Abstract
Background
Professional belonging is an individual's engagement in their profession and where they see themselves in that profession. Midwives who have strong sense of belonging can provide compassionate care to pregnant women, newborns and families throughout their lives. The generation of evidence on sense of midwives professional belongingness is a critical step for maternal and neonatal mortality reduction. However, there is a lack of evidence about professional belongingness and influencing factures among midwives in Ethiopia particularly the study area.
Objective
To determine factors influencing midwives’ professional belongingness in public hospitals in Amhara regional state, northwest Ethiopia, 2022.
Methods
Institution-based cross-sectional study was conducted from February 21 to April 1, 2022. A cluster sampling technique was used to select 636 midwives. Data were collected using a self-administered and structured questionnaire, entered into Epi-Data version 4.6.software and exported to SPSS version 23 for analysis. A binary logistic regression analysis was fitted to identify factors associated with professional belongingness and p-value <0.05 at 95% confidence interval was used to declare statistical significance.
Results
The proportion of belongingness was 52.7% (95% CI = 48.7, 56.6).Midwives who satisfied with their jobs [AOR = 3.50, CI= (2.48, 4.93)], had co-worker support [AOR = 1.54 CI= (1.08, 2.19)], had BEmONC training [AOR = 1.53 CI= (1.01, 2.30)], and experienced workplace violence [AOR = 0.55, CI= (0.39, 0.77)], had significant association with professional belongingness.
Conclusion
The proportion of professional belongingness was low. Increasing job satisfaction, providing professional training, strengthening co-worker support, and developing workplace violence prevention strategies are all important steps toward increasing midwives’ professional belongingness.
Keywords
1. Introduction
The individual's interest in their profession and where they see themselves in this profession is professional belongingness.
1
There is limited evidence about professional belongingness among health workers worldwide.2
,3
According to a study conducted in Turkey, the mean total score of midwives' belongingness was 75.99 ± 18.94.4
A strong sense of belonging is correlated to a higher level of self-efficacy, self-esteem, stress-coping abilities, social and psychological functioning. It has a direct impact on a person's work life, quality of life, and job satisfaction.1
,4
Midwives’ clearly demonstrates their belonging to the midwife by accepting their place in it; being willing to defend the profession, accepting responsibility for the profession, genuinely wanting to advance in their field, working hard to fulfill their responsibilities, believing in the values of their profession, and being determined to keep their profession.
5
Low job performances, low self-esteem, increased stress, anxiety, depression, a decrease in overall wellbeing and happiness, lower cognition, and an increase in linked attitudes such as adherence and compliance have all been associated to a lack of belonging to one's profession.
6
,7
Professional belongingness is a powerful source of motivation because it influences individuals' attitudes and behaviors toward professionalism, as well as their profession.4
,8
, 9
, 10
Employees with a strong sense of professional belonging accept the goals of their profession work to achieve those goals and are satisfied with the jobs.11
A person's professional life is influenced by a variety of factors. Being satisfied with one's choice of profession; management and attitude of the administration; the view of society; relationship with colleagues; trainings; career opportunities; financial and moral rewards; the employee's personality; social and economic needs; work demands and employee demands
1
,12
,13
were all examples. Low job satisfaction leads to frequent job changes, poor job performance, a hostile work environment, and a loss of loyalty to the profession and the organization.14
Midwives who have a strong sense of belonging can provide compassionate care to pregnant women, newborns and families throughout their lives.15
Professional belonging is an important component of motivation because it influences an individual's attitude toward and behaviors' in their professional life, as well as their work performance.
1
,8
The generation of evidence on sense of midwives professional belongingness is a critical step for maternal and neonatal mortality reduction. However, there is a lack of evidence about professional belongingness and influencing factures among midwives in Ethiopia particularly the study area. Thus, the study aimed to determine factors influencing midwives' professional belongingness in public hospitals in Amhara regional state, northwest Ethiopia, 2022.2. Methods and materials
2.1 Study design, period and study setting
An institutional based cross sectional study was conducted in public hospitals in Amhara regional state, Northwest, Ethiopia, from February 21 to April 1, 2022.
