Document Type : Original Research Article
1 MSc in Midwifery, Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
2 Lecturer, Department of Midwifery, School of Nursing and Midwifery, Mashhad University of Medical Sciences, Mashhad, Iran
3 Professor in Biostatistics, Department of Social Medicine, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
Today, all organizations have realized that employees' physical and mental health should be considered alongside the organizational productivity in order to achieve success (1). Manpower is the most important resource in any organization, and plays a pivotal role in meeting organizational objectives; in fact, organizations, without considering their employees’ tendencies, will not accomplish their goals (2). If the employees have motivation, satisfaction, and high spirit, they direct their talents and skills toward organizational purposes.
Job satisfaction is defined as the fulfillment of major occupational needs in the workplace and feeling of effectiveness (3, 4). In general, job satisfaction represents the positive or negative attitude of an individual toward his/her occupation (1). Job satisfaction affects important aspects of life such as life satisfaction, organizational commitment, job performance, occupational stress, and quality of service (5).
Employees play a key role in the continuous quality improvement of an organization. Most importantly, job satisfaction has an impact on work efficiency and quality and employee retention (1). In fact, job satisfaction, as an important factor contributing to employment success, leads to higher performance level and self-satisfaction. It is thought that satisfied employees have more effective and efficient performance, which is the basis of promotion, employment design, and management (6, 7). Yperen (2003) stated that positive attitude improves and balances people’s behaviors, and leads to better job performance. As a matter of fact, job satisfaction contributes to job productivity.
Job satisfaction is of high significance in health care field (8). The purpose of health care systems is providing physical, psychological, and social health and creating conditions in which individuals can perform with higher quality and effectiveness (9). In the field of health care, studies have shown that job satisfaction affects the quality of patient care and satisfaction (6, 10). Considering the impact of job satisfaction on the quality of health care services for the patients, assessing job satisfaction is recommended in order to investigate the related changes, at least once every six months (11).
Developed countries spend a lot of money to investigate the annual changes in their employees’ job satisfaction. Records of annual changes in employees’ job satisfaction are available in information resources. Such high expenses indicate the significance of this phenomenon in these countries. Unfortunately, in our country, Iran, little attention has been paid.
Job satisfaction is one of the most important factors in increasing the employees’ performance. It is well established that dissatisfied employees would not perform effectively in the workplace (12). Job dissatisfaction leads to serious consequences (5). Mirmolaee et al. (2005) showed that 49%, 49.4%, and only 1.6% of midwives had low job satisfaction, average job satisfaction, and high job satisfaction, respectively (5). Since midwives are at the forefront of providing health care services for patients and their performance shows the quality of health care, evaluation of their job satisfaction is of importance (13).
Midwives in their workplace are exposed to stressful situations, which can affect their performance and job satisfaction (14). The first step in designing programs to maintain or improve the quality of care is assessing the quality of medical care. The concept of medical care quality was first introduced in 1980 (15). High quality of services and products has always attracted people’s attention. According to Joint Commission on Accreditation of Healthcare Organization, quality is defined as an acceptable level of health care services, provided for people and populations, in order to increase desirable health outcomes and raise professional knowledge (16).
Studies on quality assessment have focused on the direct observation of performance and evaluating the outcomes, costs, and patient satisfaction (17). An important tool for evaluating the quality of patient care is direct observation of health care provision (16). Shiuan‐Ying (2013) showed that job satisfaction could affect the quality of teaching and education (18). Gharebigloo et al. (2012) in their research showed that job satisfaction affects the performance of the staff (19). However, Kazemian et al. (2005) indicated that there is no significant relationship between job satisfaction and performance of nurses (3).
Every organization should pay considerable attention to job performance and satisfaction and continually measure these phenomena. Therefore, the aim of this study was to determine the relationship between job satisfaction and performance of midwives, working in health care centers of Mashhad, Iran.
