Correlation between Ethical Intelligence, Quality of Work Life and Caring Behaviour of Paediatric Nurses

Abstract Aims The aim of this study is to determine correlation between paediatric nurses' “ethical intelligence” with “quality of work life” and “caring behaviour.” Design Descriptive correlational study. Methods Data were collected with EIQ, QWL and CBI. Two hundred and one nurses and 201 caregivers of children hospitalized in a paediatric hospital in Tehran were randomly selected as participants. Data were analysed by SPSS. The data were collected in 2019. Results Comparison of the subscale “ethical intelligence” with the scale “quality of work life” indicated a significant positive correlation between “honesty” with “job and carrier satisfaction” and “forgiveness” with “job and carrier satisfaction”. In addition, findings showed a significant positive correlation between “honesty” and “control at work” and between “accountability” with “home–work interface.” There was no significant correlation between “ethical intelligence” and “caring behaviours” and between nurses' “quality of work life” and “caring behaviours.” Structural equation modelling showed a correlation between nurses' “ethical intelligence” and “quality of work life.”


| INTRODUC TI ON
Developing ethical intelligence makes individuals, organizations and social systems more positive and healthy (Ghayumi & Imani, 2015).
Studies show that there is a relationship between awareness of professional ethics and compliance with nursing standards in hospitals (Abedi et al., 2015). The quality of care depends largely on the performance of the nurses. Also, Ethics and clinical practice cannot be separated. As a result, nurses' ethical behaviour is considered an effective factor in improving and restoring clients' health (Tanner & Christen, 2014). Assessment of nurses' caring behaviour is different when children are the recipients of care (Salmani et al., 2017). The basic disparities between children and adults, paediatric nursing has its own features that are different from those of adults (Hesanpour et al., 2018). Moreover, nurses' quality of work life influences patient safety and health outcomes both directly and indirectly (Wu et al., 2011). Therefore, emphasizing the promotion of ethical environment through the cultivation of ethical intelligence can eliminate

| Background
Nursing care is an intrinsic issue, and it is expected that nurses behave ethically all the time as part of their professional character. It is highly important for nurses to remain sensitive to the consequences of their interventions for patients despite various ethical problems they encounter (Escolar-Chua, 2018). Nurses' performance is based on humanistic values and the quality of the care provided depends greatly on nurses' performance, ethics cannot be practically separated from clinical practice (Beykmirza et al., 2019). Since nurses form the greatest community in the healthcare system (Pishgooie et al., 2019), their reduced quality of work life may be associated with decreased revenue and organization leave, affecting their occupational performance negatively (Lin et al., 2013). Quality of work life in healthcare organizations has been recognized as a combination of advantages and disadvantages in the work environment (Phan & Vo, 2016). It exerts a significant effect on personnel's behavioural feedbacks such as job and career satisfaction, occupational contribution, professional efforts, occupational fatigue/burn out and organizational change and transfer (Najibi et al., 2017). Factors such as age, gender, work shift, work milieu, occupational satisfaction and work-home equilibrium affect nurses' quality of work life (Lee et al., 2013). According to Said et al, there are six factors related to quality of work life in nursing: Job and career satisfaction, general well-being, stress at work, control at work, home-work interface and working conditions (Said et al., 2015). Additionally, differences in patient satisfaction with nursing care quality may be attributed to various factors including culture, expectations, previous experiences, personal and social values, life style and patients' awareness of their rights (Shahvali et al., 2018). The basic disparities between children and adults, paediatric nursing has its own features that are different from those of adults. Paediatric nursing is exposed to greater risk of occupational dissatisfaction, emotional stress, diminished mental health and occupational burn out due to exposure to emotional tension of child care whereby affecting nurses' quality of work life (hesanpour et al., 2018).
The results of Braithwaite study also showed that the workload in the neonatal department is effective on job satisfaction, quality of care provided and quality of work life of nurses (Braithwaite, 2008).
Also, the result of research in paediatric department showed that the significant positive relationship between quality of work life and quality of nursing care suggests that employees with high quality of work life are able to deliver high quality of care (Mohamed et al., 2016).
Supervision of nurses' work conditions and improvement of organizational conditions of hospitals would predispose to increased patient safety. Managers can influence job satisfaction through affecting the ethical milieu of the organization (Abou Hashish, 2017).
Nurses' ethical behaviour is considered as an effective factor in improving and restoring clients' health (Tanner & Christen, 2014).
Besides, nurses spend more time with patients compared with other healthcare staff. Thus, they enjoy a unique position in the efficacy and promotion of healthcare services (Shahvali et al., 2018). Given that children are not sufficiently grown up to express their own opinions, parents are their legal decision-makers bearing the responsibility of qualitative evaluation of the care given to their children. In the other words, parents are rendered as supporters and decision-makers of hospitalized children and their opinions represent the attitudes of the children. Investigation of opinions of parents of hospitalized children may be considered as a basis for assessing quality care and developing family-centred care and an effective factor influencing the quality of care (Salmani et al., 2017). Therefore according to the present challenges of nurses' ethical intelligence and its association with quality of work life and quality care and specific sensitivity of the issue in paediatric wards the aim of this study was determine the correlation between nurses' ethical intelligence and quality of work life and between nurses' ethical intelligence and caring behaviours in a paediatric hospital.

