1 Introduction

The COVID-19 pandemic has changed the way of living worldwide, which seriously affects many people. By 27 November 2021, 261 million positive cases of COVID-19 were documented in Iran, including 5.19 million deaths. At the time of the pandemic, healthcare workers (HCWs) have tirelessly worked to combat the situation by involving direct management of the COVID-19 patients, which increases their risk of personal infection as well as psychological suffering from issues like fear, aggression, depression, stress, etc. [1–3]. Many HCWs are reported to die by suicide due to being infected with COVID-19, work‐related stress, and fear related to COVID‐19 infection or transmission [4]. Furthermore, aggression and violence account for the negative consequences on the health of patients and nurses health, and their safety and well-being; they are the major concerns in psychiatric inpatient care globally [5].

The word aggression originated in the early 17^th century, which is derived from the Latin word, ‘aggredi’, meaning ‘to attack’ [6]. Aggression is any behavior that directly harms someone; everyone can do it [7]. Aggression can happen in different ways. For example, verbal and physical aggression represent instrumental or behavioral elements, and hostility, revelation, and anger demonstrate the cognitive aspects of aggression [8]. However, aggression towards nurses arises from various sources, such as other nurses, relatives, doctors or allied health professionals, and patients [6].

Personal experience of violence in the workplace may cause serious consequences for HCWs, patients, patient care, and the organization. Exposure to traumatic situations over the nursing career and failure to control these experiences lead to poor patient care; the complications manifest as fatigue and exhaustion [9–11]. Constant exposure leads to physical weakness, feeling angry, cynical, pessimistic, or feeling trapped, which could cause other complications such as depression and anxiety [12]. The nurse may require a response to aggression via changing the job, absenteeism from work, or leaving the nursing profession altogether. The potential of aggression and violence against HCWs is not a new phenomenon that leads to occupational anxiety; it has been reported as a frequent event [9], especially in mental health care, emergency departments, and other emergency services [13]. In the mentioned cases, the most frequently reported occupational aggressions had been imposed by patients [14]. In addition, other studies have identified the risk of aggression or violence in the workplace between healthcare employees [15]. There is, however, a lack of studies on how spirituality impacts aggression perpetration [16].

Spiritual health is considered the fourth dimension of health; its effects on bio-psycho-social health are studied worldwide [17]. Moberg first introduced the concept of spiritual health as spiritual well-being, which has always been one of the important issues in nursing. Florence Nightingale believes that spiritual care is an integral part of human needs and is necessary for healing [18]. However, spiritual health is defined as the feeling of acceptance and a positive understanding of the two-way relationship with a supernatural and superior force, which creates peace and tranquility in souls. Spiritual health can affect many psychological variables, one of which is avoiding aggression and violent behaviors [19].

As per the recent models of aggression, it is said that aggressive behaviors are the consequence of (i) personal factors such as personality traits, history of abuse, etc., (ii) situational factors such as burnout, frustration, threatening stimuli, etc., and (iii) internal states such as cognition situation [20, 21]. In addition, recent evidence indicates the importance of spirituality as a coping skill and psychological well-being maintainer for both patients and HCWs during the COVID-19 pandemic [22]. Spirituality has also been found to help HCWs combat stress, encourage recovery and resilience, and reduce burnout [23]. For instance, McSherry and Jamieson reported that 83% of nurses agreed that spiritual care and spirituality as fundamental aspects of nursing, and 90% believed that providing spiritual care enhances the overall quality of nursing care [24]. As reported in another study, nurses who had a higher level of spiritual health paid more attention and love to the patients and had more spiritual care for patients [25]. Therefore, it is hypothesized that nurses with higher spirituality will have lower aggression levels.

As stated by Panzini et al. [26], spirituality is an approach that manages people’s life-threatening conditions. It is also a mechanism to fight against occupational stress and burnout syndrome in many professions, including HCWs [27]. Furthermore, spirituality provides peace of mind and enhances the sense of purpose and life meaning [28], which can help reduce aggression. However, despite the importance of mental health in nursing care, as per our literature review, no study has been conducted about the spiritual health of nurses in relation to aggression during the COVID-19 pandemic. Accordingly, to the proposed hypothesis that spirituality appears to reduce aggression, and in this study, the levels of aggression and the effects of spirituality posed to aggression among the Iranian nurses working in the COVID-19 wards were investigated. In addition, the relationships between socio-demographics, and spirituality and aggression were also investigated.

2 Methods

3 Results

3.1 Socio‐demographic characteristics

The mean age of 200 nurses was 31.49±6.88 years. All participants were Muslim. Among the participants, 78.5% were female, and 21.5% were male. In terms of marital status, 26.5% were single, and 73.5% were married. Most of them had a bachelor’s degree (85.0%) and 1–10 years of work experience (33.5%) and worked emergency department (31.5%) (Table 1). However, the descriptive indices of spiritual health and aggression, including mean, SD, minimum, and maximum, are shown in Table 2. Results showed that participants had a mean spirituality score of 67.21 ± 12.84 out of 120, whereas the mean score of aggression was 51.77 ± 10.96 out of 116 (Table 2). A comparison of mean scores of spiritual health and aggression based on the socio-demographic variables was shown in Table 1, and none of the variables were significantly associated.

