Health, Spirituality and Medical Ethics

Introduction
Professional nursing is a supportive profession, and due to the nature of the job, the likelihood of increased mental stress is high [1]. This stress has become a significant problem for nurses, affecting their quality of life and health. One of the related variables in facing nurses’ issues and challenging conditions is psychological hardiness [2]. Hardiness means an individual with a lot of energy and great effort who confronts problems, obstacles, and suffering intensely and powerfully [3]. Psychological hardiness is a favorable personality structure that describes a sense of commitment (instead of surrender), a sense of control (instead of helplessness), and the perception of an issue as a challenge (instead of a threat) [4]. Hardiness is only attributed to constructive and positive adaptation and coping with problems and hardships and is an acquirable and learnable characteristic rather than just an inherent one. This positive characteristic originates from practical and different childhood experiences and gradually appears as a feature in the individual’s behavior and emotions [5].
Spiritual experiences are an essential part of everyone’s life, especially in their professional life [6]. Spiritual experience includes religious attitudes, mental health, supernatural beliefs, and religious practices, such as worship, intimate relationships and friendship with God, God’s attention to the individual, and a positive relationship with God [7]. Daily spiritual experience is the same as finding meaning in life, including understanding the meaning of life, positive experiences, and feelings of happiness and satisfaction with life [8]. Spiritual experience is fundamental in creating meaning and purpose, a sense of belonging, hope for power, and health [9]. The role of religious experiences in the mental well-being of nurses [10], spiritual experiences in the occupational stress of nurses [11], and the nurses’ psychological tensions [12] have been confirmed in research.
Mindfulness is another factor that affects the nursing profession [13]. Mindfulness is an aroused state of attention and awareness of what is happening in the present moment, allowing individuals to respond with thought and contemplation instead of reacting involuntarily and mindlessly to events [14]. The structure of mindfulness is defined as specific impartial attention to current conditions, allowing the mind to remain focused on the present moment without judgment. Mindfulness enables individuals to identify destructive content and habitual patterns of the mind and process this information non-judgmentally, thus facilitating their ability to choose different options [15]. Studies on the role of mindfulness in the psychological hardiness of cancer patients [16], the mental well-being of nurses [17], and the occupational stress of nurses [13] provide evidence of its impact.
The nursing profession is associated with complex and stressful conditions and some psychological consequences that threaten their health [18]. In this regard, psychological hardiness creates a positive feeling toward personal and professional life in nurses, leading to better job performance, increased commitment, and responsibility in the work environment of nurses. On the other hand, spiritual and mindful behaviors can create a better understanding of environmental relationships and affect improving job performance; therefore, considering the importance of research variables in the nursing profession and the research gap in this area, the present study aims to investigate the mediating role of mindfulness in the relationship between spiritual experiences and psychological hardiness of nurses and seeks to answer the question of whether mindfulness plays a mediating role in the relationship between spiritual experiences and psychological hardiness of nurses.
The present study was a cross-sectional analysis of the path analysis type. The research population included all the nurses in Birjand City, Iran working in the hospitals of Imam Reza, Vali Asr, and Razi (a total of 1000 people) in the second six months of 2022, during which, based on the Krejcie  and Morgan table (1970) [19], 280 eligible individuals were selected via systematic random sampling (gender-based) method. The inclusion criteria included volunteering to participate in the research, having at least two years of nursing experience, and having mental health based on the health record. The exclusion criteria included non-cooperation and willingness to complete the questionnaire.
The tools for collecting information were the following questionnaires:
Spiritual experiences questionnaire: Underwood and Teresi designed this 16-item questionnaire to measure three factors, sense of the presence of God (questions 1, 2, 4, 5, 6, 8, 9, 10, 11), relationship with God (questions 3, 7, 8, 12, 15), and sense of responsibility towards others (questions 13 and 14) using the 6-option Likert scoring method (most of the time: Score 6 and never or rarely: Score 1). Therefore, the range of scores is between 16 and 96, and higher scores indicate more spiritual experiences. While confirming the concurrent validity, Underwood and Teresi checked the scale’s internal consistency using Cronbach’s α and reported values of 0.94 and 0.95 twice [20]. Taghavi and Amiri reported the scale’s validity using concurrent validity methods and factor analysis in Iran. They confirmed the scale’s validity and reported test re-test reliability coefficients of 0.96, Spearman-Brown split-half reliability coefficient of 0.88, and Cronbach’s α reliability coefficient of 0.91 [21]. In the present study, the reliability of the α Cronbach method was obtained as 0.74.
