The study of the intention to leave work and its relationship with job burnout among midwives: the long-lasting impacts of COVID-19

Background: It is important to evaluate the long-term effects of the Covid 19 epidemic on the tendency of midwives to leave their jobs. The study was aimed to examine the intention to leave work and its relationship with job burnout among midwives working at Ayatollah Mousavi hospital of Zanjan one year after the Covid-19 disease. In a descriptive-analytical study, the tendency of 88 midwives to leave their jobs was evaluated one year after the outbreak of Covid disease in 2021. The midwives were selected by convenience sampling methods. Data were collected using the Maslach burnout questionnaire and Attwood and Hinshaw tendency to leave the job. Data analyzed by descriptive statistics, Chi-square test, Pearson correlation coecient, multiple linear regression model with the stepwise method at 95% condence level. Results: Conclusion:


Maslach burnout questionnaire/inventory
This questionnaire is the most commonly used tool for measuring job burnout. It has 22 items that are assessed in 7 degrees on a Likert scale ranging from never (zero) to very high [6]. Some elements are scored reverse, assessing the severity and frequency of burnout. The questionnaire subscales include emotional exhaustion (9 items), depersonalization (5 items), and personal accomplishment (8 items). In the three lower classes of the burnout subscale, a score of 17 would correspond to a low score in emotional exhaustion, a low score in depersonalization, and a high score in personal accomplishment. In the dimensions of emotional exhaustion, depersonalization, and personal accomplishment, the average level is 29-28, 6-11, and 34-49, respectively. A high level, by comparison, is characterized by a score of more than 30 on emotional exhaustion, more than 12 on depersonalization, and less than 33 on personal accomplishment. In 1992 [18], Filian and Ra ei [19] demonstrated the Persian version of the burnout questionnaire had good validity and reliability, in Garrosa's study reliability was approved with a Cronbach's alpha reliability coe cient more than 0.78 [20].

Anticipated turnover questionnaire by Hinshaw & Atwood
This questionnaire comprised 12 terms that are scored on a 5-point Likert scale ranging from strongly agree to strongly disagree. Thus, the range of scores for each phrase ranges from 0 to 5. Also, the job turnover forecasting tool has an overall score between 12 and 60. Higher scores indicate a stronger desire to leave the job. Scores of 39 or higher (strongly), 29-39 (averagely), and 29 or less (weakly) predict the likelihood of leaving the job. Hariri (2012) validated the validity of the job leaving prediction scale with a Cronbach's alpha coe cient of 0.80 for the entire tool [21].
Data analysis method SPSS software version 16 was used for data analysis. The data were described using descriptive statistics indicators. The Kolmogorov-Smirnov test was used to determine the data's normality. The data were normally distributed. Pearson chi-square tests with a 95% level of con dence were used to examine the associations among variables. The Durbin-Watson was used in this study to test for error independence, and the calculated value was 2.04. To assess alignment, VIF and collinearity tolerances were used. Collinearity and VIF were determined to be 0.97 and 1.02, respectively. Considering the aforementioned information, a Step-wise multiple linear regression model with a 95% con dence level was used to identify the predictors for job leave rates.

Description of burnout and intention to leave the job
According to the result, the average intention to leave job was 29.7 ± 6.75, emotional exhaustion was 16.81 ±5.49, depersonalization was 5.02 ±5.64, and personal accomplishment was 7.55 ±12.86. The frequency distribution of the tendency to leave the job was 45.5% (n = 40) at the low tendency level, 47.7% (n = 42) at the moderate tendency level, and 6.8 percentage (n = 6) at the high tendency level. Regarding the depersonalization subscale, 56.8% (50 people) showed moderate burnout, 20.5 % (18 people) showed moderate burnout, and 22.7 % (20 people) showed higher burnout. Even though 100% (n = 88) of respondents reported high levels of personal accomplishment.
The relationship between demographic characteristics, burnout, and the intention to leave the job The present study found that midwives' employment status had a statistically signi cant relationship with burnout (p = 0.035) and the type of hospital ward (p = 0.020), and shift work (p = 0.011) with the possibility of leaving the job. Thus, depersonalization was more prevalent among employed people who worked as part of a manpower plan, as well as among midwives who worked on rotational shifts in the delivery ward, emergency department, and Covid inpatient ward.
There was, however, no statistically signi cant relationship (p 0.05) between intention to leave job and burnout or other demographic characteristics (Table 1).
There was no correlation between emotional exhaustion and rotational shift work and job abandonment after adjusting the gender, age, marital status, work experience, type of employment, and hospital ward. The odds of intention to leave their jobs were 0.344 times higher in emotionally exhausted individuals, while those who worked rotational shifts had a 0.276 times higher probability of quitting (Table 2).
A substantial positive correlation was observed between burnout subscales and intention to leave work (Table 3).

