Health, Spirituality and Medical Ethics

Introduction
With the advent of positive psychology, many researchers  has paid great concerted attention to the role of moral virtues. Patience is one of the most important moral virtues, which is emphasized in religious texts and plays an important role in the spiritual perfection of mankind (1). The important religions of the world consider patience an ethical virtue (2). More specifically, patience has been pointed out in the Holy Quran 103 times in more than 93 verses, which highlights the importance of patience in Islamic culture. In this regard, Al-Asr Surah is the best Quranic expression of patience.
Due to the importance of patience in religious texts, some moral psychologists define patience a moral virtue related to persistence, forbearance, hesitation, consent, and transcendence of an individual in difficult situations (3). Accordingly, patience is way beyond the delayed satisfaction of needs (4). This ethical concept is directed by religious beliefs, such as faith and trust in God (3). In this respect, God states: “O you who have believed, seek help through patience and prayer. Indeed, Allah is with the patient.” (Surah Al-Baqarah [2:153]).
 One of the internal effective factors of related to this moral virtue can be personality traits (5). Recently, the five-factor personality model with dimensions of extraversion, openness to experience, conscientiousness, neuroticism, and agreeableness has been accepted as the descriptive theory of various personality traits (6). In addition, different studies have confirmed the relationship between these factors and the moral virtue of patience (7, 8).
In addition to the impact of personality traits on the moral virtue of patience, this concept itself can affect other factors, including wisdom. In general, wisdom is considered as one of the highly-valued virtues in different cultures (9). Moreover, wisdom includes five features of critical life experiences, emotional regulation, reminiscence/reflectiveness, openness to experience, and humor (10). It can be stated that wisdom overlaps the realm of values and morality, and the trace of morality is seen in definitions, theories, and models of wisdom. For instance, Berlin model of wisdom studies the effect of personality traits and virtue in the formation of wisdom (11).
Various studies have pointed out the association between different moral virtues and wisdom (12, 13), confirming the relationship between the ethical virtue of patience and wisdom (1). This moral virtue is also one of the important motifs related to wisdom in the implicit theories that have addressed wisdom in all age groups, demonstrating the saliency of the moral virtue of patience among Iranian intellectuals (1). In addition to the relationship among personality factors, patience, and wisdom, studies also support the direct relationship between personality traits (e.g., openness and extroversion) and wisdom (14, 15).
Therefore, the present study aimed to introduce a model based on theoretical model of Berlin as well as other disseminated studies in this field. This newly introduced model investigated the direct effects of personality factors on the moral virtue of patience and wisdom, as well as patience on wisdom. Moreover, this model evaluated the mediating role of patience in the relationship between personality factors and virtue of wisdom. The proposed model of the research is presented in Figure 1. 
 
 

Moral virtue of patience

Personality traits

Wisdom

 
 
 
 
 

Figure 1. Proposed model of the structural relationships between personality factors and wisdom with the mediating role of patience
 
