hhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhhh Copyright © 2022 Tehran University of Medical Sciences. This work is licensed under a Creative Commons Attribution-Non Commercial 4.0 International license https://creativecommons.org/licenses/by-nc/4.0/). Non-commercial uses of the work are permitted, provided the original work is properly cited. Original Article Abstract Emergency medical technicians (EMTs) are very likely to leave the profession due to their obligation to work in critical situations such as the COVID-19 pandemic. This study aimed to investigate the relationship between the ethical work climate and the intention to leave the service among EMTs. In this descriptive correlational study, 315 EMTs working in Zanjan province were surveyed using the census method in 2021. The research tools included the Ethical Work Climate and the Intention to Leave the Service questionnaires. Data were analyzed using SPSS software version 21. We found the mean (SD) score of the organization's ethical work climate to be 73.93 (±12.53), and the intention to leave the service 12.54 (±4.52), which are at a moderate level. A statistically significant positive correlation existed between these variables (r = 0.148, P = 0.017). Also, there was a statistically significant relationship between age and employment status among *Corresponding Author Mohsen Kamali Address: Abhar School of Nursing, Next to Alghadir Hospital, Parastar Blvd., Abhar, Zanjan, Iran. Postal Code: 45616- 88131 Tel: (+98) 24 35 27 94 12 Email: mkamali@zums.ac.ir Received: 28 Jun 2022 Accepted: 23 Oct 2022 Published: 28 Dec 2022 Citation to this article: Mousavi SK, Kamali M, Bahrami Eyvanaki Z. Ethical work climate and the intention to leave the service in emergency medical technicians during the COVID-19 pandemic. J Med Ethics Hist Med. 2022; 15: 9. the demographic variables, and the ethical work climate and the intention to leave (P < 0.05). Our findings indicate that ethical work climate is one of the influential but less noticed factors that affect the performance of EMTs. Therefore, it is suggested that managers implement measures to develop a positive ethical work climate to reduce the tendency to leave the service among EMTs. Keywords: Ethical work climate; Intention to leave; Emergency medical technicians; COVID-19. Ethical work climate and the intention to leave the service in emergency medical technicians during the COVID-19 pandemic 1. Researcher, Department of Nursing, Abhar School of Nursing, Zanjan University of Medical Sciences, Zanjan, Iran. PhD Candidate of Nursing, Shahid Beheshti School of Nursing and Midwifery, Guilan University of Medical Sciences, Rasht, Iran. 2. Researcher, Department of Nursing, Abhar School of Nursing, Zanjan University of Medical Sciences, Zanjan, Iran. PhD Candidate of Medical Education, Department of Medical Education, Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran. 3. Researcher, Department of Nursing, Abhar School of Nursing, Zanjan University of Medical Sciences, Zanjan, Iran. Seyed Kazem Mousavi1, Mohsen Kamali2*, Zeinab Bahrami Eyvanaki 3 Ethical work climate and the intention to leave the service in emergency medical … J. Med. Ethics. Hist. Med. 2022 (Dec); 15: 9. 2 Introduction Leaving the service is defined as the loss of an organization's workforce over time (1), and the intention to do so is an essential and significant prediction of the actual leaving of service. In other words, there is a cognitive stage before the act and refers to the thought or mental decision about staying or leaving the job (2). Job stress has been mentioned as the most important underlying factor for the tendency to leave in many jobs (3). Severe levels of job stress have led to the phenomenon of burnout and leaving the service as one of the problems of employees in many countries. EMTs experience increased levels of stress due to time constraints in performing tasks and skills as well as the critical patient conditions (4). Over the past two years, the COVID-19 pandemic has also put severe stress on health-care providers, and among them, EMTs on the front lines experience unprecedented stress (5). Stressors such as increased working hours, job insecurity, and fear of infecting and transmitting the virus to their families have caused about 40% of health-care providers to have anxiety symptoms (6). According to studies conducted in this field, emergency medical personnel have been the most likely to leave the service in the health system (7). Prior to the COVID-19, the number of employees leaving the service was approximately ten percent (7, 8), which in the current situation has almost tripled to about 30 percent (9). Mirzaei et al. found that during the COVID-19 outbreak, job stressors have led to an increase in nurses’ turnover intention (10). Also, Zandian et al. discovered that proactive psychological support is crucial to prevention of burnout and continuation of nursing services during the COVID-19 pandemic (11). One of the main factors in preventing the creation of a stressful atmosphere in the workplace is the