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The association between workplace spirituality and Job Stress with occupational ethics through mediating role of Job Enthusiasm among nurses in Zahedan City , 2017

Article Info Background: Observing ethical principles is a part of nursing occupation and nurses should be aware of the importance of this subject when providing nursing care in order to provide their skills based on occupational ethics. Therefore, this study was conducted with the aim to investigate the relationship between occupational stress and the workplace spirituality with the nurses’ occupational ethics through the mediating role of job enthusiasm. Materials and Methods: This was a cross sectional-descriptive study. The study population consisted all man and woman nurses working at hospitals in Zahedan City, Iran. Cluster sampling method was used to select the sample group. A total of 160 nurses were selected as the sample for the study. To collect data, the organizational spirituality questionnaire proposed by Milliman, et al., standard occupational ethics questionnaire by Gregory C. Petty and Expanded Nursing Stress Scale (ENSS) by French et al., and job enthusiasm questionnaire were used. The data were analyzed using path analyzing method. Results: The present study showed that the job enthusiasm variable plays a mediating role between workplace spirituality and occupational stress with the nurses’ occupational ethics (P < 0.001). In addition, the positive effect of workplace spirituality (0.277) and negative occupational stress (0.204) was significant on occupational ethics (P < 0.001). Conclusions: The results of the study, in line with other studies, show that occupational stress and workplace spirituality with impact on job enthusiasm can explain the occupational ethics of nurses.


Introduction
Occupational ethics refer to the rules and standards for occupational behavior of individuals (1). The ultimate aim of the nursing occupation is to serve human beings and to realize this only through scientific and ethical care and proper communication with the patient. In practice, it is impossible to distinguish between ethics and clinical practice. Therefore, ethical behavior along with the responsibility of nurses can be considered as effective factors in improving and returning the health of patients (2). Nurses are ethically responsible and should be responsive for their behaviors (3). Patient care is an important concept and indeed the art of nursing and requires the individual, social, moral, and spiritual ability of the nurse to provide good and ethical care. Based on the nature of nursing, more attention must be paid to care ethics compared to therapeutic considerations. Researches haves shown that there is a negative and significant relationship between the general index of occupation ethics and all its dimensions with occupational stress (4). Today, occupational stress can be observed in all occupations and has created many problems for individuals and organizations. Meanwhile, National Institute for Occupational Safety and Health (NIOSH) has introduced nursing at the top of 40 occupations with a high incidence of stressrelated illnesses, and believes that nursing is at the head of high-level careers among healthcare occupations (5, 6). Nursing occupational stress has a high level of physical and mental illness for nurses and affects their mental well-being (7). Occupational stress and its outcomes make nurses follow their work responsibilities with disappointment and lack of motivation (8). This healthcare team have close contact with patients, and hence, they are constantly faced with ethical decisionmaking (9). Workplace spirituality describes the experience of employees who perform their tasks with energy, are internally satisfied with their work, understand the meaning and purpose of their work, and feel that they have effective communication with their colleagues )10(. The study of workplace spirituality can be a powerful positive force for the lives of individuals and may make them work longer, more balanced and meaningful. Moreover, Millman et al. (11) argued that workplace spirituality improves employee attitudes including, increased job satisfaction, job engagement, decreased workplace leave intentions, and increased organizational commitment. All of these directly and indirectly improve organizational performance, profitability and effectiveness. Researches suggest that there is a relationship between occupational ethics and spirituality in the occupational performance of nurses (12,13). Job enthusiasm indicates the amount of incentives and interests of employees in their organization's identity. Therefore, the job enthusiasm can be considered as the amount of energy that a person spends for his or her job; it can also be taken into account as the work effectiveness (14(. In fact, job enthusiasm as a positive phenomenon in the workplace, is very significant for the absence of negative consequences like occupational burnout, error and sabotage in the job, and lack of work from the point of view of conservation of resources (15). Given that job enthusiasm is defined as a cognitive commitment to the organization, or the amount of purely endearing work that the individual shows in his/her work environment, job enthusiasm can be linked to other variables including occupational ethics (16). Zahed et al. (17) concluded that occupational ethics had a direct effect on job enthusiasm. The support of colleagues and supervisors, feedback from performance, diversity of duty and autonomy and learning opportunities are among the sources that increase the employee's job enthusiasm )17(. Job enthusiasm plays a mediating role in the relationship between the psychological climate, perceived organizational support and organizational outcomes like job performance. Moreover, job enthusiasm is correlated with nursing stress (18). When organizational behavior is morally weak, the cost of performance increases explicitly and implicitly. These costs can be identified in different areas of the organization including low productivity, slowness of organization dynamics, lack of transparency and congestion of communications. Based on the viewpoints of the researchers and experts, the factors like structure, technology and equipment are not the only reasons for the success of organizations, rather immaterial and spiritual factors have also been effective in this issue (19). Therefore, considering the importance of occupational ethics in increasing the efficiency and effectiveness of manpower, especially in health care and hospital climate, and due to the ignorance of the indirect effect of workplace spirituality and occupational stress on occupational ethics among nurses in research literature, the present study was carried out to determine the relationship between occupational stress and workplace spirituality with the occupational ethics of nurses through the mediating role of job enthusiasm. In this study, the following hypotheses were investigated: 1workplace spirituality and occupational stress have a direct impact on the occupational ethics of nurses. 2-Working spirituality affects the occupational ethics of nurses by increasing job enthusiasm. 3-Occupational stress affects nurses' occupational ethics through reducing job enthusiasm.

