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Siadat F, Koraei A, Shahbazi M, Dasht Bozorgi Z. Relationship Between Attachment Behaviors and Marital Trust Among Nurses With the Mediating Role of Covert Aggression. JCCNC 2023; 9 (1) :79-88
URL: http://jccnc.iums.ac.ir/article-1-419-en.html
1- Department of Counseling, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran.
2- Department of Counseling, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran. , am.koraie@gmail.com
3- Department of Counseling, Masjed Soleiman Branch, Islamic Azad University, Masjed Soleiman, Iran.
4- Department of Psychology, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran.
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1. Introduction
Most nurses in all countries, including Iran, are women (Farsi et al., 2022). Nursing is a source of stress for women as they have to balance their household and occupational duties. In other words, excessive workload and isolation from social and family life can lead to depression and job dissatisfaction (Ayaz et al., 2021). Nursing is a very stressful job that can negatively affect the physical and mental health of those employed in this profession. Nursing stress results from personal factors and workplace conditions (Ernawati et al., 2022). The nature of nursing can affect many aspects of nurses’ lives, including their marital relationships. The Relationship between spouses is of special importance because it forms the family foundation (Vaghar & Masrour, 2019). It is necessary to investigate the factors involved in marital satisfaction because people’s satisfaction with married life is an important component of their health status (Mohammadi et al., 2020; Adib-Hajbaghery et al., 2021).
Attachment behaviors are also among the factors affecting marital relationships. An attachment style can be defined as how people think about, feel, and treat their partner or other close persons. Attachment style is one of the personal factors affecting marital integration. Many studies have shown that individuals with a secure attachment style are more satisfied with their married life, whereas those with insecure attachment styles (avoidant and ambivalent) may experience lower levels of satisfaction, commitment, and confidence in their adult relationships (Beeney et al., 2019; Conradi et al., 2021). Attachment styles can predict spouses’ trust in each other. Intimate marital relationships can shape the structure of a balanced family, and the attachment styles of spouses are among the very important factors that can strengthen marital relationships. A secure attachment style can directly strengthen intimate marital relationships, improve the quality of married life, and increase marital trust. It can be generally stated that attachment behaviors can greatly affect marital relationships (Moghadam et al., 2021). Attachment behaviors are specifically related to satisfaction with relationships. Accessibility and responsiveness are key behaviors that predict security or discomfort in close relationships. It can be concluded that the attachment behaviors of couples can play an important role in increasing marital trust and improving the quality of married life (John et al., 2017).
On the other hand, marital trust plays a vital role in the continuity of family life. Trust can be defined as one’s strong belief in one’s validity, honesty, and strength as well as a non-pretested claim and also one’s attitude towards oneself and the surrounding world. Trust helps individuals to feel that others around them, the surrounding environment, and other issues in this world are reliable, stable, and continuous (Khalifian & Barry, 2016; Jiménez-Picón et al., 2021). It is obvious that trust is necessary for effective and functional relationships; in fact, trust can serve as a determining factor for close and intimate relationships. In countries (such as Iran) where the family plays an inevitable role in the social structure, higher levels of marital trust can pave the way for social solidarity and cohesion (Wiebe et al., 2017). 

A marital trust is one of the vital aspects of married life, and aggression is one of the factors that can challenge marital trust (Halmos et al., 2020). Aggression may appear in two forms: either as an open reaction to physical or verbal conflicts or covertly by hiding the outward manifestations (Leon et al., 2022). Most studies on married life have discussed overt aggression, whereas direct physical aggression is only the tip of the iceberg of interpersonal aggression (Hammett et al., 2021). In covert communication aggression, one tries to harm the audience or damage a relationship through targeted influence. Covert communicative aggression consists of two components: social image destruction and emotional withdrawal (Overall et al., 2017; Grimani et al., 2022). Social image destruction is a kind of indirect harassment through slander, rumors, disclosure of private information, or involvement of others in discussions and arguments between spouses. One who uses this type of communication aggression aims to take advantage of social pressure to control his or her spouse (Bretaña et al., 2022). It can be generally stated that aggression in a marital relationship can lead to mistrust, jealousy, and frustration and also reduce the quality of the relationship for both spouses, resulting in a crisis of marital trust. As mentioned before, the nature of the nursing profession can affect many aspects of female nurses’ lives, including their marital relationships. Therefore, based on the issues outlined above, the present study aimed to investigate the mediating role of covert aggression in relationships of attachment behaviors and marital trust in female nurses in Shiraz City, Iran.

