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Background
The increasing competition among industries and organizations and the need for organizational change and transformation have attracted the attention of researchers to find effective performance strategies in an organization through understanding organizational issues (1). The recognition of the present era as the
most motivating period for recognizing and implementing management has highlighted the fact that the success of any organization depends on the effective use of human resources (2).
The researchers have recently turned their focus toward management and leadership styles as sets of attitudes and skills developed and exercised by managers. These skills are formed by the following factors: system, values, belief in employees, leadership tendencies, and a sense of security in ambiguous situations (2). The people in authority can select different styles for the management of human resources (1).
Among the various leadership styles, paternalistic leadership as defined in the study by Farh and Cheng (2000) is based on fatherly benevolence combined with strong discipline and authority (3). This style of leadership consists of three basic parts: authoritarianism leadership, moral leadership, and benevolent leadership (3). The paternalistic leaders take on all the duties of a father, such as the provision of care, protection, and guidance (4). In addition, in order to improve organizational performance, safety leadership as a subsystem of organizational leadership can determine the quality of organizational leadership (5).
In this regard, ethical leadership is considered one of the most important characteristics of safety managers. In their study, Homayounfar et al. (2018), pointed to the impact of this leadership style on acceptance, participation, and safety motivation of employees (6). Moreover, in this context, Stacey et al. (2011) found that individuals' distrust in safety leadership was strongly influenced by serious defects in trust and benevolence of leaders (7).
In competition with other organizations, the retention of human resources which is a daunting challenge for numerous organizations is also regarded as a competitive organizational advantage (8). This organizational factor is of great importance since companies actually lose their valuable human talents by losing their employees, and this loss can be to the benefit of competitors. The training of new employees requires significant resources, takes a long time, and involves a slope of the learning curve (9).
Employee turnover can be influenced by organizational factors, such as leadership style (4, 10, 11). Lieberman (2014) considers paternalistic leadership to be effective in reducing employees' turnover intention since it leads to their emotional dependence on the organization and increases their commitment to their job (10). Ethics as one of the important behaviors of leaders performs a determining role in employees' turnover intension and behaviors through affecting organizational commitment and job satisfaction (12).
Therefore, ethical leadership as one of the dimensions of paternalistic leadership has a negative relationship with employees' turnover intention by strengthening the sense of belonging and organizational commitment (12, 13, 14). Authoritarian leaders may also obtain the same outcome by instilling fear in employees (14). Nonetheless, Cherry (2015) reported that authoritarian-led organizations are more prone to employee turnover and absenteeism (15). On the other hand, Elici et al. (2012) have pointed to the predictive role of safety facilities and safety leadership in reducing this tendency (11).
Nevertheless, the influential factors affecting employees' intention to stay or leave the organization are not limited to the aforementioned issues. Psychological factors, such as stress, (16, 12, 17, 18) and physical factors, including musculoskeletal disorders, (19, 20) can be also mentioned as other effective factors. As estimated by the Occupational Safety and Health Association (2017/2018), within 2017-18, 595,000 workers suffered from work-related anxiety, depression, and stress, and 469,000 workers suffered from work-related musculoskeletal disorders. Moreover, 15.4 and 6.6 million lost working days were reported for these workers, respectively (21).
Stress and musculoskeletal disorders can increase employees' dissatisfaction and their desire to leave; however, they can be reduced by the use of appropriate management styles (2, 22), such as authoritarian leadership which is among the organizational stressors (14, 23) and moral leadership style which is in opposition
to stressors (13). Authoritarian leadership in Iranian organizations has presented numerous problems to the implementation of new leadership styles (4).
Moreover, the effect of participatory leadership styles, such as paternalistic leadership, on instilling a sense of security in employees and their reduced turnover intention has been highlighted in various studies. In light of the aforementioned issues, the present study was conducted in a cement factory in southern Iran in 2018 to answer the following questions:
Question 1: Can safety leadership and paternalistic leadership/management style affect stress, work-related musculoskeletal disorders (WMSDs), and employees' intention to stay with an  organization.
Question 2: Do WMSDs and stress affect employees' intention to stay with in an organization?
Question 3: Is paternalistic leadership/ management style related to safety leadership?
 