This study was conducted among midwives who were working in public hospitals in Amhara regional state. Currently, the region of Amhara consists of 13 administrative zones, one special zone, 105 woredas, and 78 urban centers. There are also eight tertiary hospitals, 20 functional general hospitals, 67 primary hospitals, 862 functional health centers, and 10 private hospitals.
According to the Ethiopian Midwives' association census in 2019, there were 16,925 total midwives in Ethiopia, with 11,390 (67.3%) being females. The census also reported the national midwife to population ratio of 1:16,313 and the midwife to pregnant woman ratio of 1:212, which are far below the WHO standard (1:175). Amhara region has a total of 3370 midwives with a midwife to pregnant woman ratio of 1:218.44.
16
The study was conducted among midwives who were working at public hospitals in three randomly selected cluster zones in Amhara regional state, northwest Ethiopia. This study included 29 hospitals located in central Gondar, south Gondar and west Gojjam zones.Source population: All midwives working in public hospitals in Amhara regional state, northwest Ethiopia. Study population: All midwives working in randomly selected zones in Amhara regional state, northwest Ethiopia, who were available during the data collection period.
Inclusion criteria: All midwives who were permanently employed in the selected hospitals and available during the data collection period.
2.2 Sample size determination
The sample size for this study was determined using a single population proportion formula by with a 50% proportion because no previous study on this topic had been conducted, a 95% level of confidence and a 5% margin of error.
Where n = required sample size, = level of significance, Z = 95% confidence level standard normal distribution curve value = 1.96, P = proportion, d = margin of error Therefore,
With a 1.5 design effect and 10% non-response rate, the calculated sample size is 634. Finally, the study included all midwives in the randomly selected hospital cluster zones, and the final adequate sample size was 636.
Where n = required sample size, = level of significance, Z = 95% confidence level standard normal distribution curve value = 1.96, P = proportion, d = margin of error Therefore,
With a 1.5 design effect and 10% non-response rate, the calculated sample size is 634. Finally, the study included all midwives in the randomly selected hospital cluster zones, and the final adequate sample size was 636.
2.3 Study variables
Outcome variable: Professional belongingness.
2.4 Demographic variables: include the following socio-demographic, job demand-resource and organizational variables
Age, gender, religion, marital status, number of children, educational level, work experience, and monthly salary are all socio-demographic factors. Job demand and resource-related variables include: level of health facility, working unit, workload, duty hours/month and earn for duty; training; number of workers in the ward; educational opportunities; participation in decision-making; the satisfaction of monthly salary; and work place verbal/physical violence. Co-worker support, supervisor support, leadership quality, organizational justice, and recognition for outstanding performances all were organizational related variables.
2.5 Data collection tools and procedures
Data were collected through a pre-tested and structured self-admisntered interview. The questionnaire was developed after a review of literatures. The structured questionnaires were prepared in a local language, Amharic, to make it simple and understandable. The tool incorporates socio-demographic, job demand-resource and organizational variables. The questionnaire was prepared in English, and then translated to Amharic (local language) and back to English to maintain consistency of the tool. The outcome was assessed using 22 items divided into four domains: emotional belongingness (7 items), performance of professional roles and responsibilities (7 items), professional development and opportunity utilization (5 items), and limits of duty and authority in the profession (3 items). It was a 5-point Likert scale with 110 points, with 1 representing "absolutely disagree" and 5 indicating that the statement is felt to "absolutely agree" with 110 points.
1
High professional belongingness: Respondents who scored ≥ the mean from 22 items on a 5 point Likert scale have high sense of professional belongingness and low below the mean.