Mindfulness questionnaire: Chadwick et al. prepared this 15-question questionnaire and included three factors, conflict with thoughts (questions 2, 3, 6, 8, 13, 15), acceptance (questions 4, 7, 10, 11, 12) and awareness of thought (questions 1, 5, 9, 14), which is measured on a 7-point Likert scale from 0 (strongly agree) to 6 (strongly disagree). The range of scores is between 0 and 96, where higher scores indicate higher mindfulness and vice versa [22]. In Chadwick et al.’s study, this scale’s concurrent validity, and reliability were 0.89 in the average population and 0.82 in the clinical group using Cronbach’s α coefficient method [22]. In Foroughi et al.’s study, validity was confirmed by exploratory factor analysis. The reliability by Cronbach’s α coefficient was 0.78 for the conflict with thoughts factor, the acceptance factor was 0.69, and the mindfulness factor was 0.62. The total reliability was also 0.76 [23]. The present study obtained reliability using Cronbach’s α method as 0.74.
Psychological hardiness scale: Kiyamrie et al. developed this 20-item questionnaire to measure three subscales of combativeness (1, 2, 6, 8, and 12), control (3, 4, 5, 7, 9, and 10), and commitment (11, 13, 14, 15, 16, 17, 18, 19, and 20) on a 4-point scale (never=0 to almost always=3). However, items 21, 17, 13, 10, 7, and 6 are scored reversely. Therefore, the score range is between 0 and 60, and higher scores indicate more significant psychological distress [24].
Kiyamrie et al. calculated the validity of this test using the concurrent validity method with three criteria, the general anxiety scale, the depression questionnaire, and the Mazlou self-efficacy scale. The coefficients obtained were 0.65, 0.67, and 0.62, respectively. They calculated the reliability coefficients using the test re-test and Cronbach’s α methods, which were 0.84 and 0.76, respectively [24]. The present study’s reliability was obtained as 0.83 using Cronbach’s α.
The research was conducted by designing questionnaires face-to-face after obtaining the necessary permits. In an explanatory session, necessary explanations, such as the purpose of the study, how to answer the questions, and the importance of volunteers’ cooperation in this research were presented along with the supplementary text of the questionnaire. Individuals voluntarily participated in this research and were given two weeks to complete the questionnaires. After two weeks, if the samples were not completed, extra time was given to complete them. Mean±SD, Mahalanobis test, Kolmogorov-Smirnov test, Durbin-Watson test, tolerance statistic, inflation factor, and bootstrap test were used to analyze the data. SPSS software, version 22, and Amos software, version 22, were used at the significance level of 0.05.
Results
Based on the research results, among the participants in the study, 187 people (77%) were women, and 93 people (33%) were men. Of the maximum age of the participants, 146 people were between 20 and 30 years old (52%); 131 people (47%) had 1 to 10 years of work experience; and most individuals (including 210 people, 75%) were bachelor graduates. Table 1 presents the correlation coefficient and descriptive findings of the research variables.
In Table 1, all correlation coefficients calculated between research variables are positive and significant (P<0.01).
The positive coefficients obtained indicate a direct relationship between spiritual experiences and mindfulness with psychological hardiness. Also, considering that the data skewness and kurtosis are between 2+ and 2-, the data are typically distributed at 0.05.
The significance of the coefficients provides the necessary prerequisite for path analysis. Before analyzing the study, single variable outlier data were examined using a box plot, and multivariable outlier data were examined using Mahalanobis statistics and removed from the dataset. Skewness and kurtosis of variable scores were calculated using SPSS software, and the results showed that none of the skewness and kurtosis values exceeded the range of ±2. The normality of the data was examined using the Kolmogorov-Smirnov test.
Table 2 presents the results of the Kolmogorov-Smirnov test to examine the normality of the score distribution. Based on the Table’s results, the significance level for all variables is more significant than 0.05. Therefore, the assumption of normal distribution of scores is accepted. The assumption of error independence was examined with the Durbin-Watson statistic to calculate the equations of the regression model, and the obtained value (1.946) indicates the establishment of this assumption. The assumption of linearity between variables was examined using Pearson correlation between pairs of variables. Since the correlation of the two variables is 0.9 or higher, indicating linearity, this issue was not observed in the present research data. In addition, the tolerance statistic and variance inflation factor were calculated to examine multiple linearity. The results showed that none of the tolerance statistic values are less than the permissible limit (0.1), and none of the variance inflation factor values are more significant than the allowable limit (10); therefore, based on these two indicators, the presence of multiple linearity in the data was not observed. After examining the assumptions and ensuring their validity, path analysis was used to evaluate the model under study (Figure 1).