Materials and Methods
This correlational research was performed using structural equation modeling (SEM). Research population included all undergraduate students at Shiraz University, Iran, during the academic year of 2016-2017. In total, 440 subjects consisted the study population based on the rule expressed by Kline (16), in which the number of participants should be 2.5-5 items more than the number of items. The subjects were selected by multi-stage cluster random sampling technique. In the first stage, five faculties of Shiraz University were selected initially. In the next stage, three or four classes from each faculty were chosen randomly. The students of the selected classes formed the participants of the research.
It is worth mentioning that written informed consent was obtained from the subjects prior to the research, and the participants were assured of the confidentiality terms regarding their personal information. All the participants were willing to fill the research questionnaire voluntarily. Those who were not interested subjects to complete the questionnaires, did not take part in this research.
A total of 480 university students received the questionnaire; 440 students of them (281 females and 159 males) participated in the study. They included 115, 100, 76, 94, and 55 undergraduate students from faculties of educational sciences and psychology, basic sciences, technical and engineering, literature and Islamic thoughts, and social sciences, respectively. The mean age of the participants was 21.47±3.80 years. Descriptive data analysis was performed using SPSS (version 21) through mean and standard deviation. Moreover, AMOS (version 21) was employed to test the final hypotheses.
Research instrumentation
This research project benefited from the following instruments: A) Self-Assessed Wisdom Scale, B) Scale of tolerance, and C) Big five personality traits.
Self-assessed wisdom scale
 Webster (17) designed a 40-item scale to measure and evaluate wisdom. In this scale, items are scored based on a six-point Likert scale from completely disagree (score 1) to completely agree (score 6). In addition, this scale consists of five subscales of critical life experiences, emotional regulation, reminiscence/reflectiveness, openness to experience, and humor. The results of the factor analysis showed the validity of the five-component model. In addition, Cronbach’s alpha estimate of the reliability of the whole scale was 0.90, and reliability of the post-test after two weeks was 0.84 (18). The confirmatory factor analysis of extracted fit indexes demonstrated that the five-factor model fitted the data, compared to the original model (19). In addition, an acceptable level of Cronbach’s alpha was reported in this regard.
In the present research, confirmatory content analysis was utilized to assess the validity of the research, where the results were indicative of acceptable fit indexes. In addition, Cronbach’s alpha estimate of the reliability was 0.61, 0.76, 0.76, 0.74, and 0.55 for the components of critical life experiences, emotional regulation, reminiscence/reflectiveness, humor, and openness to experience, respectively. Furthermore, the reliability of the whole scale of wisdom was 0.88.
Scale of patience
 This scale was designed by Khormaei et al. (3) consisting of 25 positive and negative items scored based on a five-point Likert scale. Reliability and validity of the scale were assessed using exploratory factor analysis through principal component analysis by Varimax rotation (3). The results of factor analysis confirmed the presence of five factors of transcendence, forbearance, consent, persistence, and delay. Cronbach’s alpha estimated the reliability of transcendence (8 items), patience (7 items), consent (4 items), persistence (3 items), and delay (3 items), as 0.84, 0.67, 0.60, 0.61, and 0.68 respectively. In addition, Cronbach’s alpha calculated for the whole items was 0.86 (4).
In the present study, confirmatory factor analysis was applied to evaluate the validity of the scale, which showed fit indexes. Moreover, the Cronbach’s alphas calculated the reliability of 0.81, 0.67, 0.52, 0.74, and 0.50 for the components of transcendence, forbearance, consent, persistence and hesitation, respectively. Furthermore, the reliability of the whole items estimated as 0.82.
Big five personality traits
In this study, the researchers employed the modified version of Big-five factor personality test(20) designed by Khormaei et al. (21) to assess big five personality traits. Exploratory factor analysis by principal component analysis with Varimax rotation was employed to determine the validity of this 21-item questionnaire (short form). The results of factor analysis confirmed the presence of five factors. In the current research, validity was determined by measuring the correlation coefficient of items of each factor with its total score. All coefficients were reported to be significant, and each item showed the highest correlation with its factor. In this respect, the correlation of the items with the total score was estimated as 0.48-0.64, 0.61-0.77, 0.50-0.71, 0.54-0.72, and 0.66-0.70 for the dimensions of extraversion, agreeableness, conscientiousness, openness to experience, and neuroticism, respectively. Furthermore, Cronbach’s alphas estimation of reliability was 0.70, 0.68, 0.55, 0.74, and 0.53 for the dimensions of extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience, respectively.
Results
The estimation of the mean and standard deviation was 2.98±16.63, 2.71±15.88, 2.96±12.29, 2.96±12.29, 2.73±14.15, 11.50±84.04, and 19.92±186 for the dimensions of extraversion, agreeableness, conscientiousness, neuroticism, openness to experience, patience, and wisdom, respectively. Table 1 shows the correlation matrix related to research variables.
 
