1. Introduction

Nurses are among the most important occupational groups and the main body of healthcare organizations in terms of numbers. It is worth mentioning that nursing is considered a stressful job. Due to shift rotations, a nurse usually spends several hours a day in the hospital on weekdays (de Souza, Pessoa Júnior & de Miranda 2017). Literature shows that the shift work nature of nursing has had several negative impacts on their family and social life. Moreover, this condition may lead to the breakdown of common social activities with the spouse, endangering the mental health of nurses (Guo et al., 2016). Work shifts may result in social isolation, increased depression, and reduced mutual marital interactions (Orgambidez-Ramos et al., 2017), which can end in reduced quality of job commitment and job performance of nurses (Farahaninia et al., 2019; Tims, Bakker & Derks 2013). 

Job performance is considered as one of the most fundamental concepts in organizations, based on which, the responsibilities and success of each individual in the organization are formed (Masa’deh, Obeidat & Tarhini 2016). Lazaroiu (2015) believes that job performance is a product of human behaviors in such a way that motivations and needs of individuals, affect their performance and ultimately, economic growth and development. Job performance is a multidimensional construct, showing the performance of the employees in their jobs, the level of their initiative and problem-solving capabilities, and the strategies for using available resources and time and energy for performing job responsibilities (Viswesvaran & Ones 2017).

Sense Of Coherence (SOC) is one of the effective factors on the job performance of nurses. SOC refers to possessing sufficient resources to withstand stressful situations, including workplace stresses (Ando & Kawano 2018), and involves three components of understandability, manageability, and meaningfulness (Winger, Adams & Mosher 2016). If people possess such a personality characteristic, they will see internal and external stimuli in everyday life as predictable; they also believe that sufficient resources are available for facing the demands of these stimuli (Vainio & Daukantaitė 2016). Various studies have confirmed the relationship between SOC and job performance among employees and nurses (Ehteshamzadeh, Sabri Nazarzadeh & Memarbashi Aval 2014; Memarbashi, Sabri Nazarzadeh & Abdolkhodaei 2012; Debska, Pasek & Wilczek-Rużyczka 2017).

Professional ethics constitute another factor that seems to affect the job performance of nurses. Many successful workplaces have realized that an ethics-based culture must be present in the organization (Banks 2015). Professional ethics, with the meaning of respecting the rights of individuals in a profession, has a much broader concept than the professional regulations and rules. Professional ethics are more wide-ranging than the law since many ethical considerations have not been ratified in the form of laws (Kangasniemi, Pakkanen & Korhonen 2015). Various studies have confirmed the relationship between professional ethics and job performance among employees and nurses (Sagheb Esmaeelpour et al., 2019; Taheri Attar, Pourahmadi & Herati 2019; Shaghozaei Marziyeh & Nastezaei 2018; Özden et al., 2019; Skela-Savic & Kiger 2015). 

Through affecting the perceived organizational support, both SOC and professional ethics can be effective for the job performance of nurses. The theoretical foundations of organizational support are rooted in the social exchange theory. According to this theory, if someone helps or does a favor for someone else, the other party will be obligated to reciprocate the favor (Lamm,Tosti-Kharas & King 2015). In other words, perceived organizational support refers to the perceptions of the employees about how much the organization values their contributions and how much it cares about their wellbeing (Vasegh Rahimparvar et al., 2018; Caesens et al., 2016). The theory of organizational support posits that employees create a general view about the support they receive from the organization, and in turn, they pay attention to the goals and objectives of the organization as well as the realization of these goals and objectives (Zhong, Wayne & Liden 2016). 

Perceived organizational support is associated with a large number of organizational variables, including the relationship between the employees and their supervisors, and providing rewards. Organizational support creates a positive and safe environment and leads to the loyalty of the individuals towards the organization (DeConinck & Deconinck 2017). The higher the perceived organizational support by the employees, the better their performance, and this increases their efficiency and results in their willingness to stay in the organization. Perceived organizational support reduces occupational pressure and intention to leave the organization (Kim, Eisenberger & Baik 2016). The supporting behaviors of the leaders and the organizational atmosphere can create the perceived supports (Fagbenro, 2019; Zheng & Wu 2018). In similar studies, it has been shown that perceived organizational support was related to job performance. In general, job performance is not only related to people’s mental health but also their productivity. Therefore, identifying the effective mechanisms for coping with mental pressures can help promote mental health and boost the efficiency and productivity of human resources (Ghanbari, Soltaninejad & Badafara 2018; Bai 2017; Nasiri Valikbani 2014).