1
Job satisfaction: Respondents who scored more than 60 on the sum of all the satisfaction scale items were considered satisfied, while those who scored 60 or less were considered dissatisfied.Coworker support was assessed using three questions on a five-point Likert scale and categorized as low or high using their mean value as a cutoff point.15
,18
Superior support was measured using three questions on a five-point Likert scale and categorized as low or high using their mean value as a cutoff point.15
,18
Recognition: Measured using three questions with a five-point Likert scale and categorized as low/high using their mean value as a cutoff point.15
,18
Leadership quality and Organizational justice were measured using each of the four questions on a five-point Likert scale.7
Workplace Violence: When a midwife experienced at least one type of violence, such as verbal, physical, and/or psychological violence, at the workplace in the last one year by client, visitors and friends.15
,18
Verbal abuse: When midwife experiences being sworn at, cursed at, yelled at, threatened at, Behavior that humiliates, degrades, or otherwise indicates a lack of respect for the dignity and worth of an individual.Physical violence: When a midwife experienced any beating, kicking, slapping, stabbing, shooting, pushing, biting, spitting on, and/or pinching from others.15
2.6 Data quality control
Data were collected through a pre-tested semi-structured self administered questionnaire. The semi-structured questionnaires were developed in collaboration with experts in a local language, Amharic, to ensure that they were simple and easy to understand. The questionnaire was prepared in English, and then translated to Amharic (local language) and back to English to maintain consistency of the tool. The training was provided for data collectors and supervisors for one day about the purpose of the study and techniques of data collection. The trained data collectors were supervised during data collection and each questionnaire was checked for completeness daily. Data entry was conducted by one computer. The questionnaire was pretested to check the response, language clarity, and appropriateness of the questionnaire while pretest was done outside the study area at Debark and Dabat hospitals among 33(5%) of midwives of the sample size. At the end of the pre-test depending on its outcome the correction measures like arrangements of questions were undertaken. All of these processes could ensure the tool's validity and reliability.
2.7 Data processing and analysis
Data were checked, coded, and entered into a computer using Epi-Data-version 4.6 software before being exported to the Statistical Package for Social Science (SPSS) version 23 for analysis. Descriptive statistics like mean, frequencies, and proportion were used. The presence of a statistical association between independent and dependent variables was done using binary logistic regression analysis. Variables with p-value of less than 0.25 were included in multivariable logistic regression analysis model for further analysis to control for confounders. The AOR with 95% confidence interval and at P value < 0.05 was used to ensure significant association between independent variables and the outcome variable. The Hosmer-Lemeshow goodness of fit test was used to check model fitness, and the data was fit for the model (p-value = 0.301).
3. Results
3.1 Socio-demographic variables
In this study, a total of 645 midwives were involved, of which 636 of the study participants completed and returned questionnaires, giving a response rate of 98.6%. The median age of the study participants was 29.27 (±3 IQR) and more than half, 368 (57.1%) were men. In terms of marital status, two third, 409 (64.3%) were married, majority,610 (95.9%) were Orthodox believers. Majority, 507(79.7%) of were a bachelor's degree in midwifery and the median age had 5 years (±4 IQR) of work experience in the midwifery profession (Table 1).
Table 1Socio-demographic variables of midwives working in public hospitals in Amhara Regional State, northwest, Ethiopia, 2022 (n = 636).
| Variables | Category | Frequency (n) | Percent (%) |
|---|---|---|---|
| Age of participants | 20–30 | 507 | 79.7 |
| 31–40 | 122 | 19.2 | |
| ≥40 | 7 | 1.1 | |
| Sex of participants | Male | 368 | 57.9 |
| Female | 268 | 42.1 | |
| Religion | Orthodox | 610 | 95.9 |
| Muslim | 18 | 2.8 | |
| Protestant | 8 | 1.3 | |
| Marital status | Married | 409 | 64.3 |
| Single | 227 | 35.7 | |
| Diploma | 90 | 14.2 | |
| Educational status | BSc degree | 507 | 79.7 |
| MSc degree | 39 | 6.1 | |
| Work experience | <5 years | 338 | 53.1 |
| ≥5 years | 298 | 46.9 |
3.2 Job demand and resource-related variables
Half the participants, 322 (50.6%) were from district hospitals and two-thirds, (63.9%) had a heavy workload at the work. Three hounded and ninety one (61.5%) participants received capacity-building training, with 370 (58.2%) trained in BEmONC training. Only 48 participants (7.5%) obtained educational opportunities to advance their careers. Nearly half of study participants (51.3%) reported overall workplace violence. Of these, half (49.51%) were verbal, and 13 (2.0%) were patients and/or their attendants (Table 2).