Figure 1 shows the proposed model’s standard coefficients to investigate the mediating role of mindfulness in the relationship between spiritual experiences and psychological hardiness. Table 3 presents the indices related to the model’s fit.
Table 3 presents model fit indices. The root mean square error of approximation (RMSEA) is 0.067, and the standardized root mean square residual (SRMR) is 0.051, indicating a good model fit. The incremental fit index (IFI), comparative fit index (CFI), goodness-of-fit index (GFI), and normed fit index (NFI) indices are also more significant than the desired criterion of 0.90. The obtained coefficients indicate a good model fit.
Based on the results obtained from Table 4, spiritual experiences positively affect mindfulness (P<0.001, β=0.592). Spiritual experiences affect psychological hardiness directly (P=0.002, β=0.198) and through mindfulness mediation (P=0.006, β=0.224). Mindfulness has a direct positive impact on psychological hardiness (P<0.001, β=0.379).
Discussion
Psychological hardiness is described as one of the vital potentials for health in theoretical and research bases. This study was conducted to investigate the mediating role of mindfulness in the relationship between spiritual experiences and the psychological hardiness of nurses.
This study was conducted to investigate the mediating role of mindfulness in the relationship between spiritual experiences and the psychological hardiness of nurses. The first finding of the research showed that spiritual experiences have a direct and significant effect on the psychological hardiness of nurses, and it can be inferred from this finding that as spiritual experiences in life increase, the psychological hardiness of nurses also increases. The results are consistent with similar studies in this area; for example, Sharifi’s study showed a direct and significant relationship between spiritual experiences and nurses’ hardiness [10]. Another study showed that the sense of divine presence from daily spiritual experiences has a significant relationship with nurses’ job stress [11]. In this regard, Salaree et al.’s research showed that religious beliefs and spirituality can be the most critical factor in nurses’ adaptation and values as a strong support in coping with the consequences of job burnout [25].  
Strengthening religious and spiritual beliefs leads to a change in cognition. Individuals who believe in adaptive strategies, such as forgiveness, friendship with religious people, spiritual connection with God, and faith that God only brings good have better mental health. Religious beliefs lead individuals towards religious adaptation in stressful situations and improve the individual’s coping ability and resilience [26]. In other words, spiritual experiences are a form of adaptation and problem-solving that leads to internal and external harmony and unity in individuals, and a person who practices spiritual experiences can solve crises and give meaning and purpose to life. Therefore, spiritual inclination brings meaning to life and reduces incompatible and undesirable behaviors [27]. It can be said that spiritual experiences include concepts, such as connecting with divine power, seeking help from God, feeling peace, and feeling close to God, which makes the individual feel God’s presence throughout the day and moment by moment so that they can cope more effectively with problems and resolve life’s tensions and stresses. Therefore, using spiritual experiences leads to better understanding and coping with unfavorable conditions, leading to soul and psyche comfort and consequently enhancing psychological hardiness in the individual.
Another finding of the research showed that spiritual experiences have a direct positive effect on mindfulness; that is, mindfulness increases with increasing spiritual experiences. No direct research results have been obtained, but it is consistent with related studies in this field. For example, Nemati et al.’s research showed a positive relationship between spiritual intelligence and students’ mindfulness [28]. In explaining these results, it can be said that spiritual experiences give a person a general and meaningful view of life goals, experiences, and events and enable him to deepen his knowledge. People with a lot of spiritual experience deal with stressful problems more appropriately, endure the hardships of life better and give dynamism and movement to their lives.
Based on this, it is clear that one of the consequences of these spiritual sensitivities is the increase of mindfulness in a person, and the development of spirituality can also increase people’s consciousness [29]. In other words, believing in a God who controls and monitors situations dramatically reduces situational anxiety; that is, people think that by relying on God, they can take control of uncontrollable situations and overcome the tensions and pressures of life with the help of religious beliefs, and as a result, have a calmer and more focused mind.
