Introduction

In order to effectively provide reproductive health services, midwives must have sufficient self-efficacy in addition to knowledge and skills, because self-efficacy is one of the factors that influence correct performance in emergency and stressful situations (1-2). In other words, good care happens when midwives achieve full self-efficacy (3). Self-efficacy is formed from a person's beliefs regarding his abilities to organize and perform the necessary actions to achieve the desired results. High self-efficacy beliefs facilitate work participation, task selection, effort and performance, and low self-efficacy beliefs weaken determination and disrupt performance (4). Bandura considers self-efficacy as an important factor for successful performance. In fact, it can be said that effective performance requires both having skills and believing in the ability to perform those skills (5). Job self-efficacy is defined as a person's judgment about his ability to perform the main tasks in a certain job and professional framework (6). Job self-efficacy is influenced by motivation and behavior and affects them mutually, and its high levels increase the individual's participation in tasks and job behaviors (7). Strengthening and paying attention to the characteristic of self-efficacy in the performance of employees requires identifying its predictive or determining factors. One of these factors that can affect the self-efficacy of employees is the moral climate (8-9). The ethical climate of an organization is a common set of perceptions about correct behaviors and how to process ethical issues, and it reflects organizational processes, policies, and actions that have ethical consequences (10). Ethical climate in medical environments is a type of organizational climate that consists of interpersonal relationships of medical personnel, comfortable communication in the field of patient care, support provided by the medical staff and their relationship with patients and their families (11). In other words, the ethical climate in the treatment environment is: the specific conditions of the organization that facilitate the discussion about the health problems of the patients and their resolution, and provide a framework for ethical decision making in the clinical environment (12). In this regard, Olson states that ethical climate is an organizational variable that can help improve the care environment and affect ethical behavior (13). Ethical performance is one of the main components of maternal and fetal care. As a result, it is necessary for midwives to use common principles and values that represent their professional commitment to society in providing services and activities. Finally, by observing ethics, in addition to increasing the quality of care and increasing public trust, they should use it as a means to achieve standard and desirable performance (14-15). The results of past studies show that when there is a suitable moral and justice-oriented working atmosphere in the organization, employees show more job self-efficacy and ultimately have higher effectiveness and efficiency (16). Also, self-efficacy and perception of ethical work environment both directly influence people's decision-making when they face difficult issues (9). According to previous research, the findings of a study in South Africa indicate that there is a relationship between moral climate, self-efficacy and hope (11-12). The results of past studies show that when there is a suitable moral and justice-oriented working atmosphere in the organization, employees show more job self-efficacy and ultimately have higher effectiveness and efficiency (15). Also, a researcher in Australia found that self-efficacy and perception of ethical work environment both directly influence people's decision-making when faced with difficult issues (9). Another study showed that the difference in self-efficacy leads to a change in the understanding of moral issues (17). In previous studies, different results have been presented regarding the self-efficacy level of midwives. So that in a study in Mashhad, the clinical self-efficacy level of the majority of midwives was medium and high (18-22). In another study in Tehran, most midwives had an average level of self-efficacy, and only 19% of midwives had a good level of self-efficacy (23). Considering the importance of self-efficacy in effective clinical practice and the role of midwives in ensuring the health of mothers and babies and maintaining the improvement of community health and the effect of ethical climate on the performance and self-efficacy of the organization's people and its effect as an organizational variable in improving the care environment, so far no study has been conducted on the relationship between these variables in the field of midwifery. Despite the assumption of relationships between moral climate variables and self-efficacy according to previous researches, not much empirical evidence is available to confirm their relationships. Therefore, the present study was designed with the aim of investigating the relationship between moral climate and self-efficacy of midwives working in maternity hospitals in Ahvaz city. It is hoped that its results can help to understand the moral climate governing the midwives of Ahvaz city and its relationship with their self-efficacy and promotion.

