Relationship between Religious Attitude and Patience in Nursing and Midwifery Students in Shiraz , Iran , in 2015

Maryam Paran , Marzieh Akbarzadeh , Naval Heydari 1 MSc, Department of Pediatric Nursing, Faculty of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran. 2 MSc, Maternal –fetal medicine Research Center, Department of Midwifery, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran. 3 PhD Candidate, Student Research Committee, Department of Nursing, School of Nursing and Midwifery, Shiraz University of Medical Sciences, Shiraz, Iran.


Introduction
uman beings have demonstrated a dire need for a prominent supporter and superior power since the begging of life on earth; therefore, man's need for religion has a historical root (1). Religion as a gift entrusted to human beings develops a philosophy of life, enlightens peoples' intellect, and fulfills the basic needs for the soul; accordingly, religious beliefs are interwoven into human life (2). Religion is a unified system of beliefs and practices relative to sacred things. In this regard, the promotion of these beliefs leads to unity, stability, and individual sustainability (3). These attitudes signify a set of abilities and capacities of religious resources that can be applied in daily life to increase individual adaptability (4).
Larson et al. stated that religious beliefs enhance adaptation mechanisms (5). Lowha Nadal conducted a study on 500 students to assess the relationship between religious attitudes and adaptation to university life. The results of the mentioned study indicated that religious attitudes have a positive effect on new students' adaptation to university life (6). According to the Wolf San Andreas Institute of Health Sciences, 46% and 64% of male and female students suffer from anxiety, respectively.
The studies conducted in Iran demonstrated that about 30% of students suffer from some psychiatric symptoms, especially anxiety disorders and depression, and any mental disorder can affect the academic performance of adolescents (7). Religious beliefs and monotheistic attitudes are factors that can change people's perspectives on life problems (8). Religious beliefs and attitudes bring a sense of security and fill moral, emotional, and spiritual voids in individuals and society. Moreover, they serve as a sanctuary for human beings in the face of life problems and deprivations (9).
Religion gives lives meaning and purpose, a feeling of belonging to supreme power, trust in God's assistance in difficult life situations, as well as social and spiritual support. All these resources can be of great help to religious people in living a better life in the face of stressful life events (10). Numerous studies conducted in recent decades have emphasized the positive role of religion in mental health and considered religious beliefs as one of the factors that reduce psychological stress in life (11)(12)(13)(14)(15)(16)(17).
Patience is another solution suggested by psychologists for the management of life stress and difficulties. Scientific research has undermined some of the constructive features of humans, such as "patience". Moreover, psychologists have devoted little attention to patience as a personality trait, character strength, or virtue (18). Patience is one of the most important coping mechanisms in individual, organizational, social, and family life. It can be of great help in tackling life problems and relieving psychological pressures (19).
Patience as a spiritual coping strategy prepares people to adapt to the environment and difficulties (20). In previously conducted studies, patience has been recognized as a resource people can draw on to promote mental health, resilience, hope, happiness, and positive thinking (21,22). During their academic education, medical students face stressful experiences, such as the stress stemming from theoretical and clinical education, long study hours, distance from family, and insufficient economic-welfare facilities. These factors can negatively affect learning, academic success, as well as the physical and mental health of students (11,23,24).
In this regard, it is of paramount importance to ensure the mental health of nursing and midwifery students as individuals who play a peculiar role in the promotion of community health. Despite the positive role of two factors of religious attitude and patience on students' mental health, there is a dearth of limited studies on the relationship between religious attitudes and patience in nursing and midwifery students. Therefore, the present study aimed to assess the relationship between religious attitudes and patience in nursing and midwifery students.

