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. 2023 Apr 7;18(3):e72–e78. doi: 10.1016/j.teln.2023.04.002

Predictors of success in the registered nurse licensure exam for nursing graduates whose education was affected by the COVID-19 pandemic

Hui-Ling Lai 1,⁎, Shu-Ying Fu 1, Tai-Chu Peng 1
PMCID: PMC10080274  PMID: 37360268

Abstract

The Coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health-care education. However, the relationship between changes in nursing internships in Taiwan during the COVID-19 pandemic and outcome in the national registered nurse (RN) licensure exam for new nursing graduates is underexplored. The study was to explore the predictors of first-attempt success in the RN licensure exam in 2022. A retrospective review of secondary data was employed in this study. Adjusted binary logistic regression was used to analyze data. A convenience sample of 78 new graduates attempted the exam. Of these graduates, 87.2% passed the RN licensure exam. Age was the main predictor of exam success, followed by grand mean academic score and total alternative (nontraditional in-person) internship hours. Compared with those who failed the exam, the graduates who passed the exam were significantly more likely to be younger, have better academic performance, and have engaged in more alternative internship hours. Nursing faculties should consider implementing supportive strategies early for students who are underperforming or those who are older than their classmates on average to help them pass the RN exam on the first attempt. The optimal duration and long-term consequences of alternative nursing internships must be analyzed in further detail.

Keywords: Distance learning, internship, licensure, nursing education

Introduction

The World Health Organization (WHO) declared Coronavirus disease 2019 (COVID-19) as a pandemic in March 2020 (Cucinotta & Vanelli, 2020; WHO, 2022). The COVID-19 pandemic has had an unprecedented impact on education systems worldwide. Considering public health and safety, schools at all levels restricted student entry or closed their campuses during the COVID-19 pandemic, and educators had to change their teaching pedagogies to maintain students’ educational rights.

Nursing educators play an essential role in cultivating nursing students into competent health-care professionals who provide health care of high quality as well as maintain and improve patients’ safety and health. The health industry is multifaceted and challenging; thus, professional competency has long been emphasized in nursing education (International Council of Nurses, 2022).

During 2020–2022, considerable changes were made to the nursing education model to substitute for traditional face-to-face teaching globally. In particular, nursing students and faculty were temporarily prevented from conducting internships in health-care agencies because of the considerations of infection control and insufficient personal protective equipment; thus, alternative learning methods were used for imparting knowledge and skills related to direct care practice (Ministry of Education, 2021).

Before the outbreak of COVID-19, nursing internships emphasized contact with patients or clients, including establishment of therapeutic interpersonal relationships, implementation of skills, and application of the nursing process. Because of the COVID-19 pandemic, traditional in-person internships for nursing students were replaced with alternatives decided by 43 representatives from all nursing schools and the two major nursing societies in Taiwan (i.e., the Taiwan Nurses Association and Taiwan Association of Nursing Education). After the Ministry of Education in Taiwan approved these major educational changes, they were implemented in nursing schools nationwide. According to the “Ministry of Education Internship Course in Response to Severe Special Infectious Pneumonia Epidemic” regulation, the upper limit of the proportion of alternative internship hours is 50% (508 hours) of the total internship hours (1016 hours). The other half of the internship hours must be in an in-person format (Ministry of Education, 2021).

In the United States (Noone et al., 2018) and Taiwan (Lee & Chang, 2012), first-time pass rates in the registered nurse (RN) licensure exam are considered an indicator of the quality and effectiveness of a nursing program. Successfully passing a licensure exam is a fundamental requirement for the entry of new graduates into the health-care industry in Taiwan. The pass rate in the RN licensure exam among new graduates considerably affects the number of new nurses entering the profession immediately after graduation.

Researchers have estimated that the needs and responsibilities of the nursing workforce may change because of infectious diseases and economic crises (Boniol et al., 2022). Therefore, nursing educators must assist nursing graduates in passing the RN licensure exam so that these graduates can enter the workforce immediately after graduation.

The university involved in the present study offers a 4-year Bachelor of Science in Nursing (BSN) program. The students in this program must complete 1250 hours of in-person clinical internship. To be eligible for the national RN licensure exam in Taiwan, nursing graduates must complete a minimum of 1016 internship hours (Ministry of Education, 2021). In 2022, the first-attempt pass rate in the national RN licensure exam among new nursing graduates in Taiwan was more than 10% lower than that in 2021with only 45.31% of the examinees passing the exam (N = 6018) (Ministry of Examination, 2022).