organization's ethical climate. Today, attention to ethical climate is the primary organizational issue that should be at the top of managers' priorities (12). Victor and Cullen believe that ethical climate is one of the most fundamental factors in the tendency or lack thereof among employees to show different behaviors. An ethical atmosphere reflects people's perception of their organization, influences their attitudes and behaviors, and is used as a framework for employee referral (13). In other words, ethical atmosphere is the hallmark of an organization and is an organizational variable that can change or improve the working conditions. The Mousavi SK., et al. 3 J. Med. Ethics. Hist. Med. 2022 (Dec); 15: 9. existence of an ethics-oriented flow within the organization prevents many workplace tensions and promotes satisfaction, commitment, positive interactions and other variables that can improve performance and productivity (14, 15). Since ethical climate is influenced by various factors such as culture, environment, laws, and regulations, it is beneficial and of practical value to study it in different societies, working conditions, organizations and cultures (12). EMTs are the most influential group in the crisis response and are at risk of the destructive effects of job stress. The impact of a stressful work environment on health- care providers' performance is inevitable. Furthermore, considering the sensitivity of pre- hospital emergency care, especially during crises such as natural disasters, fatal accidents and pandemics, the importance of investigating stressors in their work environment doubles. Until now, researchers have studied the effects of several factors on their working environment, but ethical climate seems to have received less attention. The combination of these factors and lack of similar research led us to plan the present study to investigate the relationship between the ethical work climate and the intention to leave the service among emergency medical technicians during the COVID-19 pandemic. Methods The current research was a descriptive- correlational study that investigated the relationship between the ethical work climate of the organization and the intention to leave the service among emergency medical technicians in Zanjan province during the COVID-19 pandemic. The research population included all EMTs of Zanjan province, and the research environment was urban and road emergency medical bases. The data collection method was census, and inclusion criteria consisted of willingness to participate, being employed in urban and road emergency bases, having at least one year of work experience, and having a bachelor's or master's degree in nursing or associate or bachelor's degree in medical emergency. Data collection tools included the Ethical Climate Questionnaire developed by Victor and Cullen, and the Intention to Leave the Service Questionnaire designed by Seashore (13-17). The Ethical Climate Questionnaire was designed in 1988 and had 26 items in five dimensions: care and attention (1 - 7), law (8 - 11), rules (12 - 15), instrumental (16 - 22), and independence (23 - 26). The care dimension is related to the ethical standards of each person in the organization, but the law dimension shows the ethical standards of Ethical work climate and the intention to leave the service in emergency medical … J. Med. Ethics. Hist. Med. 2022 (Dec); 15: 9. 4 the organization. The rules dimension is indicative of individuals’ obedience to the ethical standards of the organization. Instrumental represents the individual performance based on ethical principles, and independence shows the degree of independence of the employees with regard to ethical principles. The items are scored based on a five-point Likert scale ranging between “strongly disagree” with a score of one, and “strongly agree” with a score of five. To calculate the scores for each dimension, the sum of the points of the questions related to that dimension are added together. The score range of this questionnaire is between 26 and 130, with a score of 26 to 52 indicating a weak organizational ethical work climate, 52 to 78 an average ethical work climate, and above 78 a stable ethical work climate (13). The validity of the tool was confirmed in a study by Daneshfard et al., and its reliability score based on Cronbach's alpha for the organization's ethical work climate was calculated at 0.89 (16). In the present study, we determined the reliability of the questionnaire using Cronbach's alpha of 0.95. The 4-item questionnaire designed by Seashore et al. in 1982 assesses the intention to leave the service (17). It uses a five-point Likert scale (very low to very high), and scores vary between 1 and 5. The score range of the questionnaire is between 4 and 20, with a score of 4 to 6.5 indicating the intention to leave the service at a high level, 6.5 to 13 a moderate level, and above 13 a low level. In a study by Alizadeh et al., researchers validated this questionnaire, and its reliability was estimated based on Cronbach's alpha of 0.71 (18). In