Discussion
Intention to leave the job The purpose of the study was to examine the intention to leave work and its association with burnout among midwives who work at Zanjan Teaching Hospital; one year after the Covid-19 outbreak. According to the results of this study, approximately half of the participants showed a moderate tendency to quit their jobs (47% moderate, 6.8% strong). In this context, Randa et al. found that in the rst months following the Covid -19 epidemic in Egypt, 24.8% of nurses working in Covid wards were willing to change the type of ward, and 45.2 % were willing to change the type of organization for employment. In non-Covid wards was a rate of 10%, whereas Covid wards had a rate of 34.3 percentage. Also, 51% of nurses in Covid-19 units were dissatis ed, compared to 42.9% in non-Covid units. There was a signi cant correlation between the tendency to quit a job and the number of working hours per week [22]. According to a study conducted in South Korea, 8.2 percentage of hospital employees were willing to leave their jobs during the early stages of the Covid-19 pandemic, with nurses being the most willing to leave. The tendency to quit was in uenced substantially by the type of ward, perceived disease stress, and reported risk of death due to covid [7]. In a study by Xiaoxin Liu et al., there was a moderate tendency for nurses to abandon their careers at the onset of the Covid-19 outbreak in Wuhan, China. Resilience and perceived job bene ts were directly correlated with the tendency to leave a job [23]. Although there were differences in the study population, the tendency to leave the job was higher than reported in the Randa study. Nonetheless, several predictive variables indicate a similar likelihood of leaving the job. The present study thus indicates that midwives who worked rotating shifts on delivery wards, emergency departments, Covidpatient care departments had a higher propensity to leave their jobs. Observations suggest that the continuation of the Covid-19 epidemic poses a serious threat to the increasing tendency to leave work in most countries, including Iran, and health policymakers should therefore pay attention to it.

Burnout
In the study, most participants felt moderate emotional exhaustion, depersonalization, and a low sense of failure up to the point of exhaustion. Employees who worked under a manpower plan were more likely to be depersonalized due to the association between burnout rate and employment status. Based on a meta-analysis of 14 articles, the burnout rate for midwives was moderate (40%), which is consistent with the ndings of the current study [24]. Another study of 27 articles from 17 countries showed that midwives in Australia, Canada, and Senegal suffered the highest burnout rates, while those in Finland and Norway suffered the least. Burnout has been connected to factors such as a heavy workload, signi cant environmental stress, insu cient job experience, and a lack of organizational support [25]. The ndings of Sohrabi et al. (2018) revealed that 28% of midwives working in hospitals and comprehensive health facilities in Sanandaj were struggling with emotional exhaustion, 33% were suffering from depersonalization, and 25.5% suffered from severe burnout failure. Job satisfaction, depersonalization, and failure at work were signi cantly associated with employment status [13]. In contrast to a previous study, ndings from the current study revealed a dramatic increase in midwives' sensation of personal accomplishment since before the Covid-19 outbreak. The difference could be attributed to the prevalence of the Covid -19; and the stress and differences in the research environment. Feeling successful at work leads to increased selfcon dence and mastery of tasks. On the contrary, a sense of personal accomplishment leads to depersonalization. Depersonalization leads to treating patients as if they are inanimate objects, with no regard or feeling. Experts believe that moderate to severe emotional exhaustion is caused by such personal stressors as role con ict, role ambiguity, overwork, interpersonal con icts, lack of independence, support, and reward, all of which contribute to mental exhaustion [26].
Rahmani et al. discovered that during the Covid-19, the components of emotional weariness, depersonalization, and hospital staff personal accomplishment in Zahedan were 23.2%, 7.4%, and 57.5%, respectively. Covid-19 anxiety and burnout were also found to have a strong link. Young and single people with little work experience were more prone to burnout than their colleagues [27]. In terms of feelings of personal accomplishment, the present study's ndings differed from those of the previous study, revealing that during the Covid-19 epidemic, 19 midwives working in the hospital felt more unsuccessful than nurses working in other wards. The mismatch between employment status and salary earned with hard labor in the maternity wards, particularly the double stress caused by Covid-19 infection, appears to cause a sense of personal accomplishment in midwifery staff. As a result, it appears that planning to improve the job satisfaction of medical professionals, particularly midwives, during the Covid -19 outbreak is important. There was a signi cant positive correlation between the burnout subscales and the propensity to quit in the present study.
Rotational shift work and emotional exhaustion also emerged as important factors in leaving a job. Thus, the likelihood of leaving the job was 0.344 times higher in emotionally exhausted people and 0.276 times higher in those who worked rotating shifts. In 2014, Nikbakht Nasrabadi reported a similar result. According to their study, dismissals in emergency departments occurred at a moderate rate, and there was a signi cant relationship between dismissal and burnout [28]. Selda et al. (2020) in Turkey found a signi cant relationship between midwives' resilience and burnout during the Covid-19 epidemic [15]. Another study by Haji et al. in 2020 showed that during the period of the Covid-19 epidemic, there was a positive relationship between job stress and the tendency of Mahabadi nurses to leave the service and a signi cant negative relationship with resilience [29]. Burnout is the opposite of resilience. Through resilience, people can overcome, transform, and even enjoy negative experiences. The study by Ghaderi et al. in 2018 showed that the tendency of Sanandaji nurses to leave their jobs was unrelated to burnout [30]. Observed differences could be due to differences in the statistical population or the prevalence of Covid-19. Amid the Covid 19 epidemic, midwives played a crucial role in ghting the virus and protecting mothers and children. Midwives quitting during this period can impose additional burdens on organizations and increase burnout, resulting in lower quality maternal and child health care. Midwives quitting during this period can place additional burdens on organizations and increase burnout, resulting in lower quality maternal and child health care. Thus, improving the occupational health of midwives is recommended.
The study did not measure the perceived stress or other organizational support of midwives' jobs. Therefore, it is suggested that the generalizability of the results be considered in light of this limitation.

Conclusion
According to the study, we can conclude that there is a moderate tendency to quit a job and a high level of burnout associated with personal accomplishment. Because of the connection between the tendency to leave the job and the emotional exhaustion, it is necessary to build mental strength and resilience in midwives during the Covid-19 epidemic, especially in those who work in delivery rooms and work rotating shifts.