The relationship between alexithymia and shyness in nursing students with mediating roles of loneliness and social identity

Introduction In current Iranian society, shyness and low self-esteem are problems which many people, especially teenagers and youth, suffer from,1 both in terms of etiology and clinical manifestations. Shy people ruminate frequently with their minds running at high levels in social interactions.2 In general, shyness is an extreme self-awareness, a mental employment of thoughts, emotions, and physical reactions to self,3 which can elevate weak social discomfort to the height of a deterrent and result in severe social fear.4 During longitudinal research, Cheek and Buss5 found that shyness is a low level of communicating with others; communicating with others is helpful against loneliness.6 Personality features of shy people can be considered in two categories: Neurotic Shyness and Introverted Shyness.7 In social engagements, those with Neurotic Shyness lose insight about themselves and feel uncomfortable and anxious.8 Those affected by Introverted Shyness are more willing to be alone.9 Accordingly, one issue discussed in the field of shyness is the feeling of loneliness caused by social stigma and elimination of the sponsor’s environment by choosing and continuing such socially risky behaviors.10 Feelings of loneliness are an individual’s perception of deficiency in social relationships,11 which often appears in response to quantitative or qualitative shortcomings in social relationships.12 On the other hand, studies have shown that one of the most common symptoms of shy people is feeling lonely.13,14 When a person has lower levels of emotional and social support, the person feels alone, which in turn disrupts the management of their emotions.15 The feeling of loneliness is an individual’s conception of inappropriate social


Introduction
In current Iranian society, shyness and low self-esteem are problems which many people, especially teenagers and youth, suffer from, 1 both in terms of etiology and clinical manifestations.Shy people ruminate frequently with their minds running at high levels in social interactions. 2In general, shyness is an extreme self-awareness, a mental employment of thoughts, emotions, and physical reactions to self, 3 which can elevate weak social discomfort to the height of a deterrent and result in severe social fear. 4uring longitudinal research, Cheek and Buss 5 found that shyness is a low level of communicating with others; communicating with others is helpful against loneliness. 6ersonality features of shy people can be considered in two categories: Neurotic Shyness and Introverted Shyness. 7n social engagements, those with Neurotic Shyness lose insight about themselves and feel uncomfortable and anxious. 8Those affected by Introverted Shyness are more willing to be alone. 9Accordingly, one issue discussed in the field of shyness is the feeling of loneliness caused by social stigma and elimination of the sponsor's environment by choosing and continuing such socially risky behaviors. 10eelings of loneliness are an individual's perception of deficiency in social relationships, 11 which often appears in response to quantitative or qualitative shortcomings in social relationships. 12n the other hand, studies have shown that one of the most common symptoms of shy people is feeling lonely. 13,14hen a person has lower levels of emotional and social support, the person feels alone, which in turn disrupts the management of their emotions. 15The feeling of loneliness is an individual's conception of inappropriate social conditions that are the result of being deprived of the basic human need of intimacy. 16The feeling of loneliness of a person, according to emotional and social constraints, prevents a proper understanding of the social identity. 17enerally, loneliness is a response to a lack of a positive satisfying relationship with others. 18This condition affects individuals' social identity and self-perception. 19Studies by Lecours et al 20 and Henderson et al 21 found that social interactions, in addition to major effects on development, promote other aspects of life in various dimensions, including emotional issues 22 ; shy people experience less emotional expression due to gaps in these interactions. 23ncreased shyness reactions include fear and anxiety and those affected also feel embarrassed as a result, contributing to their stress and lower self-perception. 24or the first time alexithymia, or the inability to recognize or describe one's own emotions, has been recognized as a type of shortage in cognitive processing and the regulation of emotional states associated with psychiatric patients.It is often distributed as a normal personality trait among all people. 25When the alexithymia system is faulty, often people are caught up with emotions that they cannot escape from. 26Alexithymia is a multifaceted condition that is determined by the difficulty of identifying feelings, 27 differentiation between emotions and physical emotion, 28 difficulty in describing feelings for others and limited emotional perspectives. 29Sancar and Aktas 30 found a significant relationship between levels of alexithymia and communication skills of nursing students.Research has shown that nursing students suffering from alexithymia have difficulty identifying emotions in social relationships, causing them to adopt avoidance modalities. 31They generally have a higher tendency to both introspection and shyness. 32n this regard, some studies refer to Henderson et al 21 and Weeks et al, 33 who point out that, there can be significant relationships between social identity and selfesteem, social understanding, emotional regulation, and lack of shyness.These are all important for expressing emotions, social interaction and identity formation. 34he communication structure of individuals can lead to the emergence of a variety of social identities, or social products that have relatively fixed and stable elements. 35wareness of oneself is one of the challenges of life and through the process of self-discovery people may discover aspects of themselves that they like and that they dislike. 36hyness as a dynamic social phenomenon in all societies can have many effects on different aspects of life 37 and some studies have shown that shyness can cause social phobia and social anxiety. 4Zhong et al 38 found a significant relationship between alexithymia and social support, social interactions and lack of shyness among nurses.Muyan-Yilik et al 39 found that loneliness has a two-way relationship with shyness in students.Zhao et al 40 found a significant relationship between emotional intelligence and loneliness with shyness.Zhao et al 41 found a significant relationship between shyness and loneliness with core self-evaluation and social support serving as mediating factors.Jing et al 42 found a significant relationship between identity status and shyness in students.Regarding these relationships, the present study has a strong research background to support the conceptual model provided.
In general, nursing work is such that nursing students should prepare themselves for high-stress mental and physical conditions, including interaction with patients.If a nurse is shy and embarrassed in social relationships, it will be more difficult to accomplish the required duties and tasks.In addition to being a problem for the nurse, this also reduces job performance.Because nursing students are exposed to psychological risks due to specific pressure factors, such as changes in Community Relations, and since many professions have tasks in this course of study, they are likely to experience more vulnerability.However, it seems that the experience of these symptoms varies considering individual differences in alexithymia formation, social identity, and social interactions.The present study aimed to assess the relationship between alexithymia and shyness in nursing students with an exploration of mediating factors of feelings of loneliness and social identity (Figure 1).