Materials and Methods

The present study is a descriptive-analytical cross-sectional study that was conducted with the aim of determining the relationship between morale and self-efficacy of midwives working in Ahvaz maternity hospitals in 2019. The research population consisted of 192 midwives working in the maternity department of public and private hospitals in Ahvaz. In relation to the correlation between moral climate and job self-efficacy in midwives, all midwifery personnel of maternity hospitals in Ahvaz (public and private) were included in the study based on the inclusion criteria. The inclusion criteria were: having written consent to participate in the study, having at least a bachelor's degree in midwifery, work experience of more than one year, not taking medication or being hospitalized due to mental illness in the past year, not having a history of major stress in the last six months. The exclusion criterion was: not being satisfied with participating in the research at any stage of the research.

The tool of data collection in this study was a questionnaire, which included: personal profile questionnaire, Victor and Cullen's moral questionnaire, Sherer's self-efficacy questionnaire.

Victor and Cullen's Ethical Climate Questionnaire contains 26 items, which are categorized into six areas: altruism, regulation, professionalism, instrumentality, efficiency-oriented and independent. Scoring is on a five-point Likert scale from one (completely false) to five (completely true). The total score of the questionnaire is obtained from the sum of the scores of all items. The minimum possible score is 26 and the maximum is 130. The reliability of this questionnaire has been confirmed in a brilliant study with Cronbach's alpha coefficient of 0.919(10). In this study, the test-retest method was used to confirm the reliability. Reliability was confirmed with alpha of 0.86.

Sherer's self-efficacy questionnaire has 17 items, which are categorized into three areas: willingness to initiate behavior, willingness to continue trying to complete behavior, and resistance to obstacles. The scoring method of the questionnaire is based on a five-point Likert scale from completely agree (score 5) to completely disagree (score 1). Items number (2, 4, 5, 6, 7, 10, 11, 12, 16, 17, 14) are graded in reverse. The total score is obtained from the sum of the scores of all subjects. The maximum score of the questionnaire is 85 and the minimum score is 17. The validity and reliability of this questionnaire has been confirmed in a brilliant study. The reliability coefficient was reported as 0.76 using Gutman's halving method and 0.79 using Cronbach's alpha (10). In this study, the test-retest method was used to confirm the reliability. Reliability was confirmed with alpha of 0.90.

In order to collect data, the researcher visited all the private and public hospitals of the city after the approval of the study in the research ethics committee of Jundishapur University of Medical Sciences of Ahvaz and obtaining the necessary permits. Then the researcher went to the hospitals in three shifts, morning, evening and night, and after presenting the permits obtained from the university and obtaining the necessary permits from the hospitals, he went to the maternity wards. At first, the researcher explained the objectives of the research and the steps of the work to the midwives. Then, the midwives who met the inclusion criteria completed the written consent form. After completing the consent form, personal and midwifery questionnaires, self-efficacy questionnaire and ethical climate questionnaire were provided to them to complete in the presence of the researcher. Also, according to the conditions of the country in terms of the Corona pandemic, questions were also designed in the Press Line software. In some hospitals where the entry permit was not issued, after obtaining the contact numbers of the working midwives, telephone calls were made to them. After explaining the work steps and objectives, they were given the link to the questionnaires and the consent form so that they could participate in the study if they were satisfied. All participants were assured that their information will remain confidential and if they wish, the results of the study will be provided to them at the end of the work. In addition, they were assured that they are allowed to withdraw from the research at any time. Finally, at the end of the work, all completed questionnaires were collected and coded. Data analysis was done using spss version 22 statistical software. To describe individual characteristics, descriptive statistics methods (mean, standard deviation and frequency distribution) and to determine the relationship between moral climate and self-efficacy after controlling for normality, Pearson's correlation coefficient and multiple regression analysis were used step by step. Also, linear regression model was used to determine predictor variables. All analyzes were used with alpha less than 0.05 and confidence coefficient of 95% to determine the significance level.