 

Materials & Methods

 
The present cross-sectional descriptive-analytical study 142 participants who were randomly selected from among all operational workers on fixed day shifts and rotational shiftwork. It is worth noting that subjects could withdraw from the study at any stage they wished. The data about gender, marital status, level of education, and work system were obtained through a researcher-made demographic questionnaire. Moreover, self-reported questionnaires provided the history of work-related musculoskeletal disorders and stress.
The indicators of an intention to stay, paternalistic management (including the dimen-sions of benevolent leadership, authoritarian leadership, as well as ethical leadership) and safety leadership (including the dimensions of decision-making, control, and motivation), were separately assessed in some questionnaires. In addition, a valid body map questionnaire (24) was used to determine the mean severity and location of pain in different organs of the body. To this end, the subjects determined the location of the pain by marking on the body map and indicated the severity of their pain using the ruler in the map diagram of each organ in the questionnaire. The body map divides the whole body into 13 parts, encompassing the left and right organs of the body (24).
As opposed to turnover intention, the intention to stay as a positive issue  motivates the workers to stay and work in organization (25). Work Intention Inventory was designed to assess a set of tendencies that result from
the health conditions of workers (26). This questionnaire consists of five subscales and each subscale has five items which are rated on a 7-point Likert scale. A score of 0 signifies the absence of any intention, while 6 suggests
the maximum intention (26). The validity coefficients of the questionnaire exceeded the allowable limit of 0.80, and the convergent reliability coefficients for the scores obtained from each section were obtained at 0.87 (26). As mentioned earlier, each part of the questionnaire is dedicated to one of the indicators of work intention, and the section of intention to stay was used in the present study.
The questionnaire translated by Tabibi et al. (2014) was used to collect and assess the information related to safety leadership. The reliability, as well as content and construct validity of this questionnaire, have been also confirmed (5). This 32-item questionnaire encompassed the dimensions of safety control, safety motivation, and decision making. The answers were rated on a 5-point Likert scale (very high, high, medium, low, and very low (5).
The paternalistic management was assessed using a scale designed by Cherry et al. (2004) in 26 sections encompassing the dimensions
of paternalistic leadership, including ethical leadership, authoritarian leadership, and benevolent leadership. The items in this scale were rated on a 6-point scale ranging from 1 (strongly disagree) to 6 (strongly agree) (27). The internal validity coefficient scores for the scales of benevolent leadership, ethical leadership, and authoritarian leadership were reported to be 0.94, 0.90, and 0.89, respectively (35).
The data were analyzed in LISREL and SPSS software (version 20). Minimum value, number or score (min), maximum value, number or score (max), mean, and standard deviation were among the statistical characteristics defined for the variables of age, work experience, number of work-related musculoskeletal disorders, safety leadership components (decision-making, control, and motivation), paternalistic leadership components (benevolence, authorita-rianism, and ethics), intend to stay, and stress levels. Furthermore, qualitative variables, including gender, marital status (single, married, and separated), and level of education (under diploma, diploma, postgraduate, bachelor, master and doctorate), work system (fixed day shifts and rotational shiftwork), history of musculoskeletal disorders, and stress (yes and no) were reported using frequency, frequency percentage, and cumulative percentage.
The results of the body map questionnaire for 27 identified areas of the body were summarized in tables (without pain, moderate pain, painful, and very painful) using frequency, frequency percentage, and cumulative percentage. The multivariate analysis technique of Structural Equation Modeling (SEM) was used to analyze and test the simultaneous correlation of the variables. In this model, in order to evaluate the fit of the measurement model and structural model with the sample data, measurement model fitting and reliability of the constructs (items of the questionnaires used in the research) were performed by examining the factor loadings. Cronbach's alpha coefficient, as well as its reliability and validity, were confirmed by calculating the average variance extracted (AVE), and divergent validity proposed by Fornell and Larcker (1981).
Finally, the fit of the structural model was performed using three criteria of Z-value, Q², and R². It is stated that a Z coefficient>1.96 is required for each construct to confirm its significance at 95% confidence level (28), and three values of 0.19, 0.33, 0.67 are regarded as criterion values for weak, medium, and strong levels of R² (28). Moreover, Q² >35 indicates the strong predictive power of the model (28).
 
 

Results

 
Based on the results of the study, the mean scores of age and work experience were reported as 35±6.80 and 9±5.43. Regarding marital status, 90.7, 7.9%, and 1.4% of cases were married, single, and divorced, respectively. The majority of employees (43.2%) had a diploma, 23.7%, 20.1%, 10.1%, and 2.9% of subjects had
high school education, bachelor's, associates', master's, and doctoral degrees, respectively.
Moreover, 64.3% and 35.7% of cases were fixed day workers and shift workers, respectively. In addition, 68.5% of employees stated that they had experienced musculoskeletal disorders and 31.5% denied such an experience. A history of stress was confirmed by 66.4% of subjects. The mean scores of decision making, control, and safety motivation were reported as 44.12±18.59, 21.29±9.18, 13.61± 5.59, respect-tively. Other variables, such as benevolence, authoritarianism, and ethics, three dimensions of paternalistic management, obtained the
mean scores of 41.51±15.53, 21.5±6.82, and 15.99±29.4. Moreover, the mean score of intention to stay was calculated at 20.94±6.14.
The results of the body map questionnaire demonstrated that 31 (23.9%) employees reported pain in the lower back as painful and very painful, which was higher than pain scores in other parts of the body. The percentages for the other 26 areas of the body are displayed in Table 1. The convergent validity criterion examines the correlation between each construct and the observable variables within that structure. It showed the appropriate convergence of constructs after calculating the AVE index, which was higher than 0.04 for all constructs.
As the correlation matrix (Table 2) based on Fornel and Larcker method shows, the square root of AVE of the latent variables in the present study which is given in the original diameter of this matrix in most cases is larger, compared to the correlation between them written in the lower and left cells of the original diameter. Therefore, it can be concluded that constructs in the model have a higher interaction with their indicators, compared to other constructs. In other words, divergent validity is desirable.
Cronbach's alpha coefficient indicated that the reliability of each construct was > 0.7, and the mixed reliability index was reported to be >0.7, signifying the relative reliability of the
 