Table 2Job demand and resource-related variables among midwives working in public hospitals in Amhara Regional State, northwest Ethiopia, 2022 (n = 636).
| Variables | Category | Frequency (n) | Percent (%) |
|---|---|---|---|
| Level of hospital | Primary hospitals | 322 | 50.6 |
| General hospitals | 28 | 4.4 | |
| Tertiary hospitals | 286 | 45.0 | |
| Working unit | Obstetrics | 508 | 79.9 |
| Gynecology | 93 | 14.6 | |
| Obi-Gyn | 6 | .9 | |
| Clinical Coordinator | 29 | 4.6 | |
| Work rotation | 2–5 months | 338 | 53.1 |
| 6–12 months | 12 | 1.9 | |
| >12 months | 286 | 45.0 | |
| Training opportunities | Yes | 391 | 61.5 |
| No | 245 | 38.5 | |
| BEmONC training | Yes | 370 | 58.2 |
| No | 266 | 41.8 | |
| Educational opportunity | Yes | 48 | 7.5 |
| No | 588 | 92.5 | |
| Workplace violence | Yes | 329 | 51.7 |
| No | 307 | 48.3 | |
| Types of violence | Verbal abuse | 312 | 49.1 |
| Physical abuse | 13 | 2.0 | |
| Both | 4 | .6% |
3.3 Organizational related variables
In the context of the respondents, 386 (60.7%) had a strong co-worker support, while 284 (44.7%) had superior support. Three hindered and forty two (53.8%) respondents reported high leadership quality in their organization, and 355 (55.8%) reported high justice among midwives. About 288 (45.3%) of respondents received high-recognition and 284 (44.7%) were satisfied with their work. (Table 3).
Table 3Organizational related variables among midwives working in public hospitals in Amhara Regional State, northwest Ethiopia, 2022 (n = 636).
| Variables | Category | Frequency (n) | Percent (%) |
|---|---|---|---|
| Coworker support | Low | 250 | 39.3 |
| High | 386 | 60.7 | |
| Superior support | Low | 352 | 55.3 |
| High | 284 | 44.7 | |
| Leadership quality | Low | 294 | 46.2 |
| High | 342 | 53.8 | |
| Organizational justice | Low | 281 | 44.2 |
| High | 355 | 55.8 | |
| Recognition | Low | 348 | 54.7 |
| High | 288 | 45.3 | |
| Satisfaction | Unsatisfied | 352 | 55.3 |
| Satisfied | 284 | 44.7 |
3.4 Professional belongingness and associated factors
Professional belongingness among midwives was 52.7% (95% CI: 48.7–56.6) with the mean score of ≥72.26 ± 12.98.
Job satisfaction, workload, work experience, work rotation, recognition, BEmONC training, training opportunity, facing workplace violence, and coworker support were variables siginifinalyly associated with professional belongingness in bivariate regression analysis at a p-value <0.25.The final multivariable logistic regression model included these variables. The variables that were significantly associated with professional belongingness in the multivariable logistic regression analysis were job satisfaction, BEmONC training, workplace violence and coworker support.
Midwives who were satisfied with their jobs were 3.5 times more likely to have high professional belongingness compared to those who were dissatisfied [AOR = 3.50 CI = (2.48, 4.93)]. Midwives with high co-worker support were 1.5 times more likely to have high professional belonging than those with low co-worker support [AOR = 1.54 CI = (1.08, 2.19)]. Midwives who trained BEmONC training were 1.7 times more likely to have high professional belonging than non-trained midwives to feel strong sense of professional belongingness[AOR = 1.76 CI = (1.01–2.30)]. Midwives who have experienced workplace violence have 44% less likely to have high professional belongingness than their counterparts [AOR = 0.564, CI= (0.399, 0.798)] (Table 4).