Methods
The present descriptive-analytical study aimed to determine the relationship between religious attitude and patience among nursing and midwifery students of Hazrat Fatemeh School of Nursing and Midwifery, Shiraz, in 2015. The statistical population of the study consisted of all 300 junior and senior nursing and midwifery students in the Faculty of Nursing and Midwifery of Hazrat Fatemeh (PBUH) in Shiraz. The sample size was estimated at 120 cases using the following formula and parameters based on a similar study (25). However, 144 subjects were considered for the study due to the possibility of incomplete questionnaires. r = 0.32, 0.05 = α, 1-β = 0.9 Finally, 144 students were selected via simple random sampling using random numbers in the class list. The inclusion criteria entailed willingness and giving informed consent for participation in the study, as well as junior and senior nursing and midwifery students. On the other hand, the exclusion criteria were unwillingness to participate in the study or partial completion of the questionnaire. Data collection tools included demographic characteristics form, patience questionnaire, and Religion Attitude scale-Review (RAS-R) questionnaire. The demographic information form included student code, age, gender, marital status, place of residence, semester, and grade point average.
The RAS-R was used to assess students' religious attitudes. This questionnaire RAS-R contains 25 questions within 6 areas related to religious attitudes as worship (prayer), morals and values, the effect of religion on life and behavior (prayer-fasting), social issues, ideologies, beliefs, science and religion. The items were scored on a 5-point Likert scale ranging from strongly agree=5 to strongly disagree=1. The total score range is 25-125. The correlation coefficient of each item with the total score was valid at a P-value of 0.0001. The reliability of this scale was obtained at 0.948 and 0.933 using Spearman-Brown and Guttman methods, respectively. Cronbach's alpha coefficient is equal to 0.954. According to this scale, a score above 100, within 51 to 99, and below 50 signify a strong, moderate, and poor religious attitude, respectively (26).
The Patience Scale was developed by Evans in 1980 for the assessment of patience (27) and translated into Persian by Rezakhani in 2000. This questionnaire consists of 29 three-option items. The items signifying positive, neutral, and negative attitudes were assigned scores of 0, 2, and 4, respectively. Low scores are indicative of a high level of patience. The correlation of the scores of this test with those of Ahvaz aggression inventory on a sample of 100 people (50 females and 50 males) was calculated at 0.33. Moreover, the reliability coefficients of this test were reported as 0.78 and 0.70 using Cronbach's alpha and split-half method, respectively (14).
At the commencement of the study, the participants received information on the voluntary nature of participation and the aims of the study. Moreover, they were ensured of confidentiality of their information. On a final note, after obtaining written informed consent, the questionnaires were provided to the students. The obtained data were analyzed in SPSS software (version 22) using an independent t-test and Pearson correlation coefficient. A p-value less than 0.05 was considered statistically significant. This research project was approved by the Research Ethics Committee of Shiraz University of Medical Sciences, Shiraz, Iran (IR.SUMS.REC. 1395.S101). It should be noted that this study followed the 2010 Helsinki Declaration and COPE2018.

Result
Out of 144 assessed samples, 5 questionnaires were discarded due to partial completion, yielding 139 questionnaires. The majority of students were female (77.7%), ≤ 22 years old (49.6%), single (70.5%), and studied nursing (59%; Table 1). Based on the results of the study, the majority of students obtained average scores in religious attitude and patience ( Table 2). The mean scores of religious attitude and patience were calculated at 97.21±15.5 and 45.94±8.99, respectively.
As illustrated in Table 3, according to the results of the independent t-test, there was no statistically significant difference between the mean score of religious attitude and patience based on demographic characteristics (age, gender, major, and marital status). In the assessment of the relationship between religious attitude and patience using the Pearson correlation test, the correlation coefficient of religious attitude and patience was reported as -0.343 with a significance level of 0.0001. Therefore, it can be concluded that there is a statistically significant relationship between the two variables of religious attitude and patience.