Materials and Methods
This was a cross sectional-descriptive study conducted on all nurses working at hospitals in Zahedan City in 2017. The convenient sampling method was used to select the subjects; therefore, with the permission and collaboration of 6 existing hospitals, 30 subjects were selected from each hospital, hence a total of 180 nurses were selected as the study population. This number of subjects was selected to represent the real community. Acording to Anderson (20), the minimum number of the subjects should be 150 individuals. Researchers attended hospitals after the data collection questionnaires were presented to the nurses. 90% of the total number of the distributed questionnaires (200) was filled completely by the respondents. The study inclusion criteria included working at the hospital for at least 2 years and lack of the psychiatric problems. In addition, the exclusion criteria were the absence of any of these two cases. By following ethical considerations like confidentiality of information and informed consent of individuals, self-report questionnaires were completed by nurses. Data were collected using the Nursing Stress Scale (NSS) questionnaire presented by Gray-Toft and Anderson (21). This questionnaire consisted of 34 questions in the dimensions of patient suffering and death, involvement with physicians, lack of readiness, lack of support, involvement with other nurses, pressure, and uncertainty about treatment with 7, 5, 3, 3, 5, 6, and 5 questions, respectively. The questions of this tool were based on Likert scale with four options as not stressful, rarely stressful, sometimes stressful, and always stressful with a score of 1, 2, 3, and 4, respectively. The range of scores was 34-136 and the scoring was as follows: scores less than or equal to 68, 69-103, and equal to 104 or higher indicated low, average and high stress, respectively. In a study by Rezaee (22), the reliability of the test was obtained through Cronbach's alpha coefficient as 0.74, 0.76, 0.76, 0.76, 0.74, 0.74, and 0.74 for dimensions of patient's suffering and death, conflict with the doctor, lack of adequate readiness, lack of adequate support resources, high working volume, conflict with other nurses, and uncertainty about treatment, respectively. The occupational ethics questionnaire was developed by Gregory C. Petty and includes 23 items (23). The four dimensions of occupational ethics from Petty's point of view were: attachment and interest in work, perseverance and seriousness in work, healthy and human relationships at work, and collective spirit and participation in the work with score ranges of 1-6, 7-12, 13-17, and 18-23, respectively. This questionnaire was based on the Likert scale with options as completely disagree, disagree, neutral agree, and completely agree, with a score of 1, 2, 3, 4, and 5, respectively. For the whole scale, the minimum and maximum score was 23 and 92, respectively. Higher scores reflect more occupational ethics. This questionnaire had the necessary content validity due to the appropriate theoretical foundation and confirmation of the experts. There was no reverse questions in the questionnaire. In the study by Salehi et al. (24), the face, content and structure validity of the questionnaire was evaluated and its reliability was confirmed by calculating the Cronbach's alpha coefficient. The job enthusiasm questionnaire contained 18 questions with the aim to measure the degree of job enthusiasm among the individuals in terms of the dimensions of enthusiasm, endowment for work, and attraction in work (25). The response scale of the questionnaire was based on Likert scale with options of very low, low, sometimes, high, and very high with scores of 1, 2, 3, 4, and 5, respectively, however, this scoring method was inverse in questions 5, 10, and 17. For the whole scale, the minimum and maximum score was 18 and 90, respectively. To total score of the questionnaire was obtained summing up the total scores of all questions together. Higher scores reflected more enthusiasm of nurses at work and vice versa (25). In the study by Kabirzadeh )26,( the content validity of this test was verified and confirmed by the experts. Furthermore, the reliability of the questionnaire was calculated using Cronbach's alpha coefficient. The Cronbach's alpha coefficient was obtained as 0.69, 0.71, and 0.65 for the dimensions of job enthusiasm, endowment for work, and attraction in work, respectively. The organizational spirituality questionnaire proposed by Milliman, et al. (27) was used in order to measure the organizational spirituality. This questionnaire included 20 questions and 3 components. The scoring method in this questionnaire was based on the five-point Likert scale as completely disagree to completely agree with a score range of 1 to 5, respectively. For the whole scale, the minimum and maximum scores were 20 and 100, respectively. Moreover, this questionnaire has been used in various studies so far, and the calculated Cronbach's alpha coefficient was 0.87 for this scale (28). The data were analyzed using descriptive statistics and path analyzing method and the 18 Amos software. Moreover, the Kolmogorov-Smirnov (K-S) test was used to ensure the normal data distribution. Furthermore, a significance level of 0.05 was considered.

