1. Introduction
An acute respiratory syndrome was caused by the novel coronavirus (COVID-19) in December 2019 in Wuhan, China (Wu et al., 2020). The COVID-19 pandemic is a significant crisis affecting everyone, including the healthcare staff who are one of the critical groups in this pandemic (Lancet, 2020). In addition, several factors, such as the lack of protective equipment, long working hours, risk of infection, discrimination, physical fatigue, and separation from family put heavy pressure on healthcare providers (Rajkumar, 2020; Jakovljevic et al., 2020). The COVID-19 pandemic highlighted many of the complex ethical issues that the healthcare staff face in caring for patients (Ita, 2020). Lawrence Kohlberg defines moral reasoning as an internal psychological structure that affects the performance of individuals in situations where moral claims conflict with each other (Kohlberg, 1969). 
Personality traits are one of the influential components of moral reasoning and decision-making (Bartels & Pizarro, 2011). A recent study on ethics has demonstrated essential individual differences in moral judgment (Noser et al., 2015). Personality traits reflect specific behavioral patterns that arise from the interaction of psychological mechanisms, thoughts, and emotions (McAdams et al., 1995). The outcomes indicated that pathological personality traits are different in ethics (Noser et al., 2015). Also, the personality inventory for the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (PID-5) reports this issue with numerous adverse outcomes, including poor interpersonal performance (Southard et al., 2015), antisocial behavior (Hopwood et al., 2013), and psychotic tendencies to self-harm (Strickland et al., 2013). However, these connections vary depending on different situations. For example, Southard et al. (2015) found that people with high levels of inhibition have interpersonal, cold, and non-cooperative styles. At the same time, people with high levels of psychosis have weak interpersonal relationships that are associated with low moral values. Additionally, people with high levels of neuroticism are very anxious and sensitive in interpersonal relationships, resulting in more important concerns about protecting themselves and others from harm (Oxley et al., 2008). It is also assumed that personality can affect empathy (Abe et al., 2018). 
Empathy includes the ability to understand others as well as their views and concerns, including desires and what is important to them (Hofmeyer & Taylor, 2021; Singer & Klimecki, 2014). Empathy is a vital component in the successful treatment of health problems during communication between the patient and the physician; therefore, empathetic healthcare providers are more likely to establish satisfactory and trust-based relationships and bring about better clinical results (Hojat et al., 2011); it is their empathetic and emotional ability that may affect their personality (Abe et al., 2018; Jolly, 2005). On the other hand, research indicates that spiritual well-being can increase empathy in physician-patient relationships (Hamidia et al., 2020). Spirituality is one of the fundamental components of physical and mental health and well-being (Burkhart & Schmidt, 2012). In addition, the dimensions of religiosity and spirituality have been associated with various concepts of mental health and disease. An essential aspect of spirituality is a function of spiritual well-being, a concept coined by Ellison and Smith (1991) which is additionally performed in the management of stressful events (Clark & Hunter, 2019). In an investigation conducted by 40 nurses in an emergency department, the results indicated that empathy and well-being are related. Nurses with high psychological well-being display more empathy than patients (Bourgault et al., 2015). 
In their study, “Ethical Reasoning”, Kuilman et al., describe personality traits and the lack of moral participation (2019) and study 67 nurses and 88 Dutch physician assistants. Their results indicate that stable personality traits are direct predictors of moral reasoning (Kuilman et al., 2019). The study of Yuguero et al. (2019) aimed to determine the relationship between moral reasoning and empathy in a group of 193 medical students. This study indicated the relationship between moral reasoning, moral sensitivity, and empathy. Given the importance of personality and moral reasoning, healthcare providers’ decision-making (Hojat et al., 2013), empathy, and emotional skills to understand and express emotions when providing care for their patients, and given the stressful circumstances caused by the COVID-19 outbreak, spiritual well-being can be used as a coping strategy (Kasapoğlu, 2020). In this regard, this new study considers the negative consequences along with the physical and psychological effects of COVID-19 on healthcare providers (Xiang et al., 2020). Accordingly, this study is conducted to investigate the relationship between personality, moral reasoning, and spiritual well-being with the mediating role of empathy in physicians and nurses.