the present study, the reliability of this questionnaire was 93% using Cronbach's alpha method. This research was conducted at the emergency medical departments in Zanjan province. After obtaining permission from the department managers and an introduction, the researchers announced the study goals and invited the employees to participate in the research, ensuring them that their information would be kept confidential. Next, written consent was obtained and the questionnaires were provided to participants. The researcher was present when the participants were completing the questionnaires to answer any possible questions. Due to the high number of the questions and to prevent fatigue and increase accuracy of responses, each participant was given half an hour to complete the questionnaire. The officials in the emergency bases and the research participants were thanked and assured that the results would be confidential and could be announced to them upon request. After collecting the data and entering them into SPSS Mousavi SK., et al. 5 J. Med. Ethics. Hist. Med. 2022 (Dec); 15: 9. software version 26, the obtained data were analyzed using descriptive statistics (frequency, frequency percentage, mean and standard deviation) and inferential statistics (Pearson’s correlation coefficient, independent t-test and ANOVA). In addition to invoking the central limit theorem, we used the Smirnov-Kolmogorov test to check the normality of the collected data, which was proved based on a significance level above 0.05, confirming that it was reasonable to apply parametric tests to examine the relationship between the variables. Ethical Considerations Prior to conducting this study, the researchers obtained permission from the Research Department and Ethics Committee of Zanjan University of Medical Sciences (IR.ZUMS.REC.1400.101). All the study participants were informed about the objectives of the study, the confidentiality of the information, and the voluntary nature of their participation. Results Out of the 347 EMTs who participated in the study, 315 completed the questionnaires. The Findings revealed that all pre-hospital staff participating in the present study were male, and their mean age and standard deviation was 33.57 ± 5.98. Also, most of them were married and had an associate degree. Demographic characteristics include frequency and percentage, and the total scores of ethical climate and intention to leave the service are listed in Table 1. Table 1- Frequency and percentage of demographic characteristics variables and the total scores of ethical climate and intention to leave the service Variable Number (Frequency) Total Ethical Climate Score (mean ± SD) Total Intention to Leave the Service Score (mean ± SD) Marital Status Single 72 (22.9%) 72.82 ± 12.03 12.33 ± 4.25 Married 243 (77.1%) 73.13 ± 11.71 11.02 ± 4.11 Childbearing Yes 182 (57.8%) 74.32 ± 12.10 11.15 ± 4.56 No 133 (42.2%) 73.18 ± 11.75 10.94 ± 3.19 Degree Associate Degree in Emergency 186 (59%) 71. 39 ± 13.03 12.55 ± 3.07 Bachelor’s Degree in Emergency 109 (34.6%) 72.28 ± 12.93 11.41 ± 4.02 Bachelor’s Degree in Nursing 15 (4.8%) 73.41 ± 11.98 12.04 ± 4.58 Master’s Degree in Nursing 5 (1.6%) 70.95 ± 12.23 11.23 ± 4.22 Employment Status Official 134 (42.5%) 76.53 ± 12.73 11.16 ± 3.50 Contractual 181 (57.5%) 72.01 ± 11.39 14.84 ± 4.01 Work Experience (years) < 5 82 (26%) 73.14 ± 12.43 13.04 ± 4.69 5 - 10 85 (27%) 74.97 ± 12.14 12.34 ± 3.92 10 - 15 107 (34%) 75.23 ± 11.03 11.97 ± 4.32 > 15 41 (13%) 75.07 ± 12.38 10.24 ± 3.82 Service Location Urban 181 (57.5%) 73.40 ± 12.49 12.94 ± 4.54 Road 134 (42.5) 74.74 ± 11.63 11.53 ± 4.12 Ethical work climate and the intention to leave the service in emergency medical … J. Med. Ethics. Hist. Med. 2022 (Dec); 15: 9. 6 Before starting the analysis, we knew that a high score and a low score in the ethical climate variable and its dimensions means a robust and a weak moral atmosphere, in the organization, respectively. Contrary to the scoring interpretation in the organization's ethical climate variable, there is an inverse relationship between the intention to leave the service score and participants' genuine intention to leave. In other words, a rising intention to leave the service score represents a low genuine intention to leave the service and vice versa. In the first step, we found that the participants' scores were at a moderate level in all dimensions of the ethical climate, except the rules and regulations dimension, which was at a low level. Also, the total score of ethical climate was within the moderate range (73.93 ± 12.53). Furthermore, the mean and standard deviation of intention to leave the service in pre-hospital emergency staff was 12.54 ± 4.52, which is also in the moderate range. Mean, standard deviation, maximum and minimum scores, number of questions, score ranges, and score categorizations of the ethical climate and its dimensions are presented in Table 2. We investigated the relationship between ethical climate and its dimensions, and the intention to leave scores. The results of the correlation assessment