Introduction

Midwives and nurses provide 80% of patient care (1), and they play an important role in caring for women during pregnancy, childbirth, and postpartum period. Their behavior such as providing voluntary service can have a significant impact on the perception of service quality and customer satisfaction, and might promote the quality of health care services (2-4).

Moghimi quoted from Morrison that organizations need employees who are willing to go beyond their prescribed official duties, and healthcare centers are not exempt from this. Extra-role behaviors, which are described as performing beyond formal job requirements, is called organizational citizenship behavior (OCB), which has drawn the attention of numerous researchers during the recent years (5).

OCB is a concept describing a person's voluntary commitment within an organization or company that is not part of his or her contractual tasks and is not rewarded by the system. OCB is assumed to improve the organizational roles and performance and to have a significant impact on the quality of employees’ relations (6, 7).

OCB has five dimensions including conscien-tiousness, altruism, courtesy, sportsmanship, and civic virtue. Conscien-tiousness consists of behaviors that go beyond the minimum role requirements of the organization. Altruism is defined by discretionary behaviors such as helping a colleague with an organizationally relevant task or problem. Sportsmanship signifies the employee’s tolerance of less-than-ideal organizational circumstances without complaining and blowing problems out of proportion.

Courtesy is defined as discretionary behaviors preventing work-related conflicts with others. Finally, civic virtue is characterized by behaviors that indicate the employee’s deep concern and active interest in the life of the organization (8). Rahimikian et al. (2012) reported that 98.7% of midwives had favorable level of OCB (9).

Mahjoob-Eshratabadi et al. (2012) performed a study in Tehran, which showed that consciousness, altruism, sportsmanship, and courtesy scores were above average; while civic virtue score was much lower than average among female experts in Tehran University (10).

OCB is vital for service providers and has a direct positive impact on quality of service and consequently, on the profitability of the organization. Additionally, such behaviors can increase performance and efficiency of the organization (4, 11). OCB is one of the indicators of high job satisfaction and performance, which can lead the organization toward its goals (6, 12).

Former studies demonstrated that employees with high level of job satisfaction were more likely to have OCB congruence (12, 13). Job satisfaction is one of the important indicators of proper organizational behavior, and is an important variable in organizational theories and studies (14). Predictive factors of job satisfaction play an important role in increasing the efficiency of nurses and midwives, which that can in turn, improve the quality of healthcare services (15).

Job satisfaction is defined as a positive emotional state resulting from a person’s appreciation of his/her own work or experience and reflects interest in job (16). Job satisfaction can improve productivity and performance of healthcare providers (6, 17). In medical services, job satisfaction is considered critical since public health is guaranteed by healthcare providers (18). Job satisfaction is associated with management, interpersonal relationships, career advancement opportunities, job security, income, and educational level (2).

In addition, job dissatisfaction is associated with factors such as low income, lack of job advancement opportunities and feeling success, not having decision-making power, long working hours, heavy workload, and shortage of time (16). Several researchers including Khorasani et al. (2011) and Intaraprasong et al. (2012) accentuated the relationship between job satisfaction and OCB (12, 19).

Physical and mental health of employees is to some extent affected by job satisfaction (17).
Several studies exhibited an inverse relationship between occupational stress and job satisfaction (20). Occupational stress is another factor influencing mental health (21); today, occupational stress has become a major health problem that is experienced in every occupation (20).

Studies showed that healthcare can be a stressful field (22, 21); occupational stress is perceived as an individual’s reactions to work environment, indicating a poor fit between the individual’s abilities and his/her duties (23), and it can exacerbate when employees do not feel supported by their supervisors or colleagues, or feel as if they cannot cope with work pressure (1).

Work stressors include heavy responsibilities in the organization, unpaid overtime, excessive workload, technological changes, need for high productivity, intense competition, and lack of job security (24). Stress might lead to reduced productivity and have a negative impact on organizational performance (20, 24).

Studies demonstrated that 50-60% of reasons for resigning from work were associated with occupational stress (1). Job stress is also related to fatigue at the end of the working day, tendency to leave the job, and desire to work elsewhere (25). A study by Mohamadirizi (2012) exhibited that 58.7% of midwives had severe occupational stress (22).

 Hasheminegad (2013) reported that 60.8% of midwives were suffering from some degrees of mental disorders (21). Job stress can cause physical symptoms such as fatigue, headache, hypertension, pain in the back and shoulders, sleep disorders, appetite changes, and gastroenteritis problems. It can also have psychological symptoms such as forgetfulness, concentration difficulties, anger, fear, depression, and complaining from others (23, 24).

There is no agreement regarding the relationship between job stress and OCB. Some studies have supported a negative relationship between job stress and OCB, while some others consider it as a factor which can lead to increased stress in employees (26-28). Ansary et al. (2010) conducted a study in the Iranian offshore oil drilling company employees, which did not demonstrate a significant relationship between job stress and OCB (29).

Midwives have a critical role in caring for mothers and children’s health and OCB is essential in them; however, job stress is relatively high in this profession. Give the scarcity of studies in field of midwifery, this study was conducted to determine the relationship between job satisfaction, occupational stress, and OCB.