2. Materials and Methods
The current study has a cross-sectional design. The statistical population includes all physicians and nurses working in the COVID-19 sections of hospitals of Shahid Beheshti University of Medical Sciences (Ayatollah Taleghani, Imam Hossein (AS), 15 Khordad, Tajrish’s Martyr, Akhtar, Shahid Labbafinejad, Shahid Modarres, Torafeh, Mofid, Loghman Hakim, Masih Daneshvari, Mahdiyeh, Shahid Mofateh Varamin, Pakdasht’s Martyr, Ayatollah Ashrafi Esfahani, and Sevom-e Shaban Damavand). We used the available sampling method to select the sample. The free statistical calculator software was used to calculate the sample size and the number of samples was obtained at 320. After screening, 5 samples were removed from the analysis because of being absent. We entered the following measures into the software: the effect size of 0.3, power of 0.8, α of 0.5, in addition to 17 hidden variables, and 112 observed variables (Soper, 2017). 
The collected data included demographic and quantitative information that was gathered using paper-based and online questionnaires. After selecting the sample and obtaining their consent letter to cooperate in the research, the following tools were used: demographic characteristics questionnaire, PID-5-BF-adult, defining issue test-2, interpersonal reactivity index, and the spiritual welfare scale. The inclusion criteria for the participants were being physicians or medical students (year 5 and above), having an associate degree or higher in nursing, providing a consent letter to participate in the research, no severe physical or mental illness (according to doctors and nurses), no history of concussion, no hospitalization in psychiatric centers, and no addiction. Meanwhile, the exclusion criteria were dissatisfaction to participate in the research. To analyze the structural equation model, structural equation model tests were performed using the SPSS software, version 24, and the PLS software, version 3.
Study instruments
Personality Inventory for The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition-Adul. The adult version of PID-5, developed by Krueger et al. (2012) has 25 items about self-assessment and measures personality disorders in adults with 18 years of age or higher. This scale measures five personality traits, including negative excitement, failure, opposition, inhibition, and psychosis. Krueger et al. (2012) examined its psychometric properties in standard and patient population samples and reported the internal consistency of its scales from moderate to high (0.72 to 0.95) with an average α of 0.86 (Krueger et al., 2012). In Iran, according to the results of Abdi and Chalabianlou’s research, the reliability of the Cronbach α coefficient for the internal consistency of the questionnaire ranged from 0.83 to 0.89, and the retest coefficients ranged from 0.77 to 0.87 for subtests. This is the optimal reliability of the Persian version of this questionnaire (Abdi, 2017).
Defining Issue Test-2
The defining issue test-2 was designed by Rest et al. and is used to assess the level of moral reasoning. It includes stories that present dilemmas or moral riddles to adults (Rest, 1986). Moreover, after each story, there are 12 four-choice questions that the test taker should rate from nonsignificant or insignificant to very important (Rest, 1986). The reliability of this test via the Cronbach α method in a study by Rest et al. over 20 years ranged from 0.76 to 0.80 (Rest, 1986). In Iran, to determine the validity of the test, in Ghiasizade’s study, which examined the growth of moral judgment of female students by calculating the correlation between the moral reasoning test and the children’s moral judgment test, the validity was obtained at 0.68 (Ghyasizadeh, 2012).
Interpersonal Reactivity Index
The interpersonal reactivity index scale was designed by Davis in 1983 to measure interpersonal behaviors (Jonason et al., 2013). The Cronbach α coefficient of this index was obtained ranging from 0.75 to 0.82 (Jonason et al., 2013). Allah Qalilu obtained the Cronbach α coefficient and the reliability coefficient of this index by retesting substance abusers and ordinary people at 0.77 and 0.76, respectively (Nagamitsu et al., 2015).
Spiritual Well-Being Scale
The spiritual well-being scale was designed by Dehshiri (2009) based on the model proposed by the National Association Between Religions (1975) among students of universities in Tehran City, Iran. This questionnaire includes 40 questions and has 4 subscales in the following order: communication with God, communication with self, communication with nature, and communication with others (Dehshiri et al., 2008). Each subscale has 10 questions and by adding the scores of 40 questions, the total score of spiritual well-being is acquired (Dehshiri et al., 2008). Higher total scores indicate higher spiritual well-being (Dehshiri et al., 2008). The Cronbach α coefficient of the whole questionnaire was obtained at 0.94 and the α coefficient of the subscales were 0.93, 0.92, 0.91, and 0.85 respectively (Dehshiri et al., 2008). 
Data analysis
The IBM SPSS software, version 24, and the PLS software, version 3 were used to analyze the data. In addition, the data were analyzed via structural equation models.

3. Results
Demographic characteristics
A total of 320 individuals participated in the study, of which 5 persons were excluded from the research because of being absent. Among the respondents, 36.5% (n=115) were male, 63.5% (n=200) were female, 91.4% (n=288) were single, and 8.6% (n=27) were married. Meanwhile, 52.7% (n=166) were physicians and 47.3% (n=140) were nurses.
Descriptive data
Descriptive data showed that moral reasoning was not normal with a minimum value of 0.1000, maximum of 0.7560, an Mean±SD of 0.13±0.09; in addition, the skewness and kurtosis were not in the range of -3 to 3 and, therefore, these two variables were not normal. Spiritual well-being was normal with a minimum value of 69, a maximum of 144, an average of 102.4921, and SD of 14.95202; additionally, the skewness and kurtosis were in the range of 3- to 3 and normal. Personality was normal with a minimum value of 23, maximum of 61, mean of 94.84, and SD of 44.5048; also, the skewness and kurtosis were in the -3 to 3 range and normal. Finally, empathy was normal with a minimum value of 63, maximum of 127, Mean±SD of 94.84±12.16; also, the skewness and kurtosis were in the -3 to 3 range and normal (Table 1).