Table 4Bivariate and multivariable logistic regression analysis of factors associated with professional belongingness among midwives working in public hospitals in Amhara Regional State, northwest Ethiopia, 2022 (n = 636).
| Variables | Professional belongingness | COR(95% CI) | AOR(95%CI) | ||
|---|---|---|---|---|---|
| High | Low | ||||
| Job satisfaction | Satisfied | 197 | 120 | 3.39(2.45, 4.70) | 3.50(2.48, 4.93)* |
| dissatisfied | 104 | 215 | 1 | 1 | |
| Coworker support | High | 222 | 164 | 1.64(1.19, 2.26) | 1.54(1.08, 2.19)* |
| Low | 113 | 137 | 1 | 1 | |
| Faced Violence | Yes | 178 | 151 | 0.57(0.41,0.78) | 0.56(0.40, 0.80)* |
| No | 123 | 184 | 1 | 1 | |
| Training | Yes | 106 | 139 | 0.77(0.56, 1.06) | 1.19(0.75, 1.89) .462 |
| No | 195 | 196 | 1 | 1 | |
| BEmONC Training | Yes | 212 | 123 | 1.56(1.14, 2.14) | 1.76(1.01–2.30)* |
| No | 158 | 143 | 1 | 1 | |
| Recognition Label | High | 168 | 120 | 1.52(1.11, 2.08) | 0.831(0.59, 1.18) 0.300 |
| Low | 167 | 181 | 1 | 1 | |
| Work experience | ≥5 years | 193 | 145 | 1.46(1.07, 2.00) | .773(0.55,1.09).150 |
| <5 years | 142 | 156 | 1 | 1 | |
| Workload | Yes | 36 | 299 | 0.66(0.38, 1.14) | 1.29(0.71, 2.36) .300 |
| No | 22 | 279 | 1 | 1 | |
NB: P-value *< 0.05.
4. Discussion
This study aimed to determine the proportion of professional belongingness and associated factors among midwives working at public hospitals in Northwest Amhara, Ethiopia. The findings of this study showed that the proportion of professional belongingness was 52.7%, with a mean score of ≥72.26 ± 12.98. This result is lower than the study done in Turkey, which revealed 75.99%.
19
The possible reasons for this result might be related to job satisfaction, working environment, career development opportunities, job demands, and low workloads. On the other hand the current study is only based on the outcome variable professional belongingness among midwives.According to this study job satisfaction, co-worker support, work place violence, and BEmONC training were found to be significantly associated with a sense of professional belongingness among midwives.
The odds of high professional belonging among midwives who were satisfied with their job were 3.5 times higher than as compared to their counterparts. This finding is supported by a study conducted in Turkey
19
and Jamaica.20
The possible explanation is related to the fact that the job satisfaction of midwives is highly important in building up employee motivation. A high level of job satisfaction has a positive effect on health workers' related quality of life, job performance, retention at work, quality of healthcare delivery, and patient satisfaction, whereas midwives who were dissatisfied at work were found to distance themselves from their patients, resulting in suboptimal quality of care, low job performance, lower productivity, and staff turnover, which is costly to organizations. It has been determined that employees with high occupational satisfaction in the field of health care provide more qualified care to their patients, their desire to continue their profession is strong, they are happy at work, their job stress decreases, and their level of wellbeing in terms of physical, mental, psychological, and social needs increases.8
Furthermore, the presence of co-worker/peer support was another important factor that was significantly associated with the professional belongingness of midwives. Thus, midwives with high co-worker support were 1.5 times more likely to have high professional belonging than midwives who had low co-worker support. The rationale behind it is that a positive relationship with colleagues and the presence of strong teamwork improve the sense of belonging. This could be because co-workers' relationships are vital in any working environment,
21
especially for health professionals to provide quality care for their patients and the successful implementation of their professional duties. The most frequent reason given to employees leaving their job was workplace stressors because of relationships among colleagues.22
It further stated that employees' satisfaction with their relationships with other employees is related to employee retention.12
,23
The presence of high friendship has a positive impact on their workplace experiences, such as increasing working motivation, decreasing turnover, enthusiasm, and compassionate care.