revealed a significant positive correlation between the total scores of ethical climate and intention to leave the service (r = 0.148, P = 0.017). It can be concluded that with an increase in the total score of ethical atmosphere of the organization, the intention to leave the service decreases. Moreover, an evaluation of the relationship between the ethical climate dimensions and the intention to leave the service scores revealed that there is a significant positive correlation between the total intention to leave the service score and care & attention (r = 0.299, P = 0.000) and independence (r = 0.290, P = 0.000) dimensions of the ethical climate. These results show that as the care & attention and independence dimensions of ethical climate develop and improve, employees' intention to leave the service decrease. We found that there was a statistically negative correlation between the intention to leave the service score and the law dimension of the ethical climate in the organization (r = - 0.138, P = 0.039). This finding indicates that increasing the law dimension of the ethical climate can increase the intention of the pre- hospital emergency staff to leave the service. Mousavi SK., et al. 7 J. Med. Ethics. Hist. Med. 2022 (Dec); 15: 9. Table 2- Mean, standard deviation, maximum and minimum scores, number of questions, and score ranges of the ethical climate and the intention to leave the service Variable Mean ± SD Max. Min. Number of Questions Score Range Categorization of Scores Ethical Climate Care and Attention 24.71 ± 3.06 35 7 7 7 - 35 Low: 7 - 16.33 Moderate: 16.33 - 25. 66 High: 25.66 - 35 Law 8.67 ± 3.03 20 4 4 4 - 20 Low: 4 - 9.33 Moderate: 9.34 - 14.67 High: 14.67 - 20 Rules 12.04 ± 3.11 20 4 4 4 - 20 Low: 4 - 9.33 Moderate: 9.34 - 14.67 High: 14.67 - 20 Instrumental 18.58 ± 3.97 29 9 7 7 - 35 Low: 7 - 16.33 Moderate: 16.33 - 25.66 High: 25.66 - 35 Independence 9.93 ± 2.94 20 4 4 4 - 20 Low: 4 - 9.33 Moderate: 9.34 - 14.67 High: 14.67 - 20 Total 73.93 ± 12.53 114 51 26 26 - 130 Low: 26 - 60.6 Moderate: 60.7 - 95.3 High: 95.3 - 130 Intention to Leave the Service 12.54 ± 4.52 20 4 4 4 - 20 Low: 4 - 9.33 Moderate: 9.34 - 14.67 High: 14.67 - 20 There was, however, no statistically significant relationship between the rules and instrumental dimensions of the ethical climate and the intention to leave the service (P > 0.05). Details of the correlation between the ethical climate and its dimensions and the intention to leave the service score can be seen in Table 3. At the end of our analysis, we investigated the relationship between demographic variables and the main variables of the research. Our findings showed a significant relationship between age and employment status of the participants, and the total scores of ethical climate and intention to leave the service. Based on these results, there is a significant positive correlation between the participants’ age and their ethical climate scores (r = 0.149, P = 0.038). This means that the ethical atmosphere score increases with age. Also, we discovered a significant negative correlation between the age of Ethical work climate and the intention to leave the service in emergency medical … J. Med. Ethics. Hist. Med. 2022 (Dec); 15: 9. 8 the participants and their intention to leave the service score (r = - 0.144, P = 0.045). On the other hand, our findings showed a significant relationship between the scores of the ethical climate and the intention to leave the service, and the participants' employment status. Thus, the ethical climate's mean and standard deviation score was 76.53 ± 12.73 in official staff, and 72.01 ± 11.39 in contractual employment staff, which indicates a statistically significant difference according to the obtained P-value (P < 0.05). This result means that the ethical climate score of official employees is higher than that of contractual employment staff. Moreover, we found a significant negative correlation between the employment status of participants and their intention to leave the service. According to the data from Tables 1 and 4, it can be concluded that the score of intention to leave the service is lower in official employees than contractual employment staff. The statistical relationship between demographic variables and the main variables of the research is presented in Table 4. Table 3. The correlation between the ethical climate and its dimensions, and the total intention to leave the service score Variables Intention to Leave the Service Ethical Climate Care & Attention Pearson’s correlation coefficient 0.299 P- value 0.000 Law Pearson’s correlation coefficient - 0.138 P- value 0.039 Rules Pearson’s correlation coefficient - 0.004 P- value 0.484 Instrumental Pearson’s correlation coefficient 0.139 P- value 0.082 Independence Pearson’s correlation coefficient 0.290 P- value 0.011 Total Pearson’s correlation coefficient 0.148 P- value 0.017 According to our findings, the relationship between the intention to leave the service score and the law dimension of the ethical climate in the organization is a statistically negative correlation (r = - 0.138, P Mousavi SK., et al. 9 J. Med. Ethics. Hist. Med. 2022 (Dec); 15: 9. = 0.039). This finding indicates that increasing the law dimension of the ethical climate can increase the intention of the pre-hospital emergency staff to leave the service. There was no statistically significant relationship between the rules and instrumental dimensions of the ethical climate, and the intention to leave the service score (P > 0.05). Details of the correlation between the ethical climate and its dimensions, and the intention to leave the service score can be seen in Table 3. At the final stage of our analysis we investigated the relationship between demographic variables and the main variables of the research. Our findings showed a significant relationship between the age and employment status of the participants, and the total scores of ethical climate and intention to leave the service. Based on these results, there is a significant positive correlation between the participants’ age and their ethical climate scores (r = 0.149, P = 0.038). This finding means that the ethical atmosphere score increases with employees’ age. Also, we discovered a significant negative correlation between the age of participants and their intention to leave the service score (r = - 0.144, P = 0.045). Therefore, it can be concluded that there is an inverse relationship between age and the intention to leave the service. On the other hand, our findings showed a significant relationship between the scores of the ethical climate and the intention to leave the service, and the participants' employment status. The ethical climate's mean and standard deviation score was 76.53 ± 12.73 in official staff, and 72.01 ± 11.39 in contractual employment staff, which is a statistically significant difference according to the obtained P-value (P < 0.05). This means that the ethical climate score of official employees is higher than contractual employment staff. Moreover, we found a significant negative correlation between the employment status of participants and their intention to leave the service. The results revealed that the difference between official employees and contractual employment staff is statistically significant in terms of the intention to leave the service scores. According to the data presented in Tables 1 and 4, the intention to leave the service score of official employees is lower than that of contractual employment staff. The statistical relationship between demographic variables and the main variables of the research is presented in Table 4. Ethical work climate and the intention to leave the service in emergency medical … J. Med. Ethics. Hist. Med. 2022 (Dec); 15: 9. 10 Table 4. The relationship between demographic variables and the total score of ethical climate and intention to leave the service Demographic Characteristics Variables Test Total Ethical Climate score Intention to Leave Score Age Pearson’s correlation P 0.038 0.045 R 0.149 -0.144 Marital Status Independent t-test 0.157 0.094 Childbearing Independent t-test 0.083 0.533 Degree ANOVA 0.743 0.867 Employment Status Independent t-test 0.023 -0.011 Work Experience ANOVA 0.054 0.062 Service Location Independent t-test 0.133 0.541 Discussion This study aimed to investigate the relationship between the ethical work climate of an organization and the intention to leave the service among emergency medical technicians during the COVID-19 pandemic. Based on our findings, the average score of the organization's ethical work climate was at a moderate level, which is consistent with the findings of studies such as Donkers et al. (19) and Jiang et al. (20). Among the dimensions of the ethical work climate of the organization, only the dimension of law received a low score, and the average scores of the other dimensions were at a moderate level. In this regard, we can say that the law dimension is related to the acceptance and observance of legitimate behaviors by members of the organization, and during the COVID-19 pandemic, the instructions for dealing with this disease have changed several times. It is possible that the EMTs did not have enough opportunities to comply with the regulations and were somehow confused, which in turn has harmed the overall score of the work ethics of the organization. Like the ethical work climate score, the EMTs’ average score of the intention to leave the service was at a moderate level, similar to studies by Mirzaei et al. (10) and Zandian et al. (20), both conducted in the same period of time in Iran. Moreover, among the demographic variables, there was a significant relationship between EMTs’ age and employment status, and the ethical work climate and intention to leave the service scores. According to our findings, participants who were older and had a more stable Mousavi SK., et al. 11 J. Med. Ethics. Hist. Med. 2022 (Dec); 15: 9. employment status better assessed the ethical work climate of the organization and were less likely to leave the service. In line with these results, Teresi et al. also found that participants with a higher level of experience