Reflective outer model test measurements
Before performing the validity and reliability tests of the structure and the qualitative evaluation of the external model, as the main task of the model, it was first modified in the form of the initial homogeneity test.
The external load test was used for homogeneity, in which the findings showed that question 37 of spiritual well-being and question 17 of the personality questionnaire for PID-5-BF had a factor load of less than 0.65; accordingly, they were removed from the model, and the model was modified.
Divergence validity
To evaluate the validity of cross-load divergence, 3 cross-loading tests, namely Fornell, Larker, and HTMT were used. They showed that the divergent validity of the questions of each variable was established in comparison with the questions of the other variables. Fornell and Larker tests showed that the mean root of variance extracted from each variable was greater than the correlation of that variable with other variables. Meanwhile, HTMT showed that all pairs of variables had a multivariate ratio of less than 1. Based on the results, the divergent validity test of the research model was confirmed; however, it had structural validity because of convergent validity.
Outer model test
The CV com test was used to evaluate the quality of the external model. All CV com values of the variables were much higher than 0.35; therefore, the quality of the external model was satisfactory (Table 2).



Inner model quality
The test quality of the internal model cv red showed 0.004 for moral reasoning and the result was desirable; however, it was not the same for all variables (Table 3).



Hypothesis testing
The findings showed that empathy had a positive and significant effect on moral reasoning (P=0.032) and the intensity of this effect was β=0.117. In addition, spiritual well-being had a significant effect on empathy (P<0.000), thus the hypothesis was confirmed and the intensity of this effect was β=0.236. Meanwhile, spiritual well-being had no significant effect on moral reasoning (P=0.294). The results also showed that personality had no significant effect on empathy (P=0.136) and it had no significant effect on moral reasoning (P=0.309) (Table 4).



This study aimed to determine the prediction accuracy or the variance explained by the endogenous variables of the conceptual model. In the present study, there is an endogenous variable and the value of R2 in the present model was 0.019. Accordingly, all exogenous variables can predict the dependent variables because of the 3 weak fold values (Table 5).