2. Materials and Methods
This correlational study investigated the relationship between variables through the path analysis of a causal model. The statistical population consisted of all married female nurses working in public and private hospitals in Shiraz, Iran. The sample recruitment was done from March to June 2021. A total of 310 nurses were selected as participants through two-stage cluster random sampling. In path analysis, the number of parameters is calculated based on the number of direct paths, exogenous variables, and error variances. 
According to Kline’s (1998) recommendation, researchers should enroll at least 10 participants per estimated parameter. It should be noted that enrolling about 25 participants per parameter would increase the adequacy of the data for testing the model. To this end, 8 hospitals (5 public hospitals and 3 private hospitals) of Shiraz and then 2 wards from each hospital were randomly selected, and all female married nurses of these wards were invited to participate in the study. The inclusion criteria were as follows: working in public and private hospitals in Shiraz, the age range of 25-55 years old, lack of any psychological disorders based on participants’ self-reports, at least 2 years of work experience, at least 2 years of cohabitation with husband, and the consent for participation in the research. The exclusion criteria were as follows: failure to answer all the questionnaire items and temporary marriage. 

Research instruments
Trust in close relationships scale

 This scale was developed by Rempel et al. (1985) to measure marital trust. This self-reporting tool consists of 18 items scored based on a 7-point Likert scale (from strongly disagree to strongly agree). This scale has three subscales of predictability (5 items), dependability (5 items), and faith (8 items). The minimum and maximum scores on this scale are 18 and 126, respectively. A higher score on this scale means more marital trust. Rempel et al. (1985) reported a Cronbach α coefficient of 0.81 for this scale. The validity and reliability of the Persian version of this scale were confirmed by Javidmehr et al. (2014). They reported the internal consistency coefficient for the scale as 0.82. In the present study, the reliability of the scale was calculated as 0.84 using Cronbach α.

Brief accessibility, responsiveness, and engagement (BARE) scale
 This 12-item scale was developed by Sandberg et al. (2016) to measure attachment behavior in couple relationships. The items are scored based on a 5-point Likert scale (from 1: No, to 5: Always right). Six items are about attachment behaviors of oneself, including accessibility (2 items), responsiveness (2 items), and engagement (2 items), and 6 items are about the other party’s attachment behaviors, including accessibility (2 items), responsiveness (2 items), and engagement (2 items). The range of scores on this scale is between 12 and 60, and higher scores indicate a higher level of attachment behaviors in couples in marital relationships. In this study, the respondents were asked to answer only the first 6 items. The reliability of the original version of the scale was reported by its creators to be 0.81 based on Cronbach α. The reliability of the Persian version of the scale was obtained as 0.71 using Cronbach α (Hashemi Gplpayegani & Yazdi, 2021). In this study, the reliability of the scale was 0.89 using Cronbach α.

Couples relational aggression and victimization scale (CRAViS)
Carroll et al. (2010) developed CRAViS to assess covert aggression in couples. The scale consists of two subscales: emotional withdrawal (items 1-6) and social image destruction (items 7-12). The items are scored based on a 7-point Likert scale (from 1: very low to 7: very high). The minimum and maximum scores on this scale are 12 and 84, respectively. A higher score on this scale means more covert aggression. Carroll et al. (2010) reported that the Cronbach α values of emotional withdrawal were 0.90 for men and 0.86 for women, and the Cronbach α values of social image destruction were 0.88 for men and 0.90 for women. The reliability of the Persian version of the scale was obtained as 0.85 using Cronbach α (Khazaei et al., 2016). In this study, the reliability of the CRAViS was 0.90 using Cronbach α.

Statistical analysis
The model proposed in this study was tested using Structural Equation Modeling (SEM) in AMOS-24. The mediating relationships in the final model were also examined using the Bootstrap method.

3. Results
The descriptive data showed that the mean±SD age of participants was 35.52±6.42 years, and their mean work experience was 6.76±2.88 years. Also, the mean±SD marriage duration of the participants was 8.25±3.28 years. In addition, 70.00% of participants were working in public hospitals, and 30.00% of them were working in private hospitals.
The results showed that the mean±SD scores of accessibility, responsiveness, and engagement were 5.94±2.17, 6.64±2.01, and 6.50±1.68, respectively. The Mean±SD scores of emotional withdrawal and social image destruction were obtained at 17.61±5.11 and 14.69±5.98, respectively. The results also indicated that the Mean±SD score of marital trust was 64.33±12.63. In addition, the skewness values obtained for all variables were in the range of -3 and +3, and the kurtosis values were in the range of -2 and +2. Therefore, the normal distribution of all research variables was confirmed (Table 1).

Table 2 shows that all correlation coefficients between the research variables were statistically significant.