Results

The results of the data analysis showed that the age of most of the people (78 people = 40.6%) was 30-40 years and most of the people (62 people = 32.3%) had a work experience of 5-10 years. Most people were married (125 people = 65.1%) and had a bachelor's degree (165 people = 85.2%). The employment status of most of the participants in the study was official (76 people=39.6%) (Table 1).

Also, the results of self-efficacy and ethical climate and their dimensions are shown in table number (2).

Also, the results of the Pearson correlation coefficient test showed that there is no statistically significant relationship between the overall score of moral climate and the overall score of self-efficacy (p=0.119). However, a statistically significant relationship was observed between the overall score of self-efficacy and all dimensions of moral climate (p<0.05).

 The relationship between self-efficacy variables and moral climate dimensions of altruism, regulation, professionalism, and efficiency was positive, and the relationship between self-efficacy variables and instrumental and independent moral climate dimensions was negative (Table 2).

Also, the results of the data analysis showed that there is a statistically significant relationship between the moral climate and the dimension of resistance (p=0.020) (Table 3).

In addition, the investigation of the relationship between moral climate and demographic variables showed that there is a significant relationship between moral climate and marriage. Also, self-efficacy had a significant relationship with age, work experience, marital status, and employment status (p˂0.05). Also, the results showed that the most influential variable on the dependent variable of self-efficacy is the income variable (p=0.001), which according to the obtained beta coefficient, there is a direct relationship between the income parameter and self-efficacy (Table 5).

The results showed that the most influential variable on the dependent variable of self-efficacy is the income variable (p=0.001), which according to the obtained beta coefficient, there is a direct relationship between the income parameter and self-efficacy (Table 6).

Discussion

The results of this study showed that there is no statistically significant relationship between moral climate and self-efficacy. Also, the results showed that there is a positive significant relationship between self-efficacy and the dimensions of regulations, professionalism, efficiency and friendliness, and there is a negative significant relationship between the variables of self-efficacy and the dimensions of instrumental and independent ethical climate. But the correlation obtained for all variables is weak.

According to the obtained results, there is no statistically significant relationship between the ethical climate and the initiation dimension. Also, no statistically significant relationship was observed between the ethical climate and the effort dimension. On the other hand, there is a statistically significant positive relationship between the ethical climate and the resistance dimension. The intensity of the obtained correlation is weak. No study was found in this field. In the study of Swanepoel et al., according to the results obtained, there is a significant positive correlation between the three scales of moral climate, self-efficacy and hope, which organizational behavior model creates a new perspective on the effect of hope, self-efficacy on moral climate. This article shows that there is a relationship between compliance with moral principles, self-efficacy and hope (25). Which is contrary to the results of the present study, which can be due to the difference in the society and the research environment. Apriliani et al.'s study shows that the dimension of ethical laws and codes is the most influential dimension among other types of ethical climate. In addition, self-efficacy has been proven to moderate organizational factors, organizational ethical culture, and ethical climate. This effect was inversely proportional to the effect of both independent variables of ethical decision-making (17). The study of Naboureh et al. showed that the intensity and frequency of moral stress and the level of self-efficacy of nurses in special and emergency departments are at an average level. Also, a significant negative relationship was observed between the intensity of moral tension and the frequency of moral tension with perceived self-efficacy in nurses. In this way, with the increase in the intensity and frequency of moral tension, the level of perceived self-efficacy of nurses decreases (4). In the Derakhshan study, there were positive and significant relationships between moral climate, psychological capital and organizational voice. Also, the results showed that the relationship between moral climate and self-efficacy, resilience and optimism is significant. Other results indicated that the relationship between the dimension of altruistic atmosphere, legal dimension, legal dimension, independent dimension and self-efficacy which is one of the dimensions of psychological capital is significant, but the relationship between instrumental atmosphere and self-efficacy was not significant (10). Stenmark et al. found that cognition is affected by self-efficacy and, in addition, the perception of the moral issue was investigated. The results showed that the difference in self-efficacy does not lead to a change in moral knowledge, but it does lead to a change in the understanding of moral issues (26). Shacklock et al found that the results are consistent with the proposed model. They also found that self-efficacy is ideal for predicting their possible behavior and self-efficacy is a mediating variable between the perceptions of ethical organizational climate and the level of resistance against unethical organizational orders (9). Other studies have shown that self-efficacy helps people to resist unethical behaviors (26). For example, Fida et al. found that self-efficacy is related to the reduction of unethical behaviors and the reduction of justification mechanisms that people use to justify such unethical behaviors (27). Mullen et al found that with higher general self-efficacy, people believe more in their ability to manage ethical and legal issues. Research on the role of self-efficacy and attitudes and perceptions shows that threats related to self-efficacy may affect how a person perceives a moral situation (26). The results of the above studies are inconsistent with the present study. The reason for the lack of coordination of this research with the mentioned studies can be considered the tools used and the difference in the number of samples. Also, the working and organizational conditions in the mentioned studies and the current research can be different.