| Design
The study units in this descriptive correlational study consisted of 201 nurses and 201 caregivers of children hospitalized in a major paediatric hospital in Tehran, capital of Iran. Sample size was calculated in G-Power software. The samples were selected with random simple sampling method. The attendants of hospitalized children were also selected with random simple sampling based on inclusion criteria and hospitalization ward, provided that parents take care of the child under care of nurses participating in the study.

| Measures
Data were collected with the researcher-made "Demographic Questionnaire" and Lennick and Kiels' Ethical Intelligence Questionnaire that is a 40-item instrument and uses a 5-point Likert scale ranging from "never"-"always." Any of 10 aspects of ethical intelligence are assessed with four items. A score of 90-100 is rendered as excellent, 80-89 as very good, 70-79 as good and 69 and less as weak. The face and content validity and reliability of the instrument have been approved by previous studies (Ghayumi & Imani, 2015;Jirdehi et al., 2018). In the present study, Cronbach's α reliability coefficient of the instrument was .92 using internal consistency coefficients. The Nurses' Quality of Work Life Scale is a 24-item inventory developed by Easton & Van Laar. It includes six subscales and uses a 5-point Likert scale ranging from "strongly disagree = 1"-"strongly agree = 5." In this instrument, a score of 23-73 indicates low quality of work life, 74-84 moderate quality of work life and 85-115 high quality of work life. The face and content validity and also reliability of the instrument have been approved in some studies (Duyan et al., 2013;Lin et al., 2013) In this study, Cronbach's α coefficient of the tool was .86. Moreover, the 16-item Wolf et al.'s "Caring Behaviors Checklist" was used with a 5-point Likert scale.
This checklist consists of four subscales of "respect for others," "ensuring of human presence," "communication and positive inclination" and "professional knowledge and skills." The face, content and construct validity and reliability of the instrument were confirmed by previous studies (Asadi & Shams Najafabadi, 2014;Atashzadeh-Shoorideh et al., 2017;Rafii et al., 2008;Wolf et al., 2017).

| Analysis
In the present study, Cronbach's α internal consistency coefficient was estimated at .97.
Sampling was done during the morning, afternoon and evening shifts in eight episodes. First, the Ethical Intelligence Questionnaire and Quality of Work Life Questionnaire were distributed among the nurses and the completed questionnaires were collected.
In addition, child attendants simultaneously with distribution of nurses' questionnaires completed the Caring Behaviors Checklist.
Confounding data were excluded. The sample loss was not significant. In the course of the research, any bias was attempted to avoid.
Data were analysed with SPSS21 using descriptive statistics of frequency, mean, SD, Spearman correlation coefficient and regression analysis using the step by step method (CI = 95%).

