A mixed-methods sequential explanatory design will be used to conduct this study by collecting, analyzing, and integrating the qualitative and quantitative data. The mixed-methods paradigm is based on the principles and logic of pragmatism. According to this paradigm, using qualitative and quantitative approaches results in a better understanding of the problem [24, 25]. This study will have three phases, and the qualitative and quantitative data will be collected in the first and second phases, respectively. Phase one is an exploratory qualitative study to explore challenges experienced by midwifes in working setting in more detail. Phase two is cross-sectional study to assess the evaluation of the working condition of midwives such as job stress, quality of working life, and workload of their job. Phase three is about developing an evidence based and culturally sensitive guideline based on the results of phase one and two and experts’ opinion using the nominal group technique (Fig.1).
First Phase: qualitative study
The first Phase is an exploratory qualitative study with a conventional content analysis approach to explore experiences challenging which midwives are facing in the work setting.
The research participants will be selected through purposive sampling among midwifes who work in hospital or health care centers. After the process of obtaining permission to conduct research from the officials of Ahvaz, Ilam and Tabriz universities, the study will begin. Inclusion criteria including: working in hospitals and health centers, having at least one year of work experience, Absence of any illness or mental disorder. The withdrawal and non-attendance of the participants were considered as the exclusion criteria.
Qualitative data will be collected using in-depth and semi-structured interviews, containing open questions. Before conducting the interviews, the research team reviews the questions, and the ways to obtain valid data and focus on research questions. The interviewer will pilot the interview on a subset of participants, and used this information to further refine the guide with respect to culturally sensitive and appropriate questions. The interview will begin with a key question, “What are your experiences and feelings about midwifery?”, “What are the problems with your job at work?”, “What do you think about the various occupational hazards of midwifery?”, What do you think are the difficulties in midwifery?”, “What do you think are the factors that cause problems and occupational hazards?”, and “What do you think are the factors that prevent job problems and risks?” to explore the depth of their experience. During the interview, as far as possible, the Note field will be used and non-verbal data such as tone of voice and behaviors were recorded, too. The sampling will continue until data are saturated. All interviews will be carried out in a quiet room and without someone other than the interviewees.
Data analysis process will be performed simultaneously with data collection using MAXQDA software version 10. The qualitative data will be analyzed using qualitative content analysis based on the Graneheim and Lundman method . In this approach, the data will be analyzed through frequent text reading to obtain a full understanding of it. Then, the texts will be read word by word to extract the codes. First, the objective words that contain the key concepts will be specified. The researcher continued digging the text by taking notes from the initial analysis until the major codes will be extracted. In this process, the code labels reflecting more than one key thought will be directly extracted and specified. Then, the codes will be categorized based on their difference and/or relationships. The codes will be categorized into themes and main categories. Subcategories will be extracted based on differences and similarities.
To validate the results, at first it will be tried to establish a friendly relationship with the participants. In order to increase the accuracy of the data and for verification of the accuracy of the data, after the registration, the interviews will be given to the participants to review and confirm their stated content and, if there will be any other content, it will be added to the data. Interviews will frequently read by the corresponding author of the paper; then, the text of the interviews with the extracted codes and categories will be shared with the colleagues and their comments will be used. External monitoring will be also used to increase the reliability. By providing the initial code derived from the analysis and examples of the extraction, as external observers, the concepts will be given to other researchers who will be not related to the study in order to determine whether they also will have a similar perception of the data or no.
second Phase: quantitative study
First, a cross-sectional descriptive analytical study will be conducted to evaluation of the working condition of midwives.
Sample size and sampling method
After controlling the sample size for research purposes, the maximum sample size was calculated. So that the 95% confidence interval, 90% statistical power was considered. According to the study of Abdolmaleki et al.  considering the acceptable error of 5% around the mean (m=48.86) and the standard deviation of 14.59 for the job satisfaction scale, the required sample size is 137 people and according to the study of Komeili-Sani et al. , Taking into account the acceptable error of 5% around the mean (m=183.08), and the standard deviation of 54.07 for the job stress scale, 135 people were calculated. Also, according to the report of Hadizadeh et al. , the sample size of 54 people was calculated for the quality of work life scale around the mean (m = 65.23), and the standard deviation was 12.16. In addition, regarding the workload of nurses reported by Malekpour et al. , considering the acceptable error of 6% around the average score of physical need (m = 55.83) and the standard deviation of 22.16, the sample size of 168 people was calculated. Considering the maximum sample size based on occupational hazards and considering the design effect and 10% of sample loss, the final sample size of 290 people was calculated for each city.