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Table 1. Distribution of the socio-demographic variables with spiritual health and aggression.

https://doi.org/10.1371/journal.pone.0279247.t001

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Table 2. Description of the spirituality and aggression.

https://doi.org/10.1371/journal.pone.0279247.t002

3.2 Correlation coefficient of aggression and spiritual health

According to the results of Table 3, there was a significant negative correlation between aggression and spiritual health (r = —.285, p < .01). That means, with increasing spiritual health scores, the level of aggression decreased. The correlations of aggression and spirituality subscales can be found in Table 3.

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Table 3. Correlation coefficient between aggression and spirituality.

https://doi.org/10.1371/journal.pone.0279247.t003

3.3 Factors associated with aggression

The results in Table 4, show factors associated with aggression based on two models. In the first model, only considered spiritual health and a total of 7.7% variance was explained. After adding socio-demographic factors with spiritual health in the final model, about 11.4% variance can be explained. Based on the final model, spiritual health [-.264], age [-.374], and working experience [4.156] were found as significant factors of aggression.

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Table 4. Associated factors of aggression based on spirituality and socio-demographics.

https://doi.org/10.1371/journal.pone.0279247.t004

4 Discussion

The COVID-19-related stressors have appeared to increase cognition, emotion, and physiological state problems, increasing the threat risk, leading to fight-or-flight tendencies, and elevating anger-reactive physical aggression levels [38]. Evidence supports that aggression has been raised during the COVID-19 pandemic; for instance, al-Mamun et al. observed sexual violence increment in Bangladesh [3], similar to other countries such as Russia [39], and the United States [40]. Of the healthcare professionals, about 65.5% reported being exposed to workplace violence, mainly verbal violence in 52.0% during the COVID-19 pandemic, as per a Jordanian study [41]. In the same study, the contributing factors of violence in the workplace have been reported, such as intense workload, high patient expectations, substance abuse by the patient, long waiting period, rejection of demands that cannot be accepted, and sensational reports from media, inadequate security, etc. Another study reported that nursing technicians or assistants were at higher risk of violence during the pandemic [42]. About 44.4% of the nurses have experienced physical violence during the pandemic, while 67.8% for verbal abuse [43]. Those nurses who worked for COVID-19 patient’s care were at 2.18 times and 2.10 times higher risk of physical violence and verbal abuse, respectively [43]. All of that evidence is based on type II level of aggression, that is, aggression imposed on healthcare professionals.

Despite that evidence, there is a lack of information about the nurses’ aggression toward others and the role of spirituality in aggression, especially during the COVID-19 pandemic. Based on the prior works, it is speculated that spirituality can be beneficial in controlling behaviors like aggression [44–46]. The findings of this study also depicted that spirituality can be of the factors reducing the level of aggression among the Iranian nurses working in the COVID-19 wards. It should be noted that religious health of the spirituality subdimension was not significantly correlated with aggression, although existential health was found to be negatively significantly correlated with the aggressiveness of the nurses. However, based on this study, a transcendent human being can be seen if a person can communicate ethically with others and help them in all circumstances. Therefore, it is likely that overall spiritual health training and enhancement can help decrease violent and aggressive behaviors.

The present study found a reverse relationship between spirituality and aggression. Similarly, spirituality has a positive role in reducing the aggression of undergraduate students, as reported in prior Iranian studies [45]. Furthermore, studies from other countries, for example, Jordan, indicated a significant negative correlation between the total scores of spiritual well-being and aggression [46]. Therefore, spiritual health encourages nurses to be more comfortable and relaxed, which allows them to provide more forgiveness and compassion, which may release negative emotions such as anger and hostility and decrease the levels of aggression. That is because of the fact, spirituality is recognized as a coping strategy and resource that assists people in finding meaning in their lives and safely getting through the difficult situations they face [47].

The present study had a few limitations to be noted. First, the association between nurses’ spiritual health and aggression was only investigated. Other professional nursing factors, namely attitude toward spiritual care, professional commitment, and caring, may also be correlated with spiritual health; future studies should address them. Second, the participants from four hospitals of one providence were selected; therefore, the generalization of the study results may be limited inside and outside of the country. In addition, other issues like memory recall bias, self-reported data and its inherent bias can be placed while conducting this study, limiting the findings. Third, the measure of aggression used the Buss & Perry Aggression Questionnaire version, where there are some concerns because factor analysis has not verified the original factors. The revised version has rectified this issue with a five-factor solution, and it is suggested to consider the preferable version to use for further studies [48]. Finally, the findings of this study are based on cross-sectional observation; therefore, causal relationships should be determined based on robust methodologies accounting for other shortcomings of this study.

5 Conclusions

In general, nurses who consider spirituality their standard in life perform their actions based on knowledge and awareness; they can also reduce negative emotions, such as aggression. In addition, spiritually healthy nurses may be more powerful in helping patients by providing caring or spiritual support. Therefore, it is recommended that future researches focus on developing an intervention program to improve nurses’ attitudes toward spiritual health, the feasibility and potential efficacy of promoting such a spiritual health program, and the relationship between nurses’ spiritual health and quality of care. Healthcare managers, planners and nursing educators need to reform policies with a focus on spiritual care education, providing the ground for promoting spirituality and a positive attitude towards it.

Supporting information

Acknowledgments

We acknowledge the nurses who participated in the research. In addition, the authors are grateful to the Vice-Chancellor for Research, Mazandaran University of Medical Science.