Results
Among all the participants in the study, 96 (53.33) and 84 (46.67) were women and men, respectively. In addition, 117 (65.00) and 63 (35.00) of the subjects were married and single, respectively. 36 (20.00) and 144 (80.00) of the participants worked in the emergency department and the nongovernmental sector, respectively. The mean and standard deviation (SD) of the variables studied and their dimensions have been presented in table 1. The K-S test results indicated that the scores were in normal levels. Before examining the research hypotheses in order to obtain more information, the role of the predictor of organizational spirituality, and occupational stress and enthusiasm was studied on occupational ethics. The correlation coefficient of the organizational spirituality, and occupational stress and enthusiasm with professional ethics was R = 611, indicating a high correlation between these variables. This correlation coefficient showed that 47.60% of the variance of the professional ethics involved in the study was explained by the variables of organizational spirituality, and occupational stress and enthusiasm. The role of all three variables was also significant in predicting the occupational ethics (P < 0.001). The path analysis should be confirmed in order to examine the mediating role of job enthusiasm variables among occupational stress and organizational spirituality with the occupational ethics.   reasonable  fitness  and  the  study  hypotheses  have  been confirmed. Therefore, according to these findings, it can be concluded that job enthusiasm plays a significant mediating role in the relationship between organizational spirituality and occupational stress with occupational ethics.

Discussion
The first finding of the study indicates that spirituality has a direct effect on occupational ethics. This result is consistent with the results presented in (29). Since, individuals with high workplace spirituality are more responsible, moral and hardworking, and these attributes are associated with hope for the future and interest and commitment to work. The second finding of the research suggests that occupational stress and workplace spirituality has a direct effect on occupational ethics. The results of the studies by Soleimani (30) and Burke (31) and (13) are in line with those of the present study. Stress is one of the most acute problems of today's organizations which endangers the physical and mental health of the workforce and expose heavy burden on organizations. Regarding the stressful nature of nursing occupation and its effect on burnout due to this occupation (32), it can be indicated that the perception of these stressful situations and the occurrence of burnout can affect the work ethics of nurses. Moreover, it has meaning in working alongside stressors in work and work environment, identifying and preserving real values in work leads to ethical and professional principles in organizations. Another finding of the study suggests that the job enthusiasm has a direct effect on occupational ethics. The higher job enthusiasm among the nurses leads to a higher degree of occupational ethics. Job enthusiasm among the employees is a factor that adds value to the organization and involves conscious and voluntary work of the staff to increase their career level, which results in tasks being carried out in less time and with more interest. This could support the role of enthusiasm in improving nurses' professional ethics (14). Furthermore, despite the inner motive for work and its satisfaction, the values of the organization are maintained without supervision of others. Therefore, the direct effect of job engagement on professional ethics seems natural. Regarding the findings for the effect of occupational stress and workplace spirituality on nurses' occupational ethics through job enthusiasm, it can be argued that nurses with high spirituality in work have high interactions with colleagues and feel pleasure from work and use of full individual power in accordance with the goals and values of the organization. These features will automatically enhance their potential capabilities in the workplace, hence individuals perform their tasks enthusiastically and with the pleasure. The enthusiastic nurses are not only loyal, consistent with organizational goals and values, but also have a strong incentive and are struggling with more enthusiasm. Burke (30) also stated the consequences of occupational stress including reduction of adherence to organizational ethics, resorting to behaviors to avoid work responsibilities, interruptions in effective communication and emotional interruption with the client. In a study by Marchese et al. (33), it was also shown that employees need to make good choices in balancing work demands and family responsibilities; otherwise, in addition to tolerating stress and tension, they will experience moral degradation. Regarding the sources of nurses' occupational stress and the nature of the stressful work of nursing and its effect on nursing job burnout (7), it can be concluded that stressful conditions and the resulting burnout and reducing job enthusiasm can affect nurses' occupational ethics. In general, it can be said that with recognizing the spirituality level in the workplace and occupational stress experienced by nurses, it is possible to predict the extent of their occupational ethics, either directly or through job enthusiasm. The specificity of subjects to nurses in Zahedan is one of the most important limitations of the present research. Therefore, it is suggested that similar researches be conducted in other instances, especially vulnerable businesses.

Conclusion
Predictive variables can contribute to changes in nurses' occupational ethics. Stress management training, having meaning or purpose in the job and increasing job enthusiasm result in improved nurses' occupational ethics. Therefore, it is suggested to make some plans for reducing nurses' occupational stress and increasing workplace spirituality in order to increase their willingness and enthusiasm for addressing patients' problems and concerns in the form of occupational ethics.