In order to effectively provide reproductive health services, midwives must have sufficient self-efficacy in addition to knowledge and skills, because self-efficacy is one of the factors that influence correct performance in emergency and stressful situations. Also, self-efficacy is one of the concepts affecting people's performance in difficult situations (2). On the other hand, there are no studies on the relationship between moral climate and self-efficacy of midwives, so there is a need for more research in this field to more confidently comment on the relationship between these two variables in midwifery.

The results showed that there is no statistically significant relationship between moral climate and age. In Borhani's study, the relationship between age and ethical climate was not significant (28).

While there was no statistically significant relationship between self-efficacy and age. In Fouad al-Dini's study, based on the results, a significant relationship was observed between clinical self-efficacy and age (29). However, in Salimi's study, no significant relationship was found between the demographic variable of age and clinical performance self-efficacy (30). Which is inconsistent with this study.

According to the results, there is no statistically significant relationship between moral climate and work experience. A statistically significant relationship was observed between self-efficacy and history. In Fouad al-Dini's study, a significant relationship was observed between clinical self-efficacy and work experience (29). In Salimi's study, although no relationship was found between nursing students' work experience and clinical self-efficacy, the average clinical self-efficacy score of people who had a student work experience was higher than those who did not have this experience. It seems that clinical self-efficacy increases with student employment in clinical environments and success in performing clinical skills (30). The results showed that there is a statistically significant relationship between moral climate and the marital status of the studied subjects and self-efficacy with the marital status of the subjects. In the proof study, single people's understanding of the atmosphere was significantly more favorable than married people's, and single people's view of the ethical climate of the hospital was higher than married people's, and this significant difference was obtained. It is possible that the obtained results are due to the difference in the views of single and married people towards the organization. Since married people have more conflicts and problems with life issues, they have a more complicated view of the organization where they work, but single people face fewer worries and responsibilities. Also, they spend more time communicating with their colleagues, patients and doctors, and maybe because of this, they have evaluated the atmosphere of the organization as more favorable (31). In Arabshahi's study, no statistically significant relationship was observed between marital status and self-efficacy of midwifery students (1). In this study, there was no statistically significant relationship between the moral climate and the educational levels of the studied subjects and self-efficacy with the educational levels. Also, in Taghizadeh's study, there was no significant relationship between self-efficacy and education (2). However, in a proof-of-concept study, self-efficacy had a significant relationship with the level of education (32). In Fazljoo's study, education had a significant relationship with nurses' moral climate. Fazljoo states that education affects people's attitude and moral behavior. Since the ethical climate is made up of areas that are affected by the relationships between people, therefore, the change in attitude and moral behavior and judgment is effective on a more favorable understanding of the atmosphere (31).

According to the information obtained in this study, there was no statistically significant relationship between moral climate and employment status. On the other hand, a statistically significant relationship was observed between self-efficacy and the employment status of the studied subjects. In Fazljoo's study, nurses' views on the ethical climate governing their work environment had a significant relationship with the type of employment. So that in nurses who are working informally, the moral climate has been lower in favor. Fazljoo states that this could be due to the fact that official nurses have more job security than informal nurses. Therefore, they can criticize and complain with more confidence and they can more easily express their opposition to policies that they do not consider ethical. But informal nurses refuse to express their problems due to lack of job security and as a result have a more unfavorable understanding of the organization (31).