 
Table 1. Correlation matrix among personality, patience, and wisdom

7

6

5

4

3

2

1

Variable

1

1. extraversion

1

0.28**

2. Agreeableness

1

0.30**

0.17**

3.Conscientiousnesss

1

-0.25**

-0.14**

-0.15**

4. Neuroticism

1

-0.28**

0.27*

0.20**

0.09**

5.­Openness to experience

1

0.24**

-0.39**

0.43**

0.43**

0.15**

6.­Patience

1

0.50**

0.25**

0.15**

0.16**

0.28**

0.31**

7.­wisdom

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
P≤0.05 *  P≤0.01**
 
 
In order to evaluate the mediating role of patience in the relationships between personality factors and wisdom, the researchers utilized SEM. Figure 2 illustrates the tested structural model and measurement models of the research (i.e., regression coefficients or factor loads of relationship of variables), which shows the model fits the data.
.
 

Figure 2. Structural model of personality factors, moral virtue of patience, and wisdom
 
Table 2. Fit indexes of personality model, patience, and wisdom

PCLOSE		RMSEA	CFI		Tli		IFI		AGFI		GFI		x/df	Index
0.14		0.05	0.94		0.90		0.94		0.91		0.95		2.43	Value

Table 3 indicates the obtained results of the direct, indirect, and total effects of investigated research variables.
 
 
 
 
 
 
Table 3. Direct, indirect, and total effects of investigated variables

Total effect	Indirect effect	Direct effect	Variable	Path
0.26** 0.14** 0.12** 0.15** -0.13** 0.43**	-	0.26** 0.14**	Extraversion Openness	On wisdom
	0.12**	-	Agreeableness
	0.15**	-	Conscientiousness
	-0.13**	-	-0.13**
	-	0.43**	-

 
 
 
 