Considering the profound role of nurses in maintaining the mental-social balance of the community, as well as various personal and occupational problems and issues facing the nurses, there is an urgent need for planning to resolve their problems. On the other hand, according to the research background, the perceived organizational support was used as a predictor variable for job performance. Also, in some cases, perceived organizational support was used as a criterion variable for the sense of coherence and professional ethics. Therefore, in the present study, we used perceived organizational support as a mediating variable to examine how this variable affects job performance in nurses by influencing the SOC and professional ethics.

Based on the issues outlined above, the main objective of the current study is to investigate the mediating role of perceived organizational support in the relationship between SOC and professional ethics and the job performance of nurses in Ahvaz City. Figure 1 shows the proposed model of research design.


 

2. Materials and Methods

 To attain the objectives of the study, the correlation method was utilized, while path analysis by model-based testing was used for examining the hypotheses. The study population included all the nurses working in Golestan Hospital of Ahvaz City, Iran, in 2019. Using the voluntary sampling method, 290 questionnaires measuring the variables of the study were given to the selected participants to answer. The inclusion criteria were work experience over 6 months, age range between 21-48 years, having no mental disorders, and written consent to participate in the research. The exclusion criteria included failure to completely answer all the questions and a lack of willingness to continue participating in the study. Ultimately, 252 questionnaires were filled out by the subjects and analyzed.

Research instruments 

Job Performance Questionnaire 

The job performance questionnaire was developed by Paterson (1970). It includes 15 items used to measure the job performance of employees. The scoring for the questionnaire is based on a 4-point Likert-type scale where scores of 0, 1, 2, and 3 are given to options “rarely”, “sometimes”, “often”, and “always”, respectively. The scores for each participant can range from 0 to 45. A higher score indicates better job performance. The content validity of the questionnaire was confirmed by Shaghozaei Marziyeh & Nastezaei (2018), while they reported reliability of 0.82 based on the Cronbach α coefficient for this tool. In the current study, to evaluate the internal consistency of the job performance questionnaire, a Cronbach α coefficient of 0.84 was obtained for all questions. 

Sense of Coherence Scale 

The Sense of Coherence (SOC) scale was revised and utilized by Flensborg-Madsen, Ventegodt & Merrick (2006) based on the original version of Antonovsky (1987). This scale includes 35 questions with three or five options. The options for questions 1 to 24 are scored based on a 3-point Likert scale as follows: the option “yes” gets a score of 3, the option “I don’t know” gets a score of 2, and the option “no” gets a score of 1. Moreover, questions 25 to 35 are rated on a 5-point Likert scale, and scored as follows: if the participant chooses either of the two first options (“highly satisfied” and “satisfied”), s/he gets the highest score, i.e. 3. If the participant chooses the option of “sometimes satisfied and sometimes not”, s/he will get a score of 2. Finally, if the participant chooses either of the last two options (“unsatisfied” or “highly unsatisfied”), s/he will get a score of 1, which is the lowest possible score. This scale includes three subscales, including understandability, manageability, and meaningfulness. However, in the Persian version of the scale, the subscales are not delineated. The total score for this scale ranges from 35 to 105. A higher score indicates a higher level of SOC in the individual. Flensborg-Madsen, Ventegodt & Merrick (2006) confirmed the content and construct validities of the scale. To assess the reliability of the scale, he reports the Cronbach α coefficients of 0.87 and 0.86 in two studies, respectively. Moradi, Ghodrati Mirkohi & Hayati (2019) reported that the reliability of the questionnaire was 0.84 using the Cronbach α. In the current study, a Cronbach α coefficient of 0.82 was obtained for all items of the scale after evaluating its internal consistency. 