Also, the results showed that there was no statistically significant relationship between ethical climate and shift work status of the studied subjects and self-efficacy with shift work status. According to Khazani's study, among the demographic variables, only the position and work experience of the nurses had a positive and significant relationship with the nurses' understanding of the real ethical climate. That is, nurses who have had a higher work experience had a more positive understanding of the ethical climate, and also the nursing service officials of the hospital evaluated the ethical climate more positively (13).

The relationship between moral climate and self-efficacy with the income status of the studied people has been shown. The results showed that there was no statistically significant relationship between moral climate and the income status of the studied subjects and self-efficacy with the income status.

In Mohammadi's study, it has been determined that there is no significant relationship between the variables of age, income level and education with the variable of self-efficacy (33). Also, in Mohebi's study, which studied the moral climate and its relationship with the demographic characteristics of nurses, no significant difference was observed between the moral climate and the variables of degree, marriage, type of work shift, type of employment, and work experience (34).

In Fazljoo's study, moral behavior had a significant relationship with marital status, education level, and employment status (31). In Hojjati's study, no significant difference was observed between the moral climate and the demographic variables of age, sex, marriage and work experience (35).

Adio and Popoola reached the conclusion that there is a significant relationship between demographic variables and self-efficacy (36).

Quoting Borhani, studies in America show that demographic variables such as age, gender, and level of education affect people's attitude, judgment, and moral behavior. While none of these variables have any effect in relation to the moral profile or moral climate of an organization. Considering that ethical climate is a factor dependent on managerial and individual policies and environmental factors (32). Also, few studies have investigated demographic characteristics and ethical climate, and more studies need to be done in this regard. Therefore, only this study and other studies that have been done before, cannot reach a definite result in this regard, so it is necessary to conduct more extensive studies by other researchers in the field of the effect of demographic variables on ethical climate and self-efficacy. Also, the results showed that the most influential variable on the dependent variable of self-efficacy is the income variable, which, according to the obtained beta coefficient, has a direct relationship between the income parameter and self-efficacy. In Fouad al-Dini's study, age and job experience were among the most important factors influencing nurses' self-efficacy (29).

Limitations and suggestions for future studies: The fatigue caused by the corona disease caused the questionnaires to be completed late. The impact of the environment and individual differences and mental state of midwives when answering the questionnaires, which can overshadow the answers of the midwives, can be another limitation of this study. According to the census and the type of study, the results may be generalizable to the country's midwives, but one should be cautious about other groups. It is suggested that the results obtained from this study be made available to the health officials and by holding classes and workshops, they can bring self-efficacy to the ideal level in the training of the care and treatment team, especially midwives.

Conclusion

The results of this study showed that there is no significant relationship between self-efficacy and moral climate. Since the identification of factors affecting the moral climate and the performance of personnel in clinical environments is an important step in formulating knowledge policies of the organization, hospital managers and planners should identify the factors affecting the moral climate. Considering the importance of self-efficacy in the clinical performance of midwives, managers should use interventions, including holding training courses, to improve the level of self-efficacy. Also, considering that the most influential variable on self-efficacy is income, the relevant authorities can help to improve self-efficacy by increasing the income of midwifery personnel to reach the ideal level.

Acknowledgements

The present study is the results of the master's thesis in midwifery management approved by the Research Vice-Chancellor of Jundishapur University of Medical Sciences, Ahvaz with the code IR.AJUMS.REC.1399.253. For this purpose, we would like to express our appreciation and gratitude to the Research Vice-Chancellor of Jundishapur University of Medical Sciences, Ahvaz, for funding this research. We also thank all the midwives who participated in the study.

Conflicts of interest

Authors declared no conflicts of interest.