developed by the International Confederation of Midwives with the aim of improving the health of women and children, and improving the level of midwifery care in 1996 . Gaining knowledge on the professional codes of ethics and observing them will increase the quality of care and the satisfaction of the clients . As ethical performance is one of the most important factors in providing the high- quality care, it is recommended that health professionals evaluate the level of observing the ethics codes in each profession, and examine the factors affecting it in order to improve the system performance .
Another component affecting the service delivery systems is the level of organizational commitment of the system members. Organizational commitment is a kind of psychological attachment to a particular organization. It is characterized by internal factors such as internalizing the goals and values, organizational roles, and feelings of belonging to the organization in the attitude of individuals . Organizational commitment leads to higher flexibility in employees' behavior in providing services to clients, providing care for patients based on the standards, and less clinical and legal problems . Negligence and lack of research on the level of commitment in any organization can increase the costs of staff turnover, recruiting new staff, reducing the staff performance, and establishment of complicated control mechanisms in an organization .
With regard to the relationship between professional ethics and organizational commitment, contradictory results ranging from positive and significant relationship to negative and significant relationship, as well as lack of relationship have been reported [10, 11]. Although little research was found on the relationship between the observance of ethical codes and organizational commitment, most studies conducted with regard to ethical climate or ethical leadership with organizational commitment have shown a positive relationship between these variables in health-related areas as well as other professions [12-14].
Ethical aspects have been investigated in various areas of medicine in many studies but these studies have been very rare in the midwifery profession . In Iran, midwives are at the forefront of providing health care services to clients at three levels of the hospital, health center, family and community. Among these levels, midwives working in maternity hospitals have had a lower quality of working life than midwives working in health care centers, and have experienced more pressure caused by workload and stress . The objective of this study was to evaluate the relationship between observing the midwifery ethics codes and organizational commitment in midwives working in maternity hospitals in Khuzestan province.
This cross-sectional study was conducted on all midwives working in maternity wards in Ahwaz and in four cities of Andimeshk, Mahshahr, Izeh, and Susangerd selected randomly from north, south, east and west of Khuzestan province. In this study, all 272 midwives working in the maternity ward in all hospitals, including governmental and private hospitals, were included into the study, if they had an academic midwifery degree and at least one year of job experiment in the maternity ward. Data collection tools in this study included a demographic questionnaire, professional ethics codes questionnaire, and organizational commitment questionnaire. The midwifery professional ethics codes questionnaire used in this research was designed and evaluated by Faraj Khoda et al , and it included 70 questions in 14 domains. These domains included observing human dignity of the client, giving right to make decision for client, obtaining informed consent from the client, disclosing information for the client, observing the confidentiality of information about the client, disclosing the client information, observing the privacy of the client, profitability and lack of harmfulness to the client, observing justice to client, professional communication with client, professional communication with a colleague, professional communication with the community, conscientiousness, and observing the professional standards.
In order to measure the level of observing each ethical item, a five-point Likert scale was used, so that score 1 indicated a very low observance, score 2 indicated a low observance, score 3 indicated mode level observance, score 4 four indicated high observance, score 5 indicated very high observance. The minimum score in observing professional ethics codes was 70, and the maximum score was 350. Content validity index (CVI) of this questionnaire was obtained 0.94, and its Cronbach's alpha was obtained 86%, and its Pearson correlation coefficient was obtained 95% . Allen & Meyer's Job Commitment Questionnaire included 24 questions with a 7-point Likert scale, ranging from strongly agree to strongly disagree. The questionnaire consisted of three dimensions of affective commitment, continuance commitment, and normative commitment, and each dimension had 8 items with scores ranging from 8 to 56, and the total score of this tool was between 24 and 168. Scores between 24 and 59 indicated low commitment, scores between 60 and 95 indicated moderate commitment, scores between 96 and 131 indicated high commitment, and scores between 132 and 168 indicated very high commitment. In Iran, the validity and reliability of the questionnaire using Cronbach's alpha coefficient of 93% have been confirmed . After receiving the ethics code from the Deputy of Research and Technology of Ahwaz University of Medical Sciences (IR.AJUMS.REC.1397.204) and providing a list of all medical centers, the researcher referred to all the maternity wards of selected cities. After stating the research objectives, obtaining informed consent, explaining the confidentiality of information, and providing information on the way of answering the questions, the questionnaires were given to the subjects who were willing to participate in the study. The researcher referred to the research environments in all three shifts, and if the subject was not present in the shift, the questionnaire was given to her in the next shift, and was delivered to the researcher in sealed envelopes. Out of eligible midwives, 261 participated in the study.