Professional Ethics Questionnaire

 The Professional ethics questionnaire was developed by Cadozir (2002) and includes 17 closed questions, measuring the dimensions and characteristics of professional ethics based on eight components of accountability, honesty, justice and fairness, loyalty, striving for superiority and competitiveness, respect, sympathy for others, and respect for social values and norms. To score the items in the questionnaire, a 5-point Likert scale is used as “very much” (5), “much” (4), “medium” (3), “low” (2), and “very low” (1). The questions on professional ethics include questions 1 to 17: questions 1 and 2 are related to accountability; questions 3 and 4 to honesty; questions 5 to 7 to justice and fairness; questions 8 and 9 to loyalty; questions 10 and 11 to striving for superiority and competitiveness; questions 12 and 13 to respect; questions 14 and 15 to sympathy for others; and questions 16 and 17 to respecting social norms and values. The total score for this questionnaire ranges from 17 to 85. A higher score indicates higher professional ethics. In a study, Akbari, Ghasemi Shams & Pour Mohammasali Chaijani (2018) reported a Cronbach α coefficient of 0.89 for the reliability of this scale. In the current study, the Cronbach α coefficient for the entire questionnaire was obtained as 0.86. 

Survey of perceived organizational support

 The survey of perceived organizational support was developed by Eisenberger et al. (2001). This survey includes 8 questions and evaluates perceived organizational support. To prevent bias in the answers, some questions are scored as negative, and some as positive. A 5-point Likert type scale is used for scoring, from strongly disagree (1) to strongly agree (5) for the positive questions and strongly agree (1) to strongly disagree (5) for the negative questions. The total score for this questionnaire ranges from 8 to 40. A higher score indicates higher perceived organizational support. The reliability of this scale, using the Cronbach alpha coefficient, was reported as 0.86 by Eisenberger et al. (2001). This scale was translated into Persian by Zaki (2006), who reported reliability of 0.89 using the Cronbach alpha coefficient for 100 participants. Moreover, the validity of this scale was confirmed by Oreizi Samani, Dibaji & Sadeghi (2012) using exploratory and confirmatory factor analyses, which indicated the convergent and divergent validity for the scale. Furthermore, the one-dimensionality of the scale was also confirmed by confirmatory factor analysis. In the current study, the Cronbach alpha coefficient for the entire questionnaire was obtained as 0.82.

Analysis of the data involved both descriptive and inferential statistics including mean, standard deviation, the Pearson correlation, and path analysis. Data analysis was done using SPSS version 24. Model fit was evaluated using path analysis with AMOS software.

3. Results

The participants included 252 nurses (Mean±SD age: 38.46±7.81 years). About 57.53% of the nurses participating in the study were female, and 42.47% were male. Concerning educational level, 85.31% had a bachelor’s degree, and 14.68% a master’s degree. 

Descriptive statistics including mean, standard deviation, and the list of variables of the study are presented in Table 1.



Moreover, the correlation matrix for the research variables is presented in Table 2. 


 

According to Table 2, the results of the Pearson correlation show a positive and significant relationship between all study variables at P<0.01 level. The preliminary model obtained for explaining job performance based on SOC, professional ethics, and perceived organizational support is shown in Figure 2.


 

The root mean square error of approximation index (RMSEA=0.407) showed that the preliminary model required correction (Table 3).



To correct the model, the insignificant relationship between SOC and job performance was eliminated from the model. The final model is depicted in Figure 3. The results confirm the good fit of the model.


 

The findings in Table 4 showed that the relationship between SOC and job performance was not statistically significant (β=0.080, P=0.170).



There was a positive and significant relationship between SOC and perceived organizational support among nurses (β=0.385, P<0.01). There was also a positive and significant relationship between professional ethics and job performance of the nurses (β=0.294, P<0.01). There was a positive and significant relationship between professional ethics and perceived organizational support among the nurses (β=0.421, P<0.01). Finally, there was a direct and significant relationship between the perceived organizational support and job performance of nurses in Ahvaz City (β=0.273, P<0.01). To determine the significance of mediatory-based relations, the bootstrap method was utilized. 

The indirect path from SOC to job performance through the mediating role of perceived organizational support was significant (β=0.050, P<0.01). Moreover, the indirect path from professional ethics to job performance through the mediating role of perceived organizational support was also significant (β=0.088, P<0.05) (Table 5).