*P<0.01
**P<0.001
 
 
According to the data presented in Table 3, the dimensions of extraversion and openness to experience had a direct impact on wisdom (β=0.26 and β=0.14, respectively, P=0.001), whereas, the dimensions of agreeableness, conscientiousness, and neuroticism had an indirect effect on wisdom (β=0.12, β=0.15, and β=-0.13, respectively, P=0.001). Moreover, agreeableness, conscientiousness, and neuroticism had direct effect on patience (β=0.29, β=0.35, and β=0.30, respectively, P=0.001). Similarly, there was a direct relationship between patience and wisdom (β=0.43, P=0.001). Therefore, the findings supported the research hypotheses regarding the direct and indirect effect of personality on wisdom, as well as the direct impact of personality on patience, and patience on wisdom.
Discussion
This study aimed to evaluate the relationship between personality factors and wisdom with the mediating role of the moral virtue of patience through SEM.  According to the obtained results of the study, the personality traits of agreeableness, conscientiousness, and neuroticism predicted the moral virtue of patience. In other words, they had a direct effect on wisdom, which is in line with the obtained results of other studies (7, 8).
Regarding the relationship between agreeableness and moral virtue of patience, it could be concluded that individuals with the high level of agreeableness had higher sense of altruism and sympathy, which was directly related to patience in social interactions (5). These individuals act peacefully and do not tend to struggle with others. Therefore, they show a higher level of patience at the time of disaster and interpersonal problems. With steadiness and internal resistance, these individuals avoid harsh and emotional reactions and they can greatly deal with problems with high inhibition power. Therefore, it seems that there is a relationship between agreeableness and patience.
In terms of the relationship between conscientiousness and patience, it could be stated that individuals with deontological ethics had a low level of negligence and lethargy (22). These individuals have shown greater tolerance in different life situations due to their discipline, coherence, and their goals in life (23) as well as their ability to pursue and achieve those goals.
These individuals are not into negligence and delay in various situations and have a high level of self-regulation in conducting their routine and personal tasks. They observe the scope of morality and consider the red lines of ethics in their behaviors. In other words, thoughtfulness and long-term goals enable people to be more tolerant and not transgress the lines to accelerate the process of reaching the destination. Foresight in these people leads to a high level of patience in affairs. In other words, deontologists are persistent both in the decision-making and performance with no rush, which is indicative of a relationship between conscientiousness and patience.
With regard to the relationship between neuroticism and moral virtue of patience, it can be said that the high score in neuroticism includes the lack of psychological adaptation and unfavorable emotions (24), which can cause intolerance and insecurity in people. They have anxiety, depression, and emotional instability, with the experience of a wide variety of negative emotions, which increases the possibility of abusive behaviors in these individuals (25). In addition, they would perform non-tangible behaviors with almost involuntary attitudes, which have a negative association with patience.
Wrong temperament and extreme experience of anxiety and fears make these individuals more vulnerable to psychological and physical challenges. It is clearly observed that all these experiences and attributes can reduce the strength of endurance and patience in individuals. According to the results of the current study, the dimensions of extroversion and openness to experience were able to directly predict wisdom, which is consistent with the results of some studies (14, 15). In the mentioned studies, personality is introduced as the foundation of wisdom and could be explained based on the Berlin model, in which wisdom includes the behaviors that are internalized in the person and become a part of his/her personality.
To explain the association between wisdom and the variables of openness to experience and extroversion, it can be stated that willingness to learn and gain experience is continuous and constant in wise people (26). Despite the trust in their knowledge, these people pursue their knowledge development with a dynamic learning tendency. Therefore, the trait of openness to experience and engagement in social activities, along with the adoption of an energetic approach toward the material and social world, in extroverts equip them with the ability to examine various ideas, thereby gaining in-depth knowledge. Accordingly, these conditions set the ground for the improvement of wisdom in these individuals. 
In addition, our findings were indicative of a direct relationship between the moral virtue of patience and wisdom, which is in line with some other studies (13, 14). To explain this association, it can be stated that wisdom develops in the moral principles (26), and adherence to religious and moral principles brings prosperity in wisdom. Therefore, patience heightens the ambiguity tolerance of individuals in different situations due to the fact that patience is like self-strain and tolerance (4). Moreover, patience is defined in recognized religions of the world as a moral virtue of an individual, which enables them to deal with everyday hardships and big challenges (2). As a result, patience helps individuals to accept situations, which seem difficult or even impossible to change. Patient people act with wisdom in face of incidents and events; moreover, they consider the consequences of their behavior, which enables them to avoid hasty decisions. Accordingly, patient people can also be wise, meaning that it is possible to predict wisdom by moral virtue of patience.
Finally, the obtained results of the present study revealed that agreeableness, conscientiousness, and neuroticism affected wisdom with mediating role of moral virtue of patience. Furthermore, positive personality traits, such as conscientiousness and agreeableness (with adhesion to moral principles, high self-control, and self-regulation in social interactions), can affect the patience level of people in face of problems as well as their persistence against the harms caused by others. Therefore, individuals with these traits can increase their level of wisdom by selecting challenging activities. On the other hand, negative personality traits, such as neuroticism, cause intolerance in people through the intensification of impulsive and instable behaviors when they deal with life issues. Such people act less thoughtfully and patiently in their life and are always looking for immediate results with the least effort. It is clear that their developmental process of wisdom is interrupted as soon as they show impulsive behaviors with no thought and patience. 
Conclusion
According to the results of the study, the moral virtue of patience was one of the effective variables in the relationship between personality factors and wisdom. The reason is that it affects wisdom, while it is affected by personality factors. Therefore, the moral virtue of patience has cause and effect roles. As a result, positive personality traits (e.g., agreeableness and conscientiousness) develop wisdom by affecting the enhancement of patience. It seems that individuals with positive personality traits are more patient in special situations and are, therefore, wiser. Moreover, the personality trait of neuroticism had an indirect and adverse effect on wisdom.
Therefore, it is concluded that the relatively stable and unchangeable personality traits have an indirect effect on wisdom with the mediation of patience. Considering this, it is of utmost importance to help individuals with various personality traits to benefit from the moral virtue of patience in order to develop their wisdom. In doing so, it is suggested to promote educational program on the basis of patience as well as development of patience-based materials.
Conflicts of Interest
Authors declare no conflicts of interest.
 
 Acknowledgments
This research was extracted from a PhD dissertation in Shiraz University entitled “Determining wisdom based on personality traits, successful intelligence with the intermediation of ethics (patience) and coping self-efficacy” approved with the code of 110. Hereby, we extend our gratitude to the participants of the study and authorities of the Shiraz University for assisting us in performing this research.