Materials and Methods
The present study was correlational research with structural equation modeling; in this method, relationships are examined in a model which determines the effects of variables on the variable of interest. 43The statistical population included 658 nursing students at Ahvaz University of Medical Sciences in 2018.Of these students, 331 students were selected as the sample using Cochran's formula with a 5% margin of error and 95% confidence, P = 0.05.
The sampling was to available method.The criteria for inclusion were Nursing students at Ahvaz University of Medical Sciences, male or female, ages 18 to 22 years, undergraduate students, absence of psychiatric disorders along with the diagnosis of a psychiatrist based on DSM-V criteria, and obtaining informed consent to participate in the research.The exclusion criteria were failure to complete the study tools.
After explaining the research goals and the manner of cooperation of the individuals and before the research commenced, all participants were informed and gave their consent.Scales were distributed to students in classrooms at Ahvaz Nursing and Midwifery Faculty.

Statistical analysis
Data analysis was done using descriptive statistics, including mean and standard deviation (SD) for continuous variables and inferential statistics using Pearson's correlation and structural equation modeling.The analysis was performed using SPSS 18 (IBM, SPSS Statistics for Windows Version 18.0.Armonk, NY: IBM Corp.) and Amos 23 (IBM SPSS Statistics for Windows Version 23.0.Amos™, Armonk, NY: IBM Corp).
The method of rating the test was based on a Likert scale of 1 to 5 (1 = completely opposes to 5 = fully agrees).Questions 4, 10, 18, and 19 are reverse-scored.The minimum score for this questionnaire is 20 and the maximum is 100.Construct validity and concurrent validity were confirmed by the developers.Cronbach's alpha showed a reliability of 0.88, 0.84, and 0.83 for each subscale, and 0.89 for the entire scale.Afshari, 45 in a sample of 80 students, calculated the reliability of this scale using Cronbach's alpha.For the total scale, Afshari showed 0.75; for difficulty in detecting feelings, 0.72; difficulty in describing feelings, 0.72; and thinking with external orientation was 0.53.In the present study, Cronbach's alpha showed a reliability score for the total scale of 0.76, for difficulty in detecting emotions, 0.73, for difficulty in describing emotions, 0.77, and for thinking with external orientation, 0.69.In social science research, an alpha of 0.70 is generally regarded as acceptable.

Russell, Peplau and Cutrona' Loneliness Scale
This questionnaire was developed by Russell et al 46 and has 20 items.It has a general score based on a Likert scale of 1 to 4 (1, rarely score, 2, sometimes, 3, frequently, and 4, always).Questions 1, 5, 6, 9, 10, 15, 16, 19 and 20 are reversecoded.The range of scores is between 20 (minimum) and 80 (maximum).Cronbach's alpha was used to assess the reliability of this scale, reported by Russell et al 46 as 0.88; the construct validity and concurrent validity were confirmed.This scale was translated by Davar Panah 47 and after validation, Cronbach's alpha was reported as 0.78.In this study, Cronbach's alpha was 0.66.

Safarinia's Social Identity Questionnaire
This questionnaire is based on the theory of Jenkins 34 and was developed by Safarinia et al. 48This scale includes 20 items with two subscales: items 1-10 represents the individual dimension and items 11-20 represent the collective dimension.The questionnaire scoring is a Likert scale from 1 to 5 where 1 is "totally disagree" and 5 is "totally agree".Safarinia et al 48 attested to the scale's construct validity and concurrent validity, and reported a Cronbach's alpha of 0.77 for the entire scale, for the individual dimension, 0.74 and for the collective dimension, 0.71.In the current, the reliability of Cronbach's alpha for individual dimension was 0.63 and for the collective dimension was 0.67, with an alpha of 0.66 for the entire scale.