 

4. Discussion

The present study aimed to investigate the mediating role of perceived organizational support in the relationship between Sense Of Coherence (SOC) and professional ethics, and the job performance of nurses in Ahvaz City. The results of the current study showed no direct relationship between SOC and job performance. This finding is in contrast to the findings of studies carried out by Ehteshamzadeh, Sabri Nazarzadeh & Memarbashi Aval (2014), Memarbashi, Sabri Nazarzadeh & Abdolkhodaei (2012), and Debska, Pasek & Wilczek-Rużyczka (2017). In those studies, the relationship between SOC and job performance was evaluated using correlation coefficient and regression tests, which showed a significant relationship. While in the current study, the hypotheses were tested using path analysis. It is worth mentioning that in the current study, the relationship between SOC and job performance was significant based on the Pearson test. However, in the proposed model, due to the presence of the mediatory variable, all the contributions and effects from the variable of SOC on job performance have been explained through the mediatory variable, i.e. through an indirect relation. In other words, in this model, the variable of SOC also had an indirect impact on job performance. Therefore, this finding is somewhat in line with the results of previous studies. Specifically, SOC was affecting job performance, albeit in an indirect manner, which means that the presence of SOC in the nurses had an important impact on their perceived organizational support, which in turn affected their job performance. On the other hand, it seems that in the relationship between SOC and job performance of nurses, more mediatory variables may be involved. These may include the individual specifications of participants that can also be effective in perceiving organizational support, affecting job performance, and finally, an increase in job performance. Therefore, it is possible that if we study the effects of the variables of the study more closely, we may find mediatory variables that challenge the direct impact of SOC on job performance. 

There was a positive relationship between SOC and perceived organizational support. This finding is consistent with the results of Qorbanpoor Lafmejani, Yaghouti & Rezaei (2019). To explain this finding, it can be said that SOC is felt when the people believe that the life events they face are understandable and can be resolved, i.e. there are resources for coping with these events. One of the required resources to deal with such problems is the support received from family members, friends, colleagues, and more importantly, from the boss, the supervisors, or the superiors, that could have various aspects Lamm, Tosti-Kharas & King (2015). Hence, SOC increases the perception of organizational support. In general, SOC affects the nature of interpersonal relationships when facing uncomfortable situations and problems. Moreover, utilizing transcendental awareness, creation of personal meaning, critical thinking, and the development and expansion of the state of consciousness could affect job performance (Winger, Adams & Mosher 2016). Besides, SOC provides a framework for identifying and organizing skills and capabilities as well as valuable insights, including a set of required beliefs and values. Also, these characteristics can affect the perceived organizational support (Qorbanpoor Lafmejani, Yaghouti & Rezaei 2019). 

The results showed a positive and significant relationship between professional ethics and job performance. This finding is consistent with the research results of Sagheb Esmaeelpour et al. (2019), Taheri Attar, Pourahmadi & Herati (2019), Shaghozaei Marziyeh & Nastezaei (2018), Özden et al. (2019), and Skela-Savic and Kiger (2015). To explain this finding, it can be said that professional ethics play an important role in job performance. Accordingly, religious beliefs and rituals help individuals manage their problems and tensions in cognitive, emotional, and physiological dimensions (Ekramifar et al., 2018). Moreover, these beliefs can help them to accept responsibility for their thoughts and actions when they confront conflicts and challenges and try to change them (Taheri Attar, Pourahmadi & Herati 2019). When employees show perseverance and seriousness in the workplace, respect healthy and human-based relations in the workplace, and have a collective spirit and participatory disposition, improved job performance can be expected (Ekramifar et al., 2018). 

There was a positive relationship between professional ethics and perceived organizational support. In other words, by promoting the professional ethics of the nurses, their perceived organizational support increases. To explain this finding, it can be said that organizations are always looking to find strategies for increasing the work efficiency of their employees (Özden et al., 2019). Moreover, organizations require employees with high levels of professional ethics who are accountable for the responsibilities and tasks delegated to them (Skela-Savic & Kiger 2015). Ethics leads the employees to receive organizational support from their superiors, and it increases their popularity in the organization since these people can contribute to the organization’s dynamics more than any other type of employee (Chye Koh & Boo, 2004). 

There was a positive relationship between perceived organizational support and job performance. By increasing perceived organizational support among nurses, their job performance improves. This finding is consistent with the research results of (Ghanbari, Soltaninejad & Badafara 2018; Bai 2017), and Nasiri Valikbani (2014). To explain this finding, it can be said that a high level of perceived organizational support has led to nurses’ commitment to the organization. So they have reciprocated these benefits and rewards with improved job performance. Since employees are the most important capital for any institution, the organization must provide comprehensive support for them (Bai 2017). When employees believe that they are supported by their favorite organization, they will be assured that the organization will support them in facing managerial conflicts and stressful situations. As a consequence, they like to assume higher value and respect for the organization and contribute to the organization’s goals and objectives. 