| RE SULTS
Demographic variables suggested that 96% of the nurses were female and 4% male. Most nurses (49.3%) were aged between 25-35 years. In addition, 86.6% of them held a BS degree, 58.7% were married and 80.6% had a work experience of 15 years or less.
Demographics of child attendants demonstrated that 96% of them were female, 4% were male, 49% belonged to the age group of 31-40 years, 46.5% held a high school diploma and 52.8% reported a moderate economic status. In addition, 57.5% of children had a history of previous hospitalization.
Other results revealed that the overall mean of nurses' ethical intelligence was at the very good level. The mean total score of nurses' quality of work life suggested that it was at the low level. Besides, the mean score of nurses' caring behaviour was at the moderate level (Table 1).
A comparison of the subscale's "honesty" and "forgiveness" with the subscale "control at work" (p < .05, r = .21) and the component "accountability" with "home-work interface" (p < .05, r = .25) suggested a significant positive correlation. Nevertheless, there was no significant correlation between nurses' ethical intelligence and caring behaviours and between nurses' quality of work life and caring behaviours. Linear regression analysis indicated that ethical intelligence significantly predicted 2.7% of quality of work life; however, it does not predict nurses' caring behaviour (Table 2).

| D ISCUSS I ON
In this study, the total mean score of nurses' ethical intelligence was at a very high level. The greatest mean score belonged to "honesty"  (Jirdehi et al., 2018). Another similar study (2015) reported nurses' ethical intelligence at a good level (4). Akbarilakeh et al. (2019) also reported nurses' ethical intelligence as appropriate (Akbarilakeh et al., 2019). Besides, Langlois and Lapointe (2007) assessed this variable at an appropriate level (Langlois & Lapointe, 2007), a finding which is consistent with our results. In a review study in New Zealand, Wood (2005) demonstrated that most nurses consider the ethical codes, but they do not possess sufficient power and support to perform suitably; this is not consistent with our findings (Woods, 2005).
It appears that nurses' ethical intelligence is higher than moderate in most studies confirming the high rate of ethical intelligence.
This may also be attributed to limitations of the questionnaires as Another finding of the present study indicated that the total mean score of paediatric nurses' quality of work life was low. In this regard, the maximal mean pertained to the subscale "general welfare" and the minimal mean belonged to the subscale "stress at work." In the study by Almalki et al. (2012), performed in Saudi Arabia, the participating nurses generally evaluated their quality of work life at low levels. Furthermore, in the present study, the satisfaction level with the subscale "job and career satisfaction" was low whereas in Almalki et al.'s study, the nurses assessed their satisfaction with nursing as appropriate. In addition, Almalki's study was not consistent with the present study in the subscale "general well-being" as this subscale obtained the highest score of satisfaction in the present study. Besides, in a consistent manner, the participants in this study and in Almalki's study were not sufficiently satisfied with the subscale "home-work interface" (Almalki et al., 2012). Moreover, the study by Ramesh et al. (2013) Kelbiso et al. (2017) referred to education level/literacy, monthly income, working ward and work environment as factors that determine nurses' quality of work life (Kelbiso et al., 2017).
The study by Devi and Hajamohideen (2018) (Devi & Hajamohideen, 2018). In the study by Hemanathan et al. (2017), "work conditions" received the lowest score in nurses' perspective as one aspect of nurses' quality of work life resulting from community's weak mentality towards nurses and lack of their occupational security (Hemanathan et al., 2017). Another finding of the present study showed that the nurses' mean score of satisfaction with caring behaviour was moderate.
This is consistent with the results of the study by Jirdehi et al. (2018) where 73.8% of the patients reported their satisfaction with caring behaviour at the moderate level (Jirdehi et al., 2018). Nonetheless, Dzomeku et al. (2013), inconsistent with our findings, assessed patients' satisfaction with caring behaviour as weak (Dzomeku et al., 2013). The study by Papastavrou et al. (2012) carried out in Cyprus on nurses' caring behaviour suggested a significant difference between nurses' and patients' perceptions of human presence and respect so that the percentage of negative responses to all items under study was greater for patients compared with nurses (Papastavrou et al., 2012).