Materials and Methods

This descriptive-correlational study was carried out in 122 midwives working at healthcare centers of Mashhad, Iran, during 2014. The inclusion criteria were: 1) willingness to participate in the study, 2) having midwifery certificate for at least two years, 3) working experience of at least six months, 4) having at least associate degree in midwifery, 5) no history of psychological disorders over the last year, and 6) not experiencing major stress (e.g., having a serious illness, death of a close relative, immigration, accident, or severe family conflicts) during the past six months. Some of the eligible samples were excluded due to lack of willingness to participate in the study.

Before performing the study, a letter of recommendation was obtained from School of Nursing and Midwifery, Mashhad University of Medical Sciences, to be presented to the heads of healthcare centers across the province (Khorasan Razavi). After obtaining approval of the authorities of the healthcare centers number 1, 2, 3, 5, and Samen and providing a letter of recommendation from them to all health clinics under their supervision, sampling was allowed.

The researchers attended healthcare centers and clinics in the morning and explained the objectives of the study to the participants. The samples were assured of confidentiality of personal information, and written informed consent was obtained from the midwives.

In case of eligibility for the study, the midwives completed the questionnaire related to demographic and job characteristics, OCB, occupational stress, and job satisfaction. Data collection instruments included a demographic and job characteristic form, Podsakoff’s OCB Questionnaire, Karasek’s Job Content Scale, and Minnesota Job Satisfaction Questionnaire.

The OCB scale, containing 24 items, can be divided into five subscales of altruism, conscientiousness, sportsmanship, courtesy, and civic virtue. Responses to the items are based on a 5-point Likert type scale. Five items are related to each of the subscales of conscientiousness, sportsmanship, courtesy, and altruism, while civic virtue has four items.

High scores from the OCB questionnaire indicate high OCB congruence. Shekarkan et al. (2001) first used and validated this questionnaire; moreover, Shekarkan et al. (2001) confirmed the reliability of the questionnaire using Cronbach’s alpha coefficient (α=0.90). OCB and its dimensions’ reliabilities were re-established in a study by Mahjoob-Eshratabadi (2011) using Cronbach’s alpha coefficient (α=0.87, 0.74, 0.83, 0.77, 0.74, and 0.76 for OCB, conscientiousness, sportsmanship, civic virtue, courtesy, and altruism, respectively).

In the present study, reliabilities of OCB and its subscales were calculated to be α=0.96, 0.87, 0.92, 0.88, and 0.89, respectively. Hypothetical mean score was used to evaluate the mean of the OCB and its dimensions.

Karasek’s Job Content Questionnaire is a standardized instrument assessing job stress. It consists of 34 questions related to five domains including decision latitude or job control, psychological demands, social support, incon-venience of hazardous working environments, and job insecurity

The items of Karasek’s Job Content Questionnaire are responded to using a 3-point Likert type scale (ranging from 0 to 3). The possible total scores range from 0 to 133 (0-42: slight; 42-84: moderate; 85-133: severe job stress). Reliability of this questionnaire was confirmed in a study by Mohamadirizi (2012), which calculated the Cronbach’s alpha coefficient to be 0.88 (22). In the present study, its reliability was estimated through Cronbach’s alpha coefficient (α=0.86).

Long form of Minnesota’s Job Satisfaction Questionnaire consists of 100 questions, while its standard and shortened version is comprised of 20 questions. Items of the short form of this questionnaire are rated on a 5-point Likert scale (1: very dissatisfied, 2: dissatisfied, 3: can’t decide, 4: satisfied, and 5: very satisfied).

In this study, the short form of Minnesota Job Satisfaction Questionnaire was used with total scores ranging from 20 to 100. Several studies estimated the reliability of this questionnaire to range between 0.78 and 0.93 (31). In this study, Cronbach's alpha coefficient was used to re-confirm its reliability (α=0.80).

 The data were analyzed using descriptive and inferential (Kolmogorov-Smirnov, t-Student’s test, one-sample t-test, one-way ANOVA, general linear regression, Pearson and Spearman’s correlation coefficients, and linear regression model) statistics. SPSS version 20 was employed to analyze the data, and P-value less than 0.05 was considered statistically significant.

Results

In this study, 122 midwives working at healthcare centers of Mashhad were studied. The mean age of midwives was 38.46±7.22 years. There was a significant correlation between OCB and years of service (P=0.034, r= 0.193), while there was not a significant correlation between OCB and other demographic or occupational variables (P>0.05).

Occupational stress and job satisfaction were not significantly correlated with any of the demographic and job variables (P>0.05; Table 1). The results of our study showed that mean scores of OCB and its dimensions were higher than the hypothetical means (Table 2). The mean scores of occupational stress and job satisfaction were 74.50±9.48 and 44.85±8.25, respectively. The majority of the midwives (59.0%) were satisfied with their job and most midwives (61.5%) had moderate level of job stress (Table 3).

The results of correlation, as can be observed in Table 4, demonstrated that there was a significant direct relationship between OCB, courtesy (P=0.014), and job satisfaction (P=0.026). In addition, there was a negative correlation between OCB and altruism (P=0.003), sportsmanship (P=0.005), civic virtue (P=0.031), and job stress (P=0.015).

In order to control for intervening variables, job satisfaction, occupational stress, age, and occupational experience as independent variables and OCB as a dependent variable were entered into general linear regression model. It was found that job stress, age, and work experience had a significance level of less than 0.05 and were considered as effective variables in OCB (Table 5).