There is a need for a complete set of data to examine a model based on SEM. To check univariate outliers, the Z value of each participant for each variable was calculated in SPSS software, version 24. The results showed that the dataset lacked univariate outliers. Moreover, the Mahalanobis distance was calculated for exogenous variables of the model to examine multivariate outliers. The highest and the lowest Mahalanobis distances were equal to 0.441 and 34.22, respectively. Since the critical Chi-square was equal to 15.09 and the highest Mahalanobis distance was 34.22, the Chi-square for 8 participants was greater than 2. Therefore, the data obtained from these participants were excluded from the study as multivariate outliers. Finally, the data from 310 participants were used for further statistical analysis.
The model estimation results showed the acceptable goodness of fit of the model, and all paths were statistically significant. Therefore, the model’s goodness of fit was confirmed without needing correction. Figure 1 presents the research model along with path coefficients.

Table 3 presents the results of evaluating the model’s goodness of fit indices.

According to this Table, the model’s goodness of fit indices was as follows: relative Chi-square index (χ2/df=1.06), the goodness of fit index (GFI=0.99), adaptive goodness of fit index (AGFI=0.96), comparative fit index (CFI=0.99), incremental fit index (IFI=0.99), and root mean square error of approximation (RMSEA=0.018). It can be hence concluded that the research model was acceptably fitted with the data.
According to Table 4, all paths and their standard coefficients in the proposed model presented were statistically significant (P<0.01).

The mediating relationships in the final model were also examined using the Bootstrap method. The results of testing the indirect paths in the research model are presented in Table 5.

According to the results, covert aggression had a mediating role in the relationships between attachment behaviors and marital trust in female nurses (P<0.05).

4. Discussion
This study aimed to investigate the mediating role of covert aggression in relationships of attachment behaviors and marital trust in female nurses in Shiraz (Iran). The results show that the components of covert aggression (emotional withdrawal and social image destruction), as well as dimensions of attachment behaviors (accessibility, responsiveness, and engagement), had a significant relationship with marital trust in female nurses. The results also demonstrate the direct relationship between responsiveness with marital trust and the indirect relationship between responsiveness with marital trust through two components of covert aggression (emotional withdrawal and social image destruction). This finding is consistent with the results of previous studies such as Kurdi et al. (2018). The researchers reported that attachment behaviors improved the quality of marital relationships in married female students through increasing trust and sexual intimacy. To explain this finding, it can be stated that attachment is a deep emotional bond that we establish with special people in our lives; interaction with such people can give us a sense of joy and happiness and make us feel more relaxed when we face a stressful situation. Couples who take more secure attachment styles are more likely to experience a higher quality of marital relationships (Mohammadi et al., 2016). In addition, the absence of attachment security is associated with mental and physical health problems such as depression and violence. A bonding moment called engagement occurs when spouses are accessible to each other at the right time and interact with each other peacefully (Conradi et al., 2021). Trust becomes more prominent and important when it comes to social and interpersonal interactions. Trust can be something like a double-edged sword. On the one hand, trust in someone can make you more vulnerable, as defined. On the other hand, no one can socially function without trust. It is also noteworthy that social trust can be strengthened and turned into something helpful and effective if rewarded. Trust can deepen and survive various interpersonal relationships, such as marital, friendly, family, and occupational relationships (Kurdi et al., 2018). As one of the components of secure attachment behavior, responsiveness can increase couples’ satisfaction with their married lives because they find their spouses responsive whenever necessary, which can increase marital trust (Champagne & Muise, 2022). Moreover, responsiveness can increase marital trust by preventing covert aggression. 
The results confirmed the direct relationship between engagement with marital trust and the indirect relationship of meeting with marital trust through two components of covert aggression (i.e., emotional withdrawal and social image destruction). The attachment bond involves maintaining intimate relationships, a secure base, and protesting separation. Like children, adults may have attachments to special persons, and any attachment figure has a unique and irreplaceable position. Attachment behaviors are specifically associated with relationship satisfaction (Novak et al., 2017). The findings of Sandberg et al. (2016) indicated the relationship between secure attachment styles with behaviors expressing accessibility, responsiveness, and engagement. Trust is one of the most important qualities of any close and intimate relationship, as it is often considered the central core of an ideal relationship, along with commitment and love. Trust is one of the potential factors affecting one’s functioning in a marital relationship. Trust also helps one to feel secure about the unpredictable behaviors of another person. A lack of marital trust destroys intimate interactions, whereas high levels of trust can increase marital commitment. To explain this finding, it can be stated that engagement, as an attachment behavior, makes people value their relationships, alleviate emotions and increase peace (Kamali et al., 2020). In addition, when one of the spouses faces a problem and asks his or her partner for help, the partner will help him or her peacefully. Engagement also reduces marital problems, conflicts, and aggression, thereby increasing marital trust.