 
Table 1) Percentages of pain intensity in 27 areas of the body

Pain intensity (%)				Body organ	n
Very painful	Painful	Moderate pain	Painless
0.8	10	27.7	61.5	Upper part of the neck	0
0	14	14.7	71.3	Lower part of the neck	1
2.3	5.4	17.7	74.6	Left shoulder	2
0	7	17.8	75.2	Right shoulder	3
1.6	3.9	16.3	77.5	Left arm	4
5.4	8.5	16.2	69.2	Upper back	5
1.6	0.8	18.6	79.1	Right arm	6
6.9	7.7	19.2	65.4	Middle part of the waist	7
7.7	16.2	20	55.4	L6ower part of the waist	8
6.2	7.8	5.4	80.5	Hip	9
0	3.8	9.2	86.9	Left elbow	10
0	1.5	10	88.5	Right elbow	11
0	0.8	14.6	84.5	Left forearm	12
0	2.3	14	83.7	Right forearm	13
1.6	6.3	14.1	78.1	Left wrist	14
4.7	3.9	11.7	79.7	Right wrist	15
1.5	3.1	9.2	86.2	Palm and fingers of the left hand	16
1.5	3.1	10	85.4	Palm and fingers of the right hand	17
0	3.9	14	82.2	Left thigh	18
0	5.4	13.2	81.4	Right thigh	19
4.6	10	16.9	68.5	Left knee	20
4.7	10.9	18.6	65.9	Right knee	21
2.3	2.3	14.1	81.3	Left leg	22
3.1	2.3	14	80.6	Right leg	23
0.8	5.5	14.2	79.5	Left ankle	24
0.8	3.9	14.7	80.6	Right ankle	25
0.8	5.4	12.4	81.4	Sole or the toes of the left foot	26
2.3	3.9	11.6	82.2	Sole or the toes of the right foot	27

 

constructs (28). In addition to reporting Cronbach's alpha coefficients and combined reliability, factor loading values were evaluated, and items 12 and 17 in authoritarianism dimensions with factor loadings less than 0.4 were detected. Thereafter, all factor loadings were higher than 0.4, pointing to the appropriateness of this criterion (Figure 1) (29).

 
Table 2) Correlation matrix and divergent validity of research variables

	Moral	Motivation	Control	Authoritarianism	Benevolence	Management	Safety Leadership	Intent to Stay	Decision Making
Moral	0.740
Motivation	-0.454	0.745
Control	-0.567	0.902	0.860
Authoritarianism	-0.071	0.209	0.300	0.811
Benevolence	0.756	-0.434	-0.541	-0.175	0.856
Management	0.884	-0.468	-0.584	-0.191	1.020	0.676
Safety Leadership	-0.553	0.951	0.972	0.269	-0.568	-0.602	0.820
Intent to Stay	0.605	-0.486	-0.459	0.037	0.616	0.645	-0.526	0.738
Decision Making	-0.540	0.889	0.907	0.253	-0.581	-0.610	0.999	-0.542	0.861

 

Figure 1) Executed model with factor loadings
 

Table 3) T and p-value of the effect of variables on each other

Effect of exogenous on endogenous variable	T Statistics	P-Values
Musculoskeletal -> Intent to Stay	4.102	0.000
Management -> Moral	14.507	0.000
Management -> Authoritarianism	0.904	0.366
Management -> Benevolence	287.229	0.000
Management -> Stress	6.525	0.000
Management -> Intent to Stay	3.497	0.001
Safety Leadership -> Motivation	48.331	0.000
Safety Leadership -> Control	107.380	0.000
Safety Leadership -> Musculoskeletal	0.178	0.859
Safety Leadership -> Intent to Stay	2.410	0.016
Safety Leadership -> Decision Making	336.122	0.000
Stress -> Intent to Stay	0.810	0.418