It can be said that before mindfulness, we have already conditioned ourselves to react to events and life situations. Still, after mindfulness, we become more awake and alert, and our attention is more focused on current events and life. Our reactions to stimuli and life events will be more intelligent and effective. As a result, we will have more peace and inner confidence.
The research results showed that mindfulness has a direct and significant effect on the psychological hardiness of nurses; in other words, increasing mindfulness improves the psychological hardiness of nurses. The findings are consistent with related studies in this field. For example, Kazlou et al.’s study showed that mindfulness can positively predict optimism and psychological hardiness in cancer patients [16]. Another study showed a positive relationship between mindfulness and psychological hardiness in married women [30]. Similarly, the study of Badeleh Shamooshaki et al.’s study showed that the mindfulness variable can predict nurses’ job stress, and nurses with higher mindfulness experience less stress [13]. In explaining these findings, it can be said that individuals with high mindfulness also have proper knowledge and insight into cognitive processes and their abilities, and they employ effective strategies to deal with tasks and use their skills.
Mindfulness increases an individual’s awareness of themselves, others, and the current situation, which can improve adaptability and personal abilities. In other words, raising awareness and vigilance enables the individual to be present under any circumstances and make the most of the current situation. Individuals with high mindfulness pay more attention to evaluating conditions and environments [31]. In other words, mindfulness provides opportunities for growth and excellence alongside the stresses and strains of the nursing profession. With mindfulness, nurses can overcome job tensions and stresses and become more profound, patient, challenging, and calmer with a deeper understanding of the valuable spirit of the nursing profession.
The latest research shows that spiritual experiences impact the psychological hardiness of nurses through mindfulness mediation; in other words, as spiritual experiences increase, mindfulness improves, and with increased mindfulness, the psychological hardiness of nurses improves. A direct study of the result has not been conducted; therefore, in explaining the above results, it can be said that individuals with spiritual experiences have a higher ability to change their mental frameworks, meaning that they can look at issues from various angles and find different meanings for them [32]. People can create more precise meanings for their problems using spiritual capacities and resources in such circumstances. Some personal characteristics, such as having a holistic perspective and an open and flexible mind, help individuals benefit more from spiritual experiences because these characteristics provide different ways to achieve more profound levels of meaning. Therefore, mindfulness, which includes non-judgmental and unbiased attention, can act as a coordinator or even an enhancer of abilities related to spiritual experiences.
On the other hand, individuals with mindful minds can respond to challenging situations without engaging in involuntary or non-conforming behaviors by reaching higher levels of mindfulness. Those seeking solutions for new perceptions tend to be more creative to cope with tough thoughts and feelings without weakness and distress. When a person faces tough emotional or physical situations, they become aware by not judging what they see and what should be. As a result, this awareness can lead to the growth of the person’s psychological hardiness.
Among the limitations of the present study, we can point out the cross-sectional nature of the research implementation and the self-reporting of the research tool. Given that the research was conducted on nurses, the results cannot be generalized to other communities, such as teachers and students. It is suggested that these studies be conducted in other governmental and non-governmental hospital communities and other healthcare workers such as doctors, midwives, health caregivers, and psychological counselors over different periods. Psychological therapists can help increase nurses’ awareness by providing solutions, such as holding mindfulness courses, spiritual experiences, and psychological workshops. Additionally, nursing managers can provide suitable working conditions to facilitate nurses’ multiple roles by employing effective management methods while improving nurses’ mental conditions.
Conclusion
Based on the results of this research, it is recommended to focus more on enhancing spiritual experiences and mindfulness to improve nurses’ psychological hardiness.
Ethical Considerations
Compliance with ethical guidelines
This research was approved by the Ethics Committee of Birjand University of Medical Sciences (Code: IR.BUMS.REC.1401.408).
Funding
This research is extracted from the PhD dissertation of Nahid Baradaran Bazaz, approved by Department of General Psychology, Faculty of Psychology and Educational Sciences, Zahedan Branch, Islamic Azad University.
Authors' contributions
Writing the original draft, data collection and data entery: Nahid Baradaran Bazaz; Supervision: Gholamreza Sanagouye Moharer; Advisory: Somayeh Nakhaei.
Conflict of interest
The authors declared no conflict of interest.
Acknowledgments
The authors appreciate all nurses working in Birjand City who collaborated in this research.