Nursing educators are concerned about the pass rate in the RN licensure exam, and several factors are correlated with success in this exam. Students’ demographic and academic characteristics, such as age, gender, and academic performance or grade point average (GPA) (Banks et al., 2018; Haas et al., 2004; Havrilla et al., 2018; Kaddoura et al., 2017; Monroe & Dunemn, 2020), are predictors of their outcome in the RN licensure exam. Knowledge regarding the predictors of outcome in the RN licensure exam can enable nursing educators to develop early remedies for assisting students in being successful in this exam, which will ultimately benefit the health-care industry.

Nursing students who graduated in 2022 have experienced an unprecedented learning environment because of the global COVID-19 pandemic. Considerable changes were made to courses on professional nursing practice, especially to nursing internships, between 2020 and 2022, and these changes strongly affected educators and students. One major change was that alternative internships partially replaced traditional in-person internships. In addition to internships, in-person lectures were also moved online, and digital tools were employed to enable students to learn at home. This content has now been added to the manuscript. Little evidence exists regarding the effects of this substantial change of alternative internships, especially its effect on first-attempt success in the RN licensure exam. Therefore, the present study explored the predictors of first-attempt success in the RN licensure exam in those who graduated with a 4-year BSN degree in Taiwan in 2022.

Methods

Study Design

By using a retrospective review of secondary data, we explored the relationships between new graduates’ first-attempt outcome in the RN licensure exam and various factors. The study design enabled the researchers to explain potential predictors of the first-attempt success of new nursing graduates in the RN licensure exam in Taiwan. Although anecdotal information does not have the scientific rigor of empirical research, the values of informal observation should not be ignored or underestimated (Enkin & Jadad, 1998). Thus, we included information from our anecdotal observation in the section of Additional findings below.

Sample and Setting

This study was conducted with individuals who graduated from a 4-year BSN program at a university located in eastern Taiwan. The nursing department of this university recruits approximately 80 high school graduates each year for the aforementioned course. In Taiwan, college and university education is under the jurisdiction of two departments: the Department of Higher Education and the Department of Technological and Vocational Education of the Ministry of Education. The nursing department of the target university is the only one in eastern Taiwan that comes under jurisdiction of the Department of Higher Education of the Ministry of Education; thus, the data source in this study represented half the geographical area of Taiwanese nursing schools under the jurisdiction of the Department of Higher Education.

To earn a BSN diploma, students must obtain at least 128 course credits, including 25 credits for bioscience, 30 credits for liberal courses, 70 credits for nursing, and 3 credits for physical education. Each school year comprises two 18-week semesters (i.e., the fall and spring semesters). A graduation ceremony is held in June, and the graduates of the BSN program are eligible to attempt the RN licensure exam in July. All new graduates of the BSN program of the target university participated in the RN licensure exam in 2022. The research ethics committee of the target university (IRB111-229-B) and the study site administrator approved the present study.

Variables and Measurements

The first-attempt outcome in the RN licensure exam was assessed as a dichotomous variable (pass or fail). Data were obtained from the official records of the Ministry of Examination in Taiwan (Ministry of Examination, 2022). The RN licensure exam comprises five sessions. The first, second, third, fourth, and fifth sessions are related to courses on Basic Medical Sciences, the Fundamentals of Nursing and Nursing Administration, Medical–Surgical Nursing, Maternal–Infant and Pediatric Nursing, and Psychiatric Nursing and Community Health Nursing, respectively. The licensure exam involves multiple-choice questions. An average score of 60 or higher and no score of 0 in any course are requirements to pass the exam. However, the examinee's scores were not accessible from the official website.

Graduates’ demographic and academic data were obtained from the target university's official records. Age on the date of the RN licensure exam was recorded (in years) as a continuous variable. Gender and marital status were recorded as binomial variables.

Academic variables included the total hours of alternative internship, internship grades in selected nursing courses, and grand mean academic performance score.

The total internship hours for each participant were recorded. Graduates must have at least 1060 hours of clinical practicum experience to qualify for the RN licensure exam. Because of the COVID-19 pandemic, nursing departments in Taiwan were allowed to replace a maximum of 50% of traditional in-person internship hours with alternative internship hours.