After the approval of the ethics committee and obtaining permission from the officials of hospitals and health centers, sampling will be done in several stages in the target cities and the sample size will be calculated by considering hospitals and health centers in layers and according to the number. Participants who work in these centers will be considered. Teaching hospitals and a non-teaching (private) hospital will be selected from each city. To select health centers in each city, first the clusters are identified and from each cluster, one or two health centers will be randomly selected using Randomizer software. Centers will continue until the calculated sample volume is reached.
working in hospitals and health centers, having at least one year of work experience, Absence of any illness or mental disorder.
The withdrawal and non-attendance of the participants were considered as the exclusion criteria.
Scales and data collection
Quantitative data will be collected using 5 questioners, including:
1- sociodemographic characteristics questionnaire:
consisted of questions about the Includes age, level of education, employment status, number of years of employment, place of work, job position
2- Osipow job stress questionnaire:
as first developed by Osipow and Spokane in 1987 and consists of 60 items, each of which is answered based on a 5-point Likert scale from 4: most of the time to 0: never. These questions assess six scales including role overload, role insufficiency, role ambiguity, role boundary, role responsibility, and physical environment. In addition, the score range 60–119 is interpreted as low stress, 120–179 as low-moderate stress, 180–239 as moderate-severe stress, and 240–300 as severe stress. Based on previous studies conducted in Iran, the Cronbach’s alpha coefficient for this questionnaire has been reported to be more than 80% [7, 31].
3- Work-Related Quality of Life Scale (WRQoL-2):
Work-Related Quality of Life Scale-2 (WRQoL-2), including 7 factors, 33 items. Using the Likert 5 rating (1 = very disagree, 2 = disagree, 3 = no opinion, 4 = agree, 5 = very agree), convert the score of the reverse items and then calculate the score. The scores of the scale range from 33 to 165. The higher the score of the scale, the higher the quality of work life .
4- Minnesota Satisfaction Questionnaire (MSQ):
The short version of the MSQ-SF assesses job satisfaction using a 5-point Likert scale ranging from one (extremely dissatisfied) to five (extremely satisfied). It consists of three subscales including intrinsic satisfaction, extrinsic satisfaction, and general satisfaction. As a whole, MSQ-SF contains 20 items, and each item represents a feature in the work environment. The possible scores for MSQ-SF range from 20 to 100 . It is a reliable (0.78) and valid (Cronbach’s alpha coefficient: 0.82) questionnaire in Persian language [33, 34].
5- NASA task-load index (TLX):
One of the most widely used instruments for measuring subjective mental workload is the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) . The NASATLX provides an overall index of mental workload as well as the relative contributions of six subscales: mental, physical, and temporal task demands; and effort, frustration, and perceived performance . The psychometric characteristics of the NASA-TLX are well documented, and it has been validated and used initially by the Human Performance Group at the NASA Ames Research Laboratory as a tool for subjective evaluation of individual’s workload in flight simulation, air traffic control studies, automated and manual control, and vigilance tasks. More recently, it has been used in a variety of tasks outside of the aeronautical field including the medical domain .
The quantitative data will be analyzed with SPSS-22. Sociodemographic, job stress, Work-Related Quality of Life, MSQ, and NASA task-load questionnaires score will be described by frequency (percent), as well as mean (standard deviation) if the data are normally distributed. The relation between Sociodemographic with main variables will be determined using the independent test, ANOVA, and logistic linear regression adjusting the confounding variables in the multivariate analysis.
Third Phase: Integration of quantitative and qualitative data
To develop strategies for increasing satisfaction and improving the improving workplace conditions. The results from qualitative and quantitative studies will be delivered to 10–12 experts. Then, their feedback and comments will be taken into account, using the nominal group technique.