Materials and Methods
This descriptive-correlational study was performed in 2014, on midwives working in health care centers of Mashhad, Iran. Two-stage sampling was applied; in the first stage, stratified sampling was used and in the second stage, convenience method was employed. Thus, the first stage included five main health centers of Mashhad, and the second stage consisted of health care centers and health units covered by the five main health centers of Mashhad. In the first stage, the centers and in the second stage, the subjects were selected.
Considering the official cooperation of five centers and the sampling technique, all centers, which gave permission, were included in this study. Finally, 90 subjects who met the inclusion criteria, were enrolled in the study. The inclusion criteria were as follows: 1) having at least associate degree of midwifery, 2) no previous history of visits to psychiatrists or psychologists, 3) no medication or hospitalization due to mental illnesses in the previous year, and 4) lack of having an emotional crisis within the last six months.
First, the researcher attended the health care centers and obtained the ethical permission. Afterwards, the study procedure was generally explained to the subjects, and informed consents were obtained. The selection forms were completed through interview, and if the midwives met the inclusion criteria, the demographic and job satisfaction questionnaires were handed to them.
The demographic questionnaire consisted of two sections: 1) demographic data such as age, marital status, and education, and 2) occupational information including work experience, satisfaction with workplace environment, interest in obstetrics, and occupational stress, evaluated by Visual Analog Scale (VAS). VAS is a commonly used standard instrument, the reliability and validity of which have been confirmed. For instance, Lesage (2011) used this scale to measure the occupational stress of health care center employees, and expressed that this scale is highly correlated with other scales such as Karasek scale and Perceived Stress Scale (20).
The validity of Minnesota Satisfaction Questionnaire (MSQ) has been confirmed in various studies. In Iran, it was firstly used by Khalilzadeh (1999) to investigate the contributing factors for job satisfaction of students and teachers in Urmia (12). The reliability of MSQ, according to Cronbach's alpha in Kargar and Amin Bidakhti’s study, was 0.73 (12); in the current study, it was reported as 0.81. This questionnaire included 20 questions with a four-point Likert scale. The scale of the scores was as follows: 20-35 as very dissatisfied, 36-50 as dissatisfied, 51-65 as satisfied, and 66-80 as very satisfied.
After completing the questionnaires, the performance of midwives was observed and the job performance checklist was completed. This checklist included three sections of educational, health care, and communicative performance. The checklist was made by the researcher with regard to the books and articles related to the study, similar questionnaires in previous studies, self-assessment questionnaire of New Guinea, midwifery job descriptions, and the instructions and health booklets of the Ministry of Health.
For content validity, the checklist was given to 10 faculty members of Nursing and Midwifery Department. Their comments were taken into consideration and the final form was written. To determine the reliability of the checklist, inter-rater reliability was used; the researcher and co-researchers, with similar educational status, separately observed 10 midwives simultan-eously. Then, by using Pearson’s correlation coefficient, education (rp=0.86), health care (rp=0.82), and communication sections (rp=0.96) were estimated. The education, communication, and health care sections included 17, 10, and 19 items, respectively.
If performance (according to the item) was completely done, "All done" option was selected. If performance was necessary, but the midwife neglected it, "Not done" option was ticked. In case of incomplete performance (according to the item), "Incompletely done" was selected, and "Not necessary" option was chosen if the action was not necessary to be performed in that specific situation. Scores 0, 1, and 2 were given if the item was "Not done", "Incompletely done", and "All done", respectively. "Not necessary" items were not allocated any scores, and they were removed in the sum of the mean of scores; therefore, the calculated score did not include these items.
The scores were graded as follows: 0-0.67 as poor, 0.68-1.39 as average, and 1.40-2 as good performance. It should be noted that for more accuracy, two checklists in two separate observations were completed in one day for each midwife; thus, the mean score of two observations was the score of the midwife. All observations were performed by one individual.
Data were entered into SPSS version 19, and after being ensured about the correct inclusion of data, descriptive methods were used to describe demographic characteristics. The Spearman correlation coefficient and Kruskal-Wallis test were performed to determine the relationship between job satisfaction and demographic characteristics. Linear correlations between job satisfaction and performance and between work experience and job performance were estimated by Spearman correlation coefficient.