The internship grades for Fundamentals of Nursing, Medical–Surgical Nursing (I), and Community Health Nursing were examined because only these three nursing courses provide thorough in-person practice of direct patient care. The internships in the remaining nursing courses combined different proportions of alternative and in-person modalities. The contents of the alternative internship included online learning, virtual simulation, and blended learning. The detailed content of the alternative internship was authorized at the discretion of the target university. The evaluation of student internship performance had to be changed because the original evaluation scales (designed for in-person internships) were not applicable to all alternative internships, which resulted in the inability to compare internship performance between graduates from different years. Thus, the internship grades for only the aforementioned three courses were considered in the present study.

Grand mean academic performance scores were measured by summing the graduates’ grades for all courses and then dividing the sum by the number of courses over the 4 years of study. Scores ranged between 0 and 100 and represented the graduates’ overall performance.

Data Analysis

The collected data were analyzed using PASW 18.0 for Windows (SPSS Inc., Chicago, IL, USA). Univariate statistics were used to determine the frequencies and percentages of the categorical variables and means and standard deviations (SDs) of the continuous variables. The association between a selected independent variable (demographic and academic characteristics) and the outcome in the RN exam (pass or fail) was tested using independent t tests and χ2 tests. Binary logistic regression analysis was conducted to identify predictors of success in the RN licensure exam. When the 95% confidence intervals of the relative risk of a given factor did not include 1, the risk was considered statistically significant.

Results

Participant Characteristics

In 2022, 78 students graduated with a BSN degree from the target university. Of these students, five were foreign citizens of Chinese origin and spoke Chinese as their primary language. All the graduates were unmarried and aged 23–25 years (mean = 23.15, SD = 0.486). Most of the participants were women (75.6%, n = 59). Although the pass rate in the target university for the RN licensure exam has continually been considerably higher than the corresponding national average (Fig. 1 ), the target university's pass rate reached its lowest level in 2022. Table 1 presents the characteristics of the sample in this study.

Fig 1.

Fig 1

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The average pass rates of the RN licensure exam of the university were constantly higher than nationwide over time. The national average of the RN licensure exam pass rates were calculated to blend with the Bachelor of Science in Nursing, Accelerated Bachelor of Science in Nursing, and Junior College programs. Data source: Ministry of Education, Taiwan, ROC.

Table 1.

Participants’ Characteristics Between Groups (N = 78)

Total (N = 78) Pass (n = 68) Fail (n = 10) t p
M† SD† M† SD† M† SD†
Age (yr) 23.15 0.49 23.09 0.38 23.6 0.84 1.89 0.089
Fundamentals of Nursing in-person internship grades 83.38 3.63 83.90 2.95 79.9 5.65 -2.20 0.054
Medical-Surgical Nursing (I) internship grades 83.44 4.73 84.26 4.12 78.40 5.36 -4.00 0.006**
Community Health Nursing in-person internship grades 88.42 1.69 88.47 1.73 88.10 1.37 -0.65 0.520
Total hours of alternative internships 336.92 78.95 344.25 79.58 287.10 54.90 -2.19 0.032*
Grand mean scores of academic performance 81.31 4.11 82.10 3.56 76.00 3.66 -5.04 <0.001***
N % n % n % χ2 p
Gender 1.52 0.217
 Female 59 75.6 53 67.9 6 7.7
 Male 19 24.4 15 19.2 4 5.1
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Note: †M = mean; †SD = Standard Deviation

*p < 0.05, **p < 0.01, ***p < 0.001

The total internship hours required for graduation was 1250, which exceeded the minimum requirement to take the RN licensure exam in Taiwan. However, the internship hours in 2022 were 9 hours less than those in a usual study year because one of the internship days in 2022 was a national holiday, and students are not assigned internship work on holidays. Figure 2 presents the average hours of internship modes (in-person vs. alternative) for each nursing student.

Fig. 2.

Fig 2

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The average hours of internship modes (in-person vs. alternative) for each nursing student.

The average total alternative internship hours was 336.92 (SD = 78.95, range = 180–504 hours); alternative internship hours accounted for 27.15% (range:14.5%–40.61%) of the total internship hours. Of the complete research sample, 87.2% (n = 68) passed the national RN licensure exam in their first attempt.