Discussion
The present study aimed to assess the relationship between religious attitude and patience in nursing and midwifery students of Hazrat Fatemeh School of Nursing and Midwifery in Shiraz, Iran. Based on the obtained results, the majority of students had a moderate level of religious attitude, and there was s no statistically significant difference between the two groups of nursing and midwifery. Along the same lines, the results of a study performed on medical students in Mazandaran (Iran) pointed to medical students' positive attitude towards the theoretical foundations of Islam, some ancillaries of the faith, and ethical issues (28).
This discrepancy between the results of the present study and the mentioned study can be attributed to the larger sample size and inclusion of all medical students, not only nursing and midwifery students, in the mentioned study. However, more studies are required due to the limitations of studies conducted in this field. Nursing and midwifery students can provide appropriate spiritual care to patients when they are concerned about their own spiritual-religious attitude.
The rich Islamic culture in Iran provides a suitable context in this regard, and it is expected that the spiritual well-being of students will improve during their academic education. This result can be ascribed to the fact that the nursing and midwifery education system in Iran has not yet included spiritual care and education in its various dimensions as part of its comprehensive curriculum (29). Other studies have suggested that spirituality has received less attention in nursing students' curricula .
The results of the present study pointed to a significant relationship between religious attitude and patience. Given that patience was scored reversely in this study, a lower score is indicative of a higher level of patience, it can be concluded that students with higher levels of religious attitude show greater patience. It is noteworthy that although religious ideas date back to ancient times, experts in the psychology of religion have discussed contradictory views at the theoretical level about the effects of religious beliefs on mental health (34).
In the same context, Sharifi et al. carried out a study to determine the relationship of religious attitude with patience and the general health of students. The results of the mentioned study showed that religious attitude is positively correlated with patience (14). In another study, Mirzaei et al. examined the relationship between religious orientation and patience in nursing students. The results of the stated research showed a positive relationship between religious orientation and patience (19). In their study, Siddiqui et al. assessed the relationship of students' resilience with religious orientation and spiritual intelligence. Based on the results of the referred study, internal religious orientation showed a significant positive relationship with students' spiritual intelligence and resilience (35). Mehdi Yar et al. conducted a study to predict patience based on belonging and attachment to God in students. The findings of the referred study indicated that secure attachment to God can be a positive and significant predictor of patience (36).
In the same context, the results of a study conducted by Marhamati on the relationship between religiosity components and patience study demonstrated that religiosity is associated with increased patience (37). In a similar vein, another study was conducted on 252 Iranian college students (129 females and 123 males) in Iran. The results showed that three types of patience (interpersonal, life hardship, and daily hassles) were associated with higher levels of life satisfaction as well as lower levels of depression, anxiety, and mental disorders (18).
The results of the aforementioned studies are consistent with the findings of the present study. Some researchers, such as those mentioned above, have a positive attitude about the consequences of religious orientation on mental health (38). Nonetheless, some others had a negative assessment of the role and effect of religion on mental health. A review of empirical research is also suggestive of wide discrepancies in the findings regarding the relationship between religious orientation and mental health (39).
Furthermore, some other studies neither agree nor disagree with the effects of religious attitudes. For instance, a cohort study on 543 subjects investigated the effect of pre-adolescent religiosity on mental health during adolescence. Based on the stated study, it is hard to say that there is no relationship between pre-adolescent religiosity and mental health in a clinical group of adolescents. The exception is that among women, strong humanistic beliefs have been associated with internalizing problems (40). This discrepancy in the results of the mentioned studies can be attributed to the impact of religious background on participants. For example, the majority of studies with similar results have been conducted on Muslim and Iranian students.
Therefore, it is of utmost importance to pay attention to the demographic characteristics and context of the study group. The findings of the present study can be justified on the ground that ones' religious attitude can determine how he/she adapts to problems. In the face of difficulties and problems, a religious person can draw on his/her own resources, such as high resilience, patience, and trust in God (41). Different aspects of religion play a key role in the promotion of health in various ways, such as the adoption of a low-stress lifestyle, increasing self-esteem, self-worth, and understanding the controllability of problems.
People with religious inclinations consider events less stressful or as an opportunity for personal and spiritual growth (19). One of the limitations of the present study is the mere inclusion of nursing and midwifery students. Therefore, it is suggested that future research be conducted on students from other medical disciplines and larger sample sizes.

Conclusion
The results of the present study pointed out that students with higher religious attitudes show greater patience. Therefore, the promotion of students' religious attitudes may lead to their greater patience in patient care, which in turn, brings substantial benefits to patients, families, and even the organization .Religious beliefs and attitudes exert positive effects on the ability of people to cope and adapt to problems, and they are closely related to mental health. This highlights the need for fostering deep and heartfelt beliefs and devoting closer attention to teaching students about religion. In so doing, we can strengthen religious values and promote the physical and mental health of students.