In this study, 90 midwives, working in health care centers of Mashhad, were evaluated. The mean age of the participants was 39.63±6.92 years. Twelve (13.3%), 75 (83.3%), and 3 (3.3%) subjects had associate, bachelor's, and master's degrees, respectively. Twenty-three midwives (25.6%) had work experience of more than 21 years, 21 (23.3%) subjects had 16-20 years of experience, 14 (15.6%) subjects had 11-15 years of experience, 20 (22.2%) had 6-10 years of experience, and 12 (13.3%) midwives had 1-5 years of experience.
Frequency distribution of job satisfaction of midwives is demonstrated in Table 1. The mean of job satisfaction was 52.29±9.68, with the
minimum and maximum scores of 28 and 68, respectively. As to Spearman correlation test, job satisfaction was not significantly associated with education, income, and work experience (P=0.562, r=0.062; P=0.064، r=0.196; and P=0.060، r=0.199, respectively).
Kruskal-Wallis test also showed no association between marital status and job satisfaction (P=0.298). However, according to Kruskal-Wallis test, there was a significant association between the type of employment and job satisfaction (P=0.003); those who were officially employed or had a contract reported higher satisfaction scores. In addition, Spearman correlation test showed a significant association between age and job satisfaction (P=0.047, r=0.210). Spearman correlation test showed a significant inverse correlation between occupational stress and job satisfaction (P<0.001, r=-0.415). Also, job satisfaction had a significant positive correlation with workplace satisfaction and interest in the profession of midwifery (P=0.017, r=0.251; and P=0.004, r=0.298, respectively).
The linear relationship between job satisfaction and performance of midwives is shown in Table 2. Spearman correlation test showed no significant association between work experience and job performance, as presented in
Table 3. As it can be observed in Figure 1, the graphs compare the frequency distribution of job performance.
Most midwives had an average quality of educational performance; 10% had poor, 64.4% had average, and 25.6% had good educational performance. The majority of midwives had good quality of health care performance; 74.4%, 25.6%, and none of the midwives had good, average, and poor performance, respectively. In addition, most of the midwives had good
communicative performance; 1.1%, 31.1%, and 67.8% had poor, average, and good performance, respectively. In general, the majority of midwives in health care centers had an average performance.
This study was conducted with the aim to determine the relationship between job satisfaction and performance of midwives, working in health care centers. Overall, the findings in Table 1 showed that 38.9% of the midwives had no job satisfaction. Mohammadirizi et al. (2012), in their study called “The relationship between occupational stress and job satisfaction of midwives working in public hospitals and health centers in Mashhad in 1390”, showed similar results and indicated the low job satisfaction of most midwives (14).
Similarly, Mirmolaee et al. (2005), in their study in health care centers and hospitals of Tehran, Iran, stated that half of the midwives had low satisfaction and the other half had moderate satisfaction; only 1.6% of midwives were highly satisfied (5). Watson et al. (1999) in Australia showed that 80% of midwives had high job satisfaction (21). In addition, Skinner et al. (2006) in Australia demonstrated that 96% of midwives had high job satisfaction (22). This variation in the results might reflect the non-recognition of the professional status of midwifery, inappropriate policies in the workplace, inappropriate working conditions of midwives in Iran compared to other developed countries, and other issues related to job satisfaction (23).
The results of our study showed that there is a relationship between age and job satisfaction. In fact, satisfaction increases with age, which might be related to people's more realistic expectations and higher job compatibility. Also, there was a relationship between employment status and job satisfaction; midwives under contracts and those officially employed expressed greater satisfaction. This can be related to the fact that the officially employed midwives have higher job security and assurance; also, regarding the midwives, working under contracts, their fresh start at work and thus their higher motivation and energy for working can result in their higher satisfaction.