Briggs, Cheek and Buss' Shyness Scale
The Shyness Scale was developed by Briggs et al 49 and included 14 items with 3 subscales: Lack of determination (1 to 4), distress and social exclusion (5 to 11) and shyness associated with unfamiliar people (12 to 14), which is used to measure shyness.The scoring questionnaire is a 5-point Likert scale where 1, 2, 3, 4, and 5 matched the options "Absolutely Disagree, " "Disagree, " "have no idea, " "Agree, " and " totally agree, " respectively.The construct validity and concurrent validity were confirmed by the developers.Cronbach's alpha was used to establish reliability: Lack of determination was 0.84, distress and social exclusion was 0.82, shyness associated with unfamiliar people was 0.86, and the entire scale was 0.87.Rajabi and Abbasi 50 confirmed the construct validity and concurrent validity and found a Cronbach's alpha for Lack of determination of 0.80, distress and social exclusion of 0.81, shyness associated with unfamiliar people of 0.82, and 0.86 for the total scale.In this study, lack of determination was 0.79, distress and social exclusion was 0.82, shyness associated with unfamiliar people was 0.80, and the total scale was 0.84.

Results
Statistical assumptions of the research, such as kurtosis and skewness, and normalization of the data was established and accepted by using the box test and the Kolmogorov-Smirnov test.Verification validity of the variables was confirmed by considering the questions in the measurement model and then a structural model was drawn up.
Table 1 shows the demographic information, includes age and employment status of the nursing students.
Table 2 shows a significant positive relationship between loneliness and shyness.There is also a significant negative relationship between social identity and shyness at a level of 0.01.
In Table 3, it can be seen that the RMSEA value equals 0.042, less than 0.1, which indicates that the mean error of the model is appropriate, and the model is acceptable.The chi-2 value to degree of freedom (2.457) is between the index of 1 and 3 of GFI; CFI and NFI are also roughly equal and larger than 0.9, which indicates that the measurement model of the variables of the study is an appropriate model.In Table 4, it can be seen that according to the model, alexithymia, social identity and feelings of loneliness have significant direct effects on shyness.
The results of Table 5 show that two path included alexithymia with mediation of social identity on Shyness and path of alexithymia with mediation of feeling of loneliness on Shyness with respect to the values obtained from the t-statistic is significant at the level of 0.05.
According to Figure 2, in total alexithymia, feeling of loneliness and social identity had a predictive power of 0.51% of the shyness.

Discussion
The findings of this study support other findings from previous research.Zhong et al 38 found a significant relationship between alexithymia and social support, social interactions, and shyness among nurses.Henderson et al 14 found that shyness under the influence of social anxiety includes uncontrolled emotions and loneliness.Muyan-Yilik et al 39 found that loneliness has a two-way relationship with shyness in students.Tan et al concluded that loneliness and reduced social suport relationships can lead to shyness. 9Zhao et al 40 found a significant relationship between emotional intelligence and loneliness with shyness.Zhao et al 40 found a significant relationship between shyness and loneliness with mediating factors of core self-evaluation and social support.Jing et al 42 found a significant relationship between identity status and shyness in students.On the other hand, this research's findings support the findings of Cheek and Buss 5 : in terms of social and interpersonal functions, people who are shy are willing to socially confirm and avoid conflicts and if people's performance is impaired or incomplete, it is likely that disturbed social relationships will affect patient behavior, from filling a complaint to removing self-care behavior. 51ersons with a relative inability to understand emotions are likely to have an inability to evaluate and express emotions; this condition can cause a particular disorder in the psychological function of the individual, such as alexithymia, turbulent identity, and loneliness. 51These can, in turn, directly lead to shyness in the person or even fear of connecting to or communicating with others. 52Humphreys et al 53 found that emotional collapse predicts interpersonal problems and social interactions.Because people who have this feature imagine others see their situation as embarrassing, this exacerbates their loneliness; additionally, shy people have tended to have lower self-esteem. 54herefore, shyness is thought to be a strong predictor with a positive and significant relationship with loneliness, since social identity refers to the relationship between the individual and others within the community. 3It can also be difficult to establish interpersonal relationships, which can cause shyness.Reducing emotional expression is basically a kind of loss of, or badly regulated, emotion. 55imilarly, damage to the processing capacity of emotions, or emotional deficits, may be a risk factor for a variety of mental interpersonal problems including turbulent identity, shyness and loneliness. 56

Limitations
In this research, the sample group was selected only from undergraduate nursing students of Ahvaz University of Medical Sciences in 2018.Thus the results could only be generalized within this geographical range.Additionally, a self-report method was used along with a non-clinical sample group, and questionnaires were used to measure variables of research.One of the biggest problems with the data collection is the control of the impact of social utility.

Conclusion
The results of this study show alexithymia along with loneliness and social identity can have an effect on shyness among nursing students.This information can be useful for practical applications in undergraduate training among nursing students' advisers and trainers in order to help assess and address their psychological state, feelings of loneliness, social identity, and shyness.

Figure 2 .
Figure 2. Final tested model with standardized prediction statistics.

Table 1 .
Demographic information of nursing students

Table 2 .
Descriptive indexes and Pearson's correlation matrix of subscales of alexithymia, shyness, feelings of loneliness, and social identity

Table 3 .
Goodness of fit index obtained from data analysis and variables

Table 4 .
Direct estimation of the model through maximum Likelihood method

Table 5 .
Estimating the indirect effect of exogenous variables on the endogenous variable in the model