The study results demonstrated the direct relationship of accessibility with marital trust and the indirect relationship of accessibility with marital trust through two components of covert aggression (i.e., emotional withdrawal and social image destruction). A family is a social unit and organized system and the most fundamental institution of society that plays a major role in the survival and growth of mankind. Attachment behaviors are among the variables affecting married life. Many studies have shown that individuals with a secure attachment style are more satisfied with their married life, whereas those with insecure attachment styles (avoidant and ambivalent) may experience lower levels of satisfaction, commitment, and confidence in their adult relationships (Mohammadi et al., 2016; Vollmann et al., 2019). Accessibility and responsiveness are among the key behaviors that can predict the security of close relationships. Marital violence and aggression mean treating one’s spouse violently through psychological abuse, such as intimidation, harassment, humiliation, and strong and harsh criticism, and overt aggression, like slapping and pushing. Violence against a romantic partner or spouse can restrict the victim’s personal growth, productivity, socioeconomic role, and physical and mental health. Covert aggression is also characterized by emotional withdrawal and social image destruction. To explain this finding, it can be stated that men and women form a new family to meet their needs and, therefore, it is very important to them to find their spouse accessible, when necessary, to better deal with problems and issues of everyday life. Spouses who find each other more accessible are more likely to enjoy higher levels of marital trust, which can serve as a prerequisite for establishing effective relationships and intimacy between them (Halmos et al., 2020). In addition, couples can enjoy higher levels of social trust when they know they are safe from their spouse’s covert aggression, and they can find their spouse accessible whenever necessary. 
The study results also showed a significant negative relationship between emotional withdrawal and marital trust. The overt aggression of spouses, which may be manifested through shouting and physical behaviors, requires treatment. The more dangerous type of aggression against spouses is called covert aggression, which is characterized by social image destruction and emotional withdrawal. In emotional withdrawal, one withholds his or her attention and affection from his or her spouse through neglecting or paying less attention to the spouse, refusing to have sexual relationships with him or her, threatening to leave the relationship, and similar behaviors (Kazemi et al., 2022). To explain this finding, it can be stated that emotional withdrawal can reduce marital trust. When one of the spouses takes advantage of emotional withdrawal to achieve his or her desires, he or she reduces his or her spouse’s trust. On the other hand, emotional withdrawal, as an instance of covert aggression, can lead to marital gaps and dissatisfaction (Sturge-Apple et al., 2006). The study results also showed a negative and significant relationship between social image destruction and marital trust. Covert aggression includes actions that spouses may use in their relationships. Covert aggression refers to behaviors that harm the spouse not physically but by damaging relationships and destroying friendships (Halmos et al., 2020). Social image destruction refers to slander, rumors, disclosure of private information, or involvement of others in discussions and arguments between spouses. One who uses social image destruction aims to take advantage of social pressure to control his or her spouse (Munusamy et al., 2022).
Since the statistical population of this study was restricted to only the married female nurses working in hospitals of Shiraz, the results should be cautiously generalized to male nurses and those who work in other places. 

5. Conclusion
The study findings confirmed the proposed model’s goodness of fit. It is recommended to pay special attention to covert aggression in pre-marital counseling and training courses to increase couples’ awareness of the negative effects of covert aggression on marital satisfaction and quality of married life. Policymakers, family consultants, and psychiatric nurses are also recommended to organize workshops and seminars for female staff of hospitals about ways to deal with covert aggression.   

Ethical Considerations
Compliance with ethical guidelines

The study was approved by the Ethics Committee of Ahvaz Branch, Islamic Azad University (code: IR.IAU.AHVAZ.REC.1400.125). Ethical considerations included informed consent to participate in the study, maintaining the confidentiality of the information, and respecting the rights of participants.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors.

Authors' contributions
Methodology: Fakhrossadat Siadat, Amin Koraei; Conceptualization and supervision: Amin Koraei, Masoud Shahbazi; Investigation, writing–original draft, and writing–review & editing: Fakhrossadat Siadat, Amin Koraei, Zahra Dasht Bozorgi; Data collection: Fakhrossadat Siadat, Masoud Shahbazi; Data analysis: Zahra Dasht Bozorgi, Amin Koraei; Investigation, writing the original draft, review, and editing: Siadat F., Koraei A., and Dasht Bozorgi Z; Data collection: Siadat F. and Shahbazi M; Data analysis: Dasht Bozorgi Z. and Koraei A.

Conflict of interest
The authors declare no conflict of interest.

Acknowledgments
This article was extracted from a part of the PhD dissertation of the first author in the Department of Counseling, Ahvaz Branch, Islamic Azad University, Ahvaz, Iran. The researchers wish to thank all the individuals who participated in the study.


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Type of Study: Research | Subject: General
Received: 2022/09/20 | Accepted: 2022/10/29 | Published: 2023/01/10

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