The data were analyzed by descriptive statistics (mean, standard deviation and variance), inferential statistics (Pearson correlation coefficient) and SPSS 22 software. Less than 0.05 was considered the significance level of the tests.
The mean age of the participants in this study was 33.81 ± 7.29 years, and 61.3% of them were working in university-related hospitals. Based on the research results, the level of observing midwifery ethics codes in midwives working in maternity wards in Khuzestan province was 288.33± 41.33 (minimum score of 70 and a maximum score of 350). The mean, standard deviation, and level of organizational commitment and observance of midwifery ethical codes have been shown in Table (1) and (2). The highest level of observing the ethics codes was related to the dimension of observing justice to the client, and 68.6% of the subjects reported high organizational commitment. The results presented in Table (3), showed that there was a significant and positive correlation between the level of observing the professional ethic codes and organizational commitment and organizational commitment was a predictive factor for observing the ethical codes. In other words, one unit of increase in organizational commitment increased the compliance of midwifery ethical codes by 0.33 (Table 4). Findings also revealed that the observance of ethical codes and organizational commitment were not associated with any of the demographic variables investigated (Table 5).
The results of this research revealed that midwives working in maternity wards in Khuzestan province reported a high level of observing midwifery professional ethics and organizational commitment. There was a direct and significant relationship between the total score of professional ethic codes of midwifery and organizational commitment and all dimensions of it (P <0.001). In this study, the adherence to professional ethic codes showed a positive and significant relationship with all three dimensions of organizational commitment, although this relationship was more significant with regard to the normative commitment (p <0.001 r=0.292). Niazazari et al (2014) conducted a study on the relationship between professional ethics and organizational commitment on 226 medical and administrative hospital staff. The results of this study showed that professional ethics had a positive and significant correlation with organizational commitment and its dimensions (affective, continuance, normative), and can predict the organizational commitment (P <0.001), so that by increasing one score in professional ethics, the mean score of organizational commitment of staff was increased by 0.284% . The results of this study were also in line with those of other studies such as the studies conducted by Salem and Aghil (2012)  in Libya, and Lotfi et al. in Iran (2018) . However, the study conducted by Salehi and Dadgar (2016)  on nurses in Iran and the study conducted by Simonson et al. (2017) on bank staff in the United States  did not show a significant correlation between two variables of professional ethics and organizational commitment and its dimensions. With regard to the level of observing the midwifery ethics codes, Nasiriani, et al. (2018) investigated the level of observing the midwifery professional ethic codes in Tehran health centers using Faraj Khoda Midwifery Ethics Codes Questionnaire. The results of this study showed that only 42.4% of the subjects had a high score of professional ethics codes and 49.6% of them had a moderate score , while in the present study, 78.2% of the subjects obtained a high score. Such results were in line with those of the studies conducted by Momen Nasab et al. (2015)  in Iran and Turkman, and Swasir (2015)  in Turkey. Mirlohi et al (2015) also showed that 31.9% of midwives working in university hospitals in Isfahan observed the pregnant women's bill of rights at very high levels . In this study, the highest level of observance by midwives working in maternity hospitals in Khuzestan province was related to the domain of justice toward the client, and the lowest level was related to the domain of professional standards. However, among the midwives working in health centers in Tehran, the highest level of observance of codes was related to the domain of communication with colleagues, and the lowest level was related to the disclosure of client information . As individuals' perceptions of ethical and non-ethical behavior can vary according to the individual values and the situations faced by individuals , the differences in the above-mentioned areas can be attributed to the differences in the nature and work environment of the midwives in health centers.