4. Discussion
This study aimed to predict moral reasoning through the variables of spiritual well-being and personality with the mediation of empathy in a sample of Iranian physicians and nurses. Thus, the empathy variable was evaluated as a mediating variable, spiritual welfare and personality as independent variables, and moral reasoning as a dependent variable in the conceptual model via structural equation modeling. In the current model, predictor variables could predict moral reasoning with 0.019. The results also showed that empathy had a positive and significant effect on moral reasoning. Another part of the study demonstrated that spiritual well-being had a positive and significant effect on empathy. However, no effect of personality was found on empathy and moral reasoning. In addition, spiritual well-being did not have a positive and significant effect on moral reasoning. The first research finding showed that empathy did not have a positive and significant effect on moral reasoning. Neumann et al. demonstrated that empathy is significantly reduced during medical studies when entering the clinical practice phase and by increasing contact with patients. One possible explanation may be that exposure to illness and death increases the intern’s vulnerability (Neumann et al., 2011). 
The other key factors in reducing empathy among medical students and nurses are burnout, reduced quality of life, and depression (Neumann et al., 2011). Another study found that cognitive empathy largely explains the indirect relationship between moral sensitivity and social behavior, especially in decision-making and moral responsibility. Moral sensitivity and empathy among physicians and nurses help in understanding situations and decisions that benefit patients (Suazo et al., 2020). On the other hand, Yuguero et al. demonstrated a significant correlation between moral reasoning, moral sensitivity, and the lack of progress of these two variables in the recent years of medical teaching (Yuguero et al., 2019). Empathy is a form of moral emotions (de Oliveira-Souza & Moll, 2019), and based on the research background and findings of the present study, as empathy reduces, moral reasoning reduces as well. 
The second finding of the present study demonstrated that spiritual well-being had a positive and significant effect on empathy. This finding is consistent with a study by hamidia et al. (Hamidia et al., 2020). The result of their research demonstrated a strong and positive relationship between students’ perspectives, clinical empathy, spiritual well-being, cognitive empathy, and psychology (Hamidia et al., 2020). Empathy is related to mental well-being and facilitates teamwork and care for patients provided by healthcare professionals (Cañero Pérez et al., 2019). Cognitive empathy as a variable that is directly involved in nurses’ altruism, (Perez-Fuentes et al., 2019) plays an important role in reducing fatigue and improving the well-being of healthcare professionals (Tirado et al., 2019). Spirituality and religiosity were also important and significant predictors of empathy in medical students, which can lead to different results on students’ views on clinical empathy and psychosocial or spiritual well-being (Hamidia et al., 2020). 
Considering the backgrounds and findings of this study, strengthening spiritual well-being increases empathy and morality and improves moral reasoning and appropriate decision-making in moral problems. Another finding of this study showed that personality had no significant effect on moral reasoning. This result is inconsistent with the findings of Kuilman et al. (2019) and Athota et al. (2009). Personality traits of stability directly and personality traits of flexibility indirectly affect moral reasoning through moral indifference. Highly stable people have high self-control. They are more disciplined, more responsible in interpersonal issues, and less prone to moral indifference (Kuilman et al., 2019). Also, the study of Otto et al. shows that among personality traits, agreeing is the strongest predictor of moral reasoning. However, because of the high correlation between the big five personality traits, this finding can show different results in different populations. Also, the study by Otto et al. was not consistent with another part of the present study, that is, personality can not predict empathy. They showed that people with higher levels of satisfaction experience more empathy and anxiety (Athota et al., 2009). In another study, there was a relationship between agreement, openness to experience, and empathy (Matthews et al., 2003). 
The Findings also showed a significant relationship between personality traits, moral principles, and psychological well-being. This significant relationship leads to better job performance, resilience, and spiritual well-being in individuals (Athota et al., 2020). Personality plays an important role in improving people’s well-being. Therefore, extroverts show more positive emotions (Goldberg et al., 2006) which leads to differences in the levels of moral reasoning (Athota et al., 2020). According to the background, personality factors predict at least a part of the relationship between primary emotions, empathy (Hiebler-Ragger et al., 2018), and moral reasoning (Kuilman et al., 2019). 
Finally, the moral reasoning in the present model was predicted with predictive variables by a value of 0.019. These findings show a significant relationship between empathy and moral principles, spiritual, and psychological well-being. Healthy behaviors (physical activity, worship, seeking social support, restful sleep, etc.) lead to mental health and help to interact with others. Similarly, spiritual well-being is an important aspect that affects the empathy of medical staff with patients (Damiano et al., 2017) and great empathy and compassion in healthcare by nurses and physicians can fundamentally change the ethical orientations and decisions of the profession (Kerasidou, 2019). Ethical principles of nursing care are important principles for every patient (Barlow et al., 2018). Therefore, nurses need training on skills to establish and maintain professional relationships to solve ethical problems and to participate in micro and macro political and organizational decisions (Barlow et al., 2018).

5. Conclusion
This study showed that spiritual well-being can predict empathy. In addition, empathy can predict ethical reasoning in physicians and nurses. The character could not foresee moral empathy and reasoning. On the other hand, spiritual well-being cannot predict moral reasoning. Since professional and ethical decisions are part of the clinical activities of medical staff, the quality of professional responsibility of medical staff, empathy, and helping others can be strengthened by planning and creating a suitable environment for training. Continuing research in this field can have a significant impact on promoting the growth of professional ethics along with treatment.
Study Limitations
Although the results of this study are new and help in understanding the impact of personality structures and spiritual well-being as well as empathy at the level of principled moral reasoning, one of its limitations was that the sample was from a group of physicians and nurses working in the COVID-19 ward of Shahid Beheshti University of Medical Science hospitals. Considering the difficult situation of doctors and nurses in COVID-19 wards, cooperation was low. The findings of this study should be generalized to other regions or cultures with caution. Given the limitations, training and growth of moral reasoning levels are essential components for physicians’ and nurses’ jobs.

Ethical Considerations

Compliance with ethical guidelines
The current research was confirmed in the Committee of Research of Shahid Beheshti University of Medical Sciences (Code: IR.SBMU.RETECH.REC.1399.1131).

Funding
The present article was financially supported by “The Religion and Health Research Center of Shahid Beheshti University of Medical Sciences (Grant No.: 24676).

Authors' contributions
Conceptualization: Fateme Chitgari, Maryam Bakhtiari;Methodology: Amir Sam Kianimoghadam; Investigation: Fateme Chitgari staff, Amir Sam Kianimoghadam staff, Farnaz Doostdari; Writing: Amir Sam Kianimoghadam, Farnaz Doostdari, Zahra Tavalaee Nezhad; Supervision: Maryam Bakhtiari.

Conflict of interest
The authors declare no conflict of interest.


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