and job stability could provide suitable working conditions in the organization. In other words, highly experienced individuals can play the role of good mediators and positive role models in an organization, which increases EMTs’ motivation to stay in service (21). The findings also showed a positive and significant relationship between the ethical work climate and the intention to leave the service. Given that there is an inverse relationship between the intention to leave the service score and participants' genuine intention to leave, it can be claimed that the intention to leave the service decreases with improvement of the ethical work climate. Consistent with these findings, Hojati et al., stated that improving the ethical climate of the organization increases retention of nurses in clinical work (22). Van den Bulcke et al. also stated that better ethical conditions in the organization reduce the intention of doctors and nurses to leave the service (23). Also, Ghasempour Ganji et al. found that adverse organizational ethical climate positively affects the intention of employees to leave the service (24). Examining the dimensions of the ethical work climate and the intention to leave the service showed a positive and significant correlation between the care and attention and independence dimensions of the ethical work climate, and the intention to leave the service. This result means that providing adequate care and attention and independence by the organization reduces the intention of emergency medical technicians to leave. In this regard, Rubel et al. mentioned that receiving support and attention from the organization's managers reduces the intention of employees to leave the service (25). Findings from a study by Simha et al. also showed that the organization's trust in employees (by allowing them more independence and helping them to improve their performance) reduces their intention to leave the service (26). Furthermore, we found a significant negative correlation between the law dimension of the ethical work climate and the intention to leave the service. This means that a higher score of ethical work climate in this dimension would increase the intention of the staff to leave the service. This finding indicates that the exact implementation of rules and regulations in an organization is always challenging and causes a conflict between personal and organizational interests. This issue is prominent among EMTs, because many of them inevitably have a second job Ethical work climate and the intention to leave the service in emergency medical … J. Med. Ethics. Hist. Med. 2022 (Dec); 15: 9. 12 due to low pay and job instability. On the other hand, most of these technicians work in road stations and travel long distances from home to work every day. Therefore, they may not fully comply with all organizational rules and regulations, and the organization's insistence on strict adherence to regulations can provide the grounds for their desire to leave the service. With regard to the limitations of this study, it is possible that the participants did not complete the questionnaires accurately due to their unique job conditions. Another significant limitation is the dependence of both main research variables on the environment of the study, which challenges the generalizability of the findings. Therefore, we suggest that similar studies be conducted on similar groups of EMTs in different locations with different social, cultural and economic conditions. Conclusion Based on the findings obtained from this study, it seems that managers should take the necessary measures to improve the ethical work climate, increase job satisfaction and reduce the intention to leave the service among emergency medical technicians. In other words, in addition to paying attention to the economic situation and the facilities and equipment of the workplace, managers should plan measures to develop a positive ethical work climate. It is crucial to continue to retain the services of EMTs, especially in critical conditions such as the COVID-19 pandemic. Creating a lively work environment, paying attention to employees' mental and psychological conditions, and improving their interpersonal relationships are among the measures that can improve an organization's ethical environment. Considering that few studies have been conducted on the effect of the ethical work climate on medical emergency technicians, we suggest that future studies examine this issue in the light of other aspects of their work, such as stress, job satisfaction and burnout. Funding Zanjan University of Medical Sciences financially supported our study. Acknowledgements The researchers would like to thank the participants in this study and the emergency bases for their cooperation despite the restrictions caused by the COVID-19 pandemic. Conflict of Interests The authors report no conflict of interest. Mousavi SK., et al. 13 J. Med. Ethics. Hist. Med. 2022 (Dec); 15: 9. References 1. Neves T, Parreira P, Rodrigues V, Graveto J. 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