Between-Group Comparison of First-Attempt Outcome in the National RN Licensure Exam

In bivariate analysis, the outcome in the RN licensure exam was not significantly related to age or gender (Table 1). However, internship grade for Medical–Surgical Nursing (I) (p = 0.006), total alternative internship hours (p = 0.032), and grand mean academic score (p < 0.001) were associated with success in the RN licensure exam, which indicated that graduates who passed the exam obtained higher internship grades for Medical–Surgical Nursing (I), achieved higher academic scores, and completed more alternative internship hours than did the graduates who failed the exam. Internship grades for Fundamentals of Nursing and Community Health Nursing were not significantly different between those who passed and failed the RN licensure exam.

Regression Analysis

A binary multiple logistic regression was performed to determine the influences of age, internship grade for Medical–Surgical Nursing (I), total alternative internship hours, and grand mean academic score on success in the RN licensure exam. Because age (p = 0.089 < 0.10) was a potential predictor of exam outcome (Banks et al., 2018; Eweida et al., 2020; Haas et al., 2004; Monroe & Dunemn, 2020), this variable was added to the multivariate regression model. A p value of less than 0.05 should not be the only consideration when selecting a variable for multivariate analysis so that failure in identifying crucial variables can be avoided (Bursac et al., 2008). Thus, four potential predictors were simultaneously input to the binary logistic regression model.

In the binary logistic regression model (Table 2 ), age (Wald χ2 = 4.739, p = 0.029), total online internship hours (Wald χ2 = 5.335, p = 0.021), and grand mean academic score (Wald χ2 = 6.656, p = 0.010) were significant predictors of outcome in the RN exam. Internship grade for Medical–Surgical Nursing was no longer a significant variable after adjusting for other variables in the model (Table 2); however, this factor was significantly associated with RN exam outcome in the bivariate analysis (Table 1) model. The variance explained by the logistic regression model was 69% (Nagelkerke R2), and the model correctly classified 90.9% of the sample.

Table 2.

Determinants of Licensure Exam Outcomes (N =78)

Variable† B Wald χ2 p OR‡ 95% C.I.§
Age (yr) -2.210 4.739 0.029* 0.110 0.015∼0.802
Grades of Medical-Surgical Nursing (I) in-person internships 0.113 0.903 0.342 1.120 0.887∼1.414
Total hours of online internships 0.034 5.335 0.021* 1.035 1.005∼1.065
Grand mean scores of academic performance 0.733 6.656 0.010* 2.081 1.193∼3.632
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†

Independent variables were simultaneously entered into the binary logistic regression model. Nagelkerke R2 = 0.69

‡

OR = odds ratio;

§

CI = confidence interval.

The results of multiple logistic regression indicated that first-attempt outcome in the RN licensure exam (pass or fail) was predicted by the graduates’ age, total alternative internship hours, and grand mean academic score (Table 2). The results suggested that graduates who were younger, engaged in more hours of alternative internships, and achieved higher grand mean academic scores were 0.11, 1.03, and 2.08 times more likely to pass the RN licensure exam, respectively.

In summary, the binary multivariable logistic regression indicated that age (β = -2.21) was the most influence factor of first-attempt success in the RN licensure exam, followed by grand mean academic score and total alternative internship hours. The graduates who passed the RN licensure exam were significantly more likely to be younger, have achieved a higher academic score, and have engaged in more total alternative internship hours.

Additional Findings

While writing the research results, the first and second authors encountered some of the graduates individually. The anecdotal observations were evidence gleaned from those graduates' perceptions and opinions. Although total alternative internship hours were a significant predictor of the outcome in the RN licensure exam, a few graduates stated that the alternative internships had had partial negative effects on their learning outcome. This opinion can be explained by the fact that nursing is a hands-on profession. Lack of in-person clinical practice made some graduates feel less confident to work as a nurse in health-care agencies, and their nursing competency was not fully established. However, they also mentioned that the alternative internships had helped them acquire clinical reasoning ability through online meetings with preceptors and resulted in them having more time to prepare for the RN licensure exam.

Discussion

The main finding of this study is that age, total alternative internship hours, and grand mean academic performance are predictors of success in the RN licensure exam in Taiwan. This study is the first to include total alternative internship hours in a model for predicting success in the RN licensure exam.