21
As a result, it increases the sense of professional belonging and makes one feel like part of the team.24
This could be because co-workers' relationships are vital in any working environment,21
especially for health professionals to provide quality care for their patients and successfully implement their professional duties. The most frequent reason given to employees leaving their job was workplace stressors because of relationships among colleagues.22
It is further stated that employees' satisfaction with their relationships with other employees is related to employee retention.
12
,23
Positive communication has a special implication for health professionals because health care is teamwork, which needs high relationships and communication between healthcare providers.BEmONC training increases professional belonging by 1.7 times as compared to midwives who did not take BEmONC training as part of their job. This could be because training is important to capacity building and gap filling, as well as gaining updated practice in science and art for the life-saving procedure. This might be due to the fact that the midwifery training curriculum is also being reviewed as a way of strengthening life-saving skills such as BEmONC. This training is on emergency obstetric care. Once midwives are armed with such practical knowledge, it becomes easy for them to apply this knowledge in their day-to-day work and elevates their sense of professional belonging.
3
Finally, this study found that verbal and/or physical violence in the workplace was significantly associated with professional belongingness. The experience of verbal and/or physical violence reduces the odds of having high professional belonging by 44% when compared to those who didn't experience violence in the work environment. The possible justification is due to the fact that being a midwife raises the risk of workplace violence because they are the frontline personnel in providing services to women at health facilities, which have a higher possibility of contact with women and their relatives as well as their as well as their colleagues.
24
Midwives faced workplace violence in the form of physical, emotional, or verbal abuse because of long waiting times for clients, client dissatisfaction with the care provided, miscommunication, or frustration from low obstetric outcomes. Workplace violence is emotionally, psychologically, and spiritually damaging and it can have long-term consequences for those affected. Absenteeism, mental stress, fatigue, psychological trauma, low mental health, job dissatisfaction, intention to leave a job, and loss of passion for the midwifery profession are some of the negative effects of workplace violence.
5. Limitations of the study
Due to time and financial constraints, this study was limited to public hospitals in randomly selected clusters in the Amhara region. It would have been possible to incorporate midwives working at health centers, private hospitals, and clinics.
6. Conclusion
The proportion of midwives professionally belongingness was low. Job satisfaction, having high co-worker support, BEmONC training and workplace violence were all significantly associated factors with a sense of professional belongingness. Increasing job satisfaction, providing professional training, strengthening co-worker support, and developing workplace violence prevention strategies are all important steps toward increasing midwives’ professional belongingness.
Ethical approval and consent to participate
The ethical approval letter was obtained from the Ethical Review Committee of School of Midwifery on behalf of institutional review board (IRB) of University of Gondar and also a supporting letter of study approval was obtained from Amhara public health institutions (APHI) for each hospital located in the randomly selected clusters. After receiving permission from each public hospital, study participants were informed about the study's purpose, the importance of their participation, and their rights and verbal consent was obtained. The data collection procedures were anonymous in order to protect the confidentiality of information provided by the study participants. The privacy of the study participants was respected, and no one other than the investigator had access to their data.
Consent for publication
Not applicable.
Availability of data and material
The data is available to the corresponding author upon reasonable request.
Funding
There was no specific funding provided to the authors for this work.
Authors’ contribution
ETF-: Wrote the proposal, and involved in the data collection.ETF, WZT and MMA analyzed the data. All authors read and approved the final version of the manuscript.
Declaration of competing of interest
All the authors declared that no conflicts of interest exist.
Acknowledgements
Our gratitude goes to the University of Gondar for providing ethical clearance to this study. We would also like to thank the data collectors and study participants.
List of abbreviations
AOR
Adjusted Odd Ratio
BEmONCBasic Emergency Obstetrics and Newborn Care
CIConfidence Interval
AORCrude Odd Ratio
SPSSStatistical Package for Social Science
SDGSustainable Development Goals
WPVWork place violence
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Article info
Publication history
Published online: January 20, 2023
Accepted:
January 16,
2023
Received in revised form:
January 1,
2023
Received:
September 24,
2022
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© 2023 The Author(s). Published by Elsevier B.V. on behalf of INDIACLEN.
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