Midwives, due to their responsibilities for 2 sensitive people (mother and baby) have stressful jobs. This study showed that stress and job satisfaction were inversely associated; i.e., those who had higher levels of stress had lower job satisfaction. Mohammadirizi et al. (2012), during their study in Mashhad, reached the same conclusion and stated that high stress can reduce job satisfaction in midwives (14). Rajaee et al. (2013) confirmed that occupational stress is one of the negative factors affecting the job satisfaction of female physicians (24).
Job satisfaction is associated with work motivation, acceptance of error, higher income, and greater efficiency; i.e., job satisfaction not only plays an important role in an individual’s life, but is also very important for organizations; therefore, authorities must plan on improving the job satisfaction of employees. Job satisfaction affects many aspects of one’s life, including job performance (25). Ghara Bigelow et al. (2011) during their research in Gilan, Iran, showed a significant positive correlation between job satisfaction and employees’ performance (26).
In order to increase patient self-care, and thus improve health and prevent diseases, it is necessary to educate the patients; in fact, educating the patients is considered one of the main tasks of midwives and society’s health needs. According to statistics, every dollar, spent on educating the patients, would save 3 to 4 dollars. Moazen et al. (2011) in Tehran, Iran, noted that job satisfaction is significantly (and positively) associated with the quality of teaching and job performance (27). Maulana Usop et al. (2013) in Division of Cotabato City., Philippine, stated that there is a significant association between job satisfaction and job performance of teachers (28). Simbar et al. (2012) during their study in Tehran, noted that the quality of midwives’ consultation and training in health care centers was average or unfavorable (29). In the present study, a moderate correlation was found between job satisfaction and educational performance of midwives, which was shown in Table 2; this can be due to personal or work-related factors, which can be highly effective.
Another important aspect of midwives’ performance is the quality of their care provision. Care provision is essential to satisfying the patients’ needs. The midwife's attitude plays an important role in improving the quality of care (30). The results in Table 2 showed that there is an insignificant relationship between job satisfaction and care performance. Although the midwives’ job satisfaction in this study was low and the correlation coefficient between job satisfaction and care performance was insignificant, the midwives would not compromise the quality of health care due to the high sensitivity of their job, even if they were dissatisfied. Kazemian et al. (2005) in their study, titled “Correlation between job satisfaction and performance of nurses, working in Chaharmahal and Bakhtiari, Iran”, showed that there was not a significant relationship between job satisfaction and performance (3); the results are to some extent in line with our findings.
Communicative performance has been described as the most important characteristic of those working in primary health care centers (31). The results in Table 2 showed that there is a positive and significant relationship between job satisfaction and communicative performance. Mahmoudi et al. (2013), during their study in Tehran on 242 nurses, found that there is a significant and positive relationship between job satisfaction and communicative performance (p>0.001) (32). Kounenoua (2011), during his study in Greece, found a significant relationship between nurses' communication skills and job satisfaction (33). The results of the two mentioned studies are in line with our study findings.
One limitation of this study was its cross-sectional nature. To be more realistic, job satisfaction of midwives and performance indicators should be measured at regular intervals to show the changes and the reliability of the findings. Another limitation was the presence of the researcher in observation setting, which could affect the midwife’s performance; thus, it is best to record the performance with a camera. Finally, conducting two observations in one day, due to some environmental and personal factors, such as the crowdedness of the center and midwife’s exhaustion and problems, could affect the performance; therefore, it is suggested to observe the performances on several days.
There is an insignificant positive relationship between job satisfaction and quality of performance of midwives. Considering the results of the present study and similar research, and due to the importance of job satisfaction, authorities should facilitate the employees’ improvement, so that both patients and midwives can enjoy the benefits.
This paper has been extracted from a master thesis in midwifery, approved by the vice chancellor for Research at Mashhad University of Medical Sciences, Mashhad, Iran (code: 911146). We would like to thank the university for the financial support. We also express our deepest gratitude to the subjects, who participated in this study, as well as the authorities of Mashhad Nursing & Midwifery School and Mashhad health care centers for their valuable support.
Conflict of Interest
The authors declare no conflicts of interest.