The results showed that perceived organizational support plays a mediating role in the relationship between SOC and job performance. To explain this finding, it can be said that the SOC among nurses leads to higher physical health for them (Masanotti et al., 2020). In other words, a higher sense of coherence among employees leads to increased organizational support from the supervisors, and in turn, the improved job performance of employees. When people perceive an environmental stimulus, the cognitive representation of that stimulus is created in their minds where the controllability of the stimulus is evaluated. Ultimately, the motivations and incentives of the people to deal with that stimulus determine its value and significance (Nasiri Valikbani 2014). 

The steps followed in an individual’s mind for evaluating a situation are a part of the sense of coherence. Employees with a stronger SOC have higher levels of adaptability and flexibility in their occupations and their workplace, which results in improved job performance. The attitude of these employees towards the situation, themselves, and their capabilities, as well as the value of their activities, make them decisive individuals. While employees with a weaker SOC understand their surrounding environment in a way that creates lots of problems for them. They believe life events to be uncontrollable and they don’t have the necessary resources to deal with the demands of such events. For this very reason, they consider life to be valueless and meaningless (Masanotti et al., 2020). In other words, they overestimate the stressful situation or stimulus and underestimate their abilities, causing them to be overwhelmed by the complications of the workplace stress, which not only damages their health but also reduces the perceived organizational support, leading to reduced job performance (Bai 2017). Thus, perceived organizational support could properly play a mediating role between SOC and job performance. 

Perceived organizational support plays a mediating role between professional ethics and job performance. To explain this finding, it can be said that if the employees have a higher commitment to the principles and criteria of professional ethics, they will have a higher perceived organizational support (Niazazari et al., 2014). Moreover, professional ethics improve and boost the personal accountability of the nurses in the hospital. The presence of professional ethics in nurses has increased the perceived organizational support from supervisors and superiors, improving the job performance and work efficiency of the nurses (Skela-Savic & Kiger 2015). Therefore, if nurses are hardworking, committed to their occupational responsibilities, accountable to patients and their companions and responsible, and if they pay more attention to the internal incentives for their job and have a collective spirit with their high popularity, they can receive higher levels of organizational support from coworkers and superiors. These conditions improve work conditions and job performance while minimizing the stress caused by work pressure and their work shifts (Hadian Jazi, Peyrovi & Zareian 2019).

The results of the current study showed that the sense of cohesion had a positive effect on perceived organizational support. Also, professional ethics had a positive effect on job performance and perceived organizational support. Finally, perceived organizational support had a positive effect on job performance. Therefore, perceived organizational support could properly play a mediating role in the relationship between professional ethics and job performance. According to our results, the proposed model provides a good fit, that is an important step towards identifying and understanding factors affecting job performance of nurses. This model can be considered as a good model for devising and designing programs for preventing tensions experienced by nurses, and it can be useful for increasing their job performance. 

Based on the results of this study, by improving the underlying context for professional ethics and organizational support in an organization, the trust and job performance of employees can be promoted. In this way, by making rational and informed decisions, the long-term interests of the organization can be guaranteed. Since the statistical population of the current study only included nurses working in Ahvaz City, caution must be exercised when generalizing the results of the study to other populations. It is recommended that more studies be carried out on other samples to safely generalize the results.

Ethical Considerations

Compliance with ethical guidelines

The participants willingly completed the questionnaires and signed written informed consent. The study was approved by the Ethics Committee of Islamic Azad University, Ahvaz Branch (IR.IAU.AHVAZ.REC.1398.020). 

Funding

This article was extracted from a part of the PhD. dissertation of Narges Rasouli in the Department of Psychology, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran.

Authors' contributions

Conceptualization, writing the original draft, reviewing and editing the manuscript: Narges Rasouli, Alireza Heidari; Methodology: Narges Rasouli, Alireza Heidari, Farah Naderi; Investigation: Narges Rasouli, Alireza Heidari, Fatemeh Sadat Marashian; Supervision: Alireza Heidari, Farah Naderi, Fatemeh Sadat Marashian.

Conflict of interest

The authors declared no conflicts of interest. 

Acknowledgments

We would like to thank all participants, as well as all nurses and employees of Golestan Hospital of Ahvaz City for their kind support.


 

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