Studies have indicated that demographic factors affected ethical performance, especially in specific and difficult conditions . In the present study, the observance of ethical codes was not associated with any of the demographic variables investigated. In the research conducted by Nasiriani, et al. (2018), the only demographic variable related to the ethical codes was the income level , and the research conducted by Masoumi et al reported that educational level, employment history, and marital status were associated with the level of observing the professional ethic codes among midwifery students .
Studies have also shown that organizations that had members with high levels of organizational commitment usually had higher performance and lower absenteeism of employees, and it was especially important in critical jobs . In this study, the majority of midwives had a high organizational commitment (68.6%). The highest score was obtained in the dimension of continuance commitment and the lowest score was obtained in affective commitment. Most studies conducted in Iran reported a moderate level of organizational commitment [16, 28]. However, in line with this study, Lavasani et al. (2008) reported a high level of organizational commitment in nurses in Tehran . The only research that compared the organizational commitment among midwives working in maternity and health centers in Iran showed that the score of organizational commitment in both organizations was moderate, and organizational commitment in midwives working in health centers (76.40 ± 10.06) was higher than that in midwives working in maternity wards (75.61 ± 11.09), although this difference was not significant . A study conducted in the Philippines reported a moderate level of organizational commitment and the highest level of affective commitment among the nurses . Organizational commitment in Saudi Arabia nurses was reported to be 78.46. In this study, affective commitment obtained the highest score, and continuance commitment obtained the lowest score , which was in contrast with the results of this study. However, in line with the present study, organizational commitment in Iranian nurses was reported moderate, and the continuous commitment had the highest level among the dimensions of the organizational commitment . What increased the continuance commitment of staff and their retention in an organization was the lack of a job alternative, and continuous commitment was more due to the inability to leave the organization . Given the employment problems and job security of midwives in Iran , this result seemed to be true for the participants of this study. With regard to the relationship between organizational commitment and demographic variables, the results of this study showed no significant relationship between these variables. The study conducted by Hadizadeh et al. (2014) showed that the only demographic variable associated with organizational commitment in midwives was the fixed morning shift , but in the study conducted in the Philippines, age, education, job rank, and employment history showed a significant relationship with organizational commitment . The difference in the results of the studies conducted in this regard might be due to the differences in the type of measurement tool, and the effect of many factors such as the cultural atmosphere of the study area, the motivations of people to continue working, the type of employment, the demands of the research population, individual characteristics and psychological state of the subjects. Undoubtedly, the mental and psychological atmosphere governing the midwifery job and the ethical importance of paying attention and giving reverence to pregnant women were among the factors that could affect the results of this study.
The most important limitation of the present study was using the questionnaire, the nature of self-reporting, the effect of individual values, and attitudes in responding to it. The strength of the present research was the invitation of all midwives working in maternity hospitals of selected cities (both public and private hospitals), and with different job conditions, increasing the generalizability of the results.
The results of this study suggested a significant relationship between observing the ethical codes and organizational commitment and the appropriate level of these two variables in midwives working in maternity hospitals in Khuzestan province. These factors had a strategic role in the success and the future of organizations, and the weaknesses in them made organizations vulnerable. On the other hand, improving the professional knowledge and the quality of decisions in dealing with the midwifery issues led to a more reasonable and appropriate performance in this profession, leading to the improvement of organization and the quality of care provided for mothers in the long term. In order to develop these criteria and improve the current situation, managers must provide appropriate conditions in this regard and provide knowledge and training for staff on the ethical principles, and develop professional ethics.
Conflict of Interests:
The authors declared no conflict of interest.
This research article was extracted from a master’s thesis (No: U- 97052. IR.AJUMS.REC. 1397.204). Financial support was provided by Ahvaz Jundishapur University of Medical Sciences.
Financial support was provided by Ahvaz Jundishapur University of Medical Sciences (AJUMS).This research article is extracted from a master´s thesis by B. Riahipour(No: U- 97052. IR.AJUMS.REC. 1397.204).