A total of 87.2% of the 78 graduates of the BSN program of the target university passed the RN licensure exam in their first attempt. Although this value is the lowest pass rate since the BSN program of the university was established in 1997, the value is higher than the average pass rate in Taiwan over the past years (Ministry of Examination, 2022). The pass rate of the aforementioned graduates may not be comparable with the average nationwide pass rate because the average nationwide pass rate is calculated for graduates of three programs, namely BSN, Accelerated BSN, and 5-year Junior College programs. Nevertheless, the pass rate in our study was similar to the average first-time pass rate for the National Council Licensure Examination-Registered Nurse exam, as reported in a study conducted in Oregon, United States, that analyzed a large sample (i.e., 88.86% of 4045 graduates) (Noone et al., 2018).

During 2020 and 2022, because of the effects of the COVID-19 pandemic, educators have had to modify students’ internships. Thus, all the RN licensure examinees who graduated in 2022 experienced changing clinical practice methods in Taiwan. These students experienced more distance practice hours than any group of students before them. Our study revealed that the number of alternative internship hours varied for each examinee, with alternative internship hours accounting for an average of approximately 27% (336.7 hours) of the 1250 total internship hours. This proportion is considerably higher than that in the study of Smith et al. (Smith et al., 2021). Smith et al. recruited 340 new graduate nurses from an academic medical center in the United States to examine the perceptions of these nurses regarding the transition of clinical experience to a virtual platform. These authors found that 67.5% of the new graduate nurses used virtual platforms for a median of 51 hours of internship.

In the present study, multivariable regression was used to identify significant predictors of success in the RN licensure exam in Taiwan (Al-Alawi et al., 2020). The variance explained by the prediction model’ was 69% for success in the aforementioned exam. Noticeably, the p value of age (p = 0.089) did not reach a conventional statistically significant level, and age became a significant predictor of exam outcome after adjusting for other variables in the multiple logistic regression. An explanation for the aforementioned phenomenon is provided by statisticians (Bursac et al., 2008; Sun et al., 1996); when using p values derived from bivariable analysis as inclusion criteria in multivariable analysis, potentially important variables may be erroneously excluded if a variable that confounds the relationship between a response variable and an explanatory variable is not suitably controlled for.

The findings of this study are analogous to those of previous studies that have reported older examinees to be significantly more likely to be unsuccessful in the RN licensure exam (Banks et al., 2018; Haas et al., 2004; Monroe & Dunemn, 2020). Failure related to age has been a psychological distress risk among nursing students during the COVID-19 pandemic (Eweida et al., 2020), which may explain why age was a significant predictor of failure in the RN licensure exam in the present study.

We unexpectedly found that alternative internship hours were a significant predictor of success in the RN licensure exam. This finding adds knowledge to the relevant literature. A likely reason for the aforementioned finding is that the RN licensure exam in Taiwan is currently a paper-and-pencil exam. Certain essential components of nursing competency, such as nursing skills and professional attitude, cannot be appropriately assessed using such exams (Lee & Chang, 2012). Another possible explanation is that the online internships allowed the graduates to read more and gave them more time to discuss the content of reading assignments with preceptors. This explanation was formulated on the basis of informal conversations with a few of the graduate examinees. The aforementioned effects of online alternative internships were beneficial in enhancing the performance of the graduates in the RN licensure exam.

Rapid changes in the external environment, such as epidemics or global economic crises, may result in increased demand for health-care workers (Boniol et al., 2022). In Taiwan, only 63.11% of all licensed nurses were working in 2022 (Department of Nursing and Health Care, 2022). Moreover, more than 60% of the hospitals in Taiwan have stated that they face difficulties in recruiting nursing staff (Department of Nursing and Health Care, 2022). We could not analyze the examinees’ perceptions of the transition to alternative internships because we employed a retrospective review of secondary data in this study. Nevertheless, in a qualitative study, Choi et al. found that South Korean nursing faculty members were uncertain of the effectiveness of online practical training (Choi et al., 2022). Moreover, in another study, new graduate nurses in the United States who experienced virtual learning were fearful and less confident in providing actual patient care (Smith et al., 2021).