Caring behaviours are a set of performances and purposive nursing attitudes aimed at meeting patient needs and alleviating their sufferings. Thus, the better the caring behaviour, the easier it will be to transfer professional competency to clients and hence highlighting nurses' concern for patient comfort. As shown in the study by Chen et al. (2018), caring behaviour directly affects self-awareness of critical insight and thought. Also, caring behaviour indirectly influences critical thinking through self-awareness and insight (Chen et al., 2018). On the other hand, many factors may affect nurses' caring behaviour so that the study by Sarafis et al. (2016) suggested that nurses' exposure to stressors is considered as a predictor of nurses' caring behaviour, negatively affecting their quality of work life (Sarafis et al., 2016). Another study (2019)  The present study showed that ethical intelligence predicts 2.7% of quality of work life. This is not consistent with the study by Mohamadi et al. (2014) who showed that ethical intelligence can predict home-work interface, quality of work life and quality of work background, yet it does not play a significant role in predicting quality of work programme (Mohamadi et al., 2014).
It seems that any investment in promoting ethical intelligence improves the aspects of nurses' quality of work life. It is necessary to pay due attention to nurses' quality of work life as a job with high distress and burnout to support work force, promote care and improve the organization. In addition, findings showed positive significant correlations between components of honesty and forgiveness with the subscale "job and career satisfaction," between the component "honesty" with the subscale "control at work" and between the component "accountability" and the subscale "home-work interface." In this regard, Lawler et al. (2005) concluded in their study that forgiveness, as one component of ethical intelligence, affects compatibility with stressful events; thus, the stressful environment of the hospital can negatively affect nurses' quality of work life (Lawler et al., 2005). In this study, there was no significant correlation between nurses' ethical intelligence and its components with nurses' caring behaviour. Indeed, linear regression analysis suggested that ethical intelligence does not significantly predict nurses' caring behaviour.
In this line, the study by Jirdehi et al. (2018), aimed at determining the correlation between nurses' ethical intelligence, nurses' performance and patient satisfaction, indicated no statistically significant correlation among these variables. Although ethical intelligence was estimated in the present study to be similar to the study above, the rate of patient satisfaction with nursing care was moderate (Jirdehi et al., 2018). This is consistent with our results.
On the other hand, other studies were not consistent with our research, such as the study by Updegraff (2013) that emphasized the positive correlation between ethical intelligence and promotion of nursing care (Updegraff, 2013). Donkor and Andrews (2011) showed that teaching of ethical intelligence to nurses increases quality of care Finally, this study was performed in only one paediatric hospital. This limitation attenuates the generalizability of the findings.

| CON CLUS ION
Given the significant correlation between nurses' ethical intelligence and quality of work life and considering low level of nurses' quality of work life in this and similar studies, it may be concluded that any promotion of nurses' ethical intelligence would predispose to an enhancement of their quality of work life. Given that all the nurses in the present study were selected from one hospital, the generalizability of the findings should be with caution. Consequently, it seems mandatory to create the required prerequisites for promoting and substantiating ethical intelligence in nurses to increase patient satisfaction with nursing care leading to nurses' fostered quality of work life.

| Limitation
The limitation of the present study was the use of self-reported questionnaires/tools that may limit the generalization of the results.

ACK N OWLED G EM ENTS
We thank the nurses for their willingness to participate and all individuals who helped us in carrying out the project.

CO N FLI C T O F I NTE R E S T
The authors declare that they have no conflict of interests.

AUTH O R CO NTR I B UTI O N S
All authors (FS, FA, MV, MZ, RSC and BO) have participated in the conception and design, analysis and interpretation of data.

E TH I C A L A PPROVA L
The research proposal was approved with code of ethics no.: IR.Sbmu.REC.1397.056.

DATA AVA I L A B I L I T Y S TAT E M E N T
The corresponding author will provide the data of the article upon request.