Epidemiologists have suggested that the health-care industry should prepare for unpredicted pandemics in the future (Suran, 2022). The results of our study are a useful reference for future crisis management planning related to nursing education. During pandemics and other large-scale emergencies, nursing educators must understand students’ difficulties and give them appropriate support to ensure students’ success in the RN licensure exam.

Academic performance and GPA have long been identified as significant predictors of outcome in the RN licensure exam (Haas et al., 2004; Havrilla et al., 2018; Monroe and Dunemn, 2020). Researchers found that course grades and GPA results are significant predictors of success in an RN licensure exam (Banks et al., 2018). Low grades in any nursing course increase the risk of failure in an RN licensure exam (Kaddoura et al., 2017). We found that the 4-year grand mean academic score of the graduates predicted their outcome in the RN licensure exam, which partially supports the findings reported previously (Banks et al., 2018; Haas et al., 2004; Havrilla et al., 2018; Kaddoura et al., 2017; Monroe & Dunemn, 2020).

In addition to identifying significant predictors of outcome in the RN licensure exam in Taiwan, we found that the transition to alternative internships had two effects. The new graduates perceived that the transition strengthened their critical thinking skills, and they felt that a certain amount of distance learning is beneficial in preparing for the RN licensure exam. However, the graduates were concerned regarding their preparedness to be a competent RN. Although these findings were obtained through informal conversation, they correspond to those of a previous qualitative study that have found that virtual simulation has limitations in replacing clinical practice (Joung & Kang, 2022). The educational changes caused by the COVID-19 pandemic have negatively affected new graduate nurses’ confidence and increased their new job stress (Feeg et al., 2022). In general, nursing students prefer traditional clinical practice over online clinical learning (Leighton et al., 2021).

Nursing competency includes knowledge, skills, and attitude (International Council of Nurses, 2022). The RN licensure exam in Taiwan is currently a paper-and-pencil exam and thus does not evaluate graduates’ skills and attitude. The gaps between Taiwan's education and examination systems have long been identified but have not yet been resolved (Lee & Chang, 2012). During the COVID-19 pandemic, alternative internships were a compromise adopted to enable students to fulfill the minimum requirement for the RN licensure exam. Although we found that total alternative internship hours were a predictor of success in the RN licensure exam, the underlying mechanisms of this finding must be explored, and the results of this study should be interpreted with caution.

Limitations and Implications

This study has certain limitations. First, secondary data were used in this study to explore the predictors of success in the RN licensure exam in Taiwan. Future studies can identify the influences of factors such as graduates’ learning style, their mental health during the pandemic, and different demographic and academic characteristics on outcome in the RN licensure exam. Competent nursing graduates must possess theoretical knowledge, specific skills, and a professional attitude; however, skills and attitude cannot be assessed through paper-and-pencil exams. Thus, studies should investigate the competency of newly hired nursing graduates working in health-care institutions. Nursing faculties should consider implementing supportive strategies early for students who are underperforming or those who are older than their classmates on average to help them pass the RN exam on the first attempt. The optimal number of alternative internship hours is also an aspect worthy of further analysis. Moreover, researchers can examine the long-term consequences of alternative internships on professional practice in the health-care industry. Second, the present study investigated graduates from only one university. Future studies should recruit nursing graduates from different institutions to obtain more generalized results, which can then be used by nursing educators and administrators as a reference when formulating relevant education strategies and policies for future pandemics. Lastly, only dichotomous data (pass/fail the RN licensure exam) were accessible from the official records of the Ministry of Examination in Taiwan. Future studies can apply prospective study designs to collect graduates' scores for the RN licensure examination, which would be helpful to changing educational practices.

Conclusions

In the present study, secondary data were used to identify significant predictors of outcome in the RN licensure exam in Taiwan. Underperforming as a student or being older than one's classmates on average were identified as influencing factors for passing the RN exam. Nursing faculties should consider implementing supportive strategies early for students who are underperforming or those who are older than their classmates on average to help them pass the RN exam on the first attempt. Ensuring that students undergo a specific number of hours of an online internship can help them pass their RN licensure exam. The findings of this study can be used as a reference by health-care educators and policymakers when modifying professional pedagogies for health-care students during pandemics. Fig. 2 .

Author Contribution

Hui-Ling Lai: Conceptualization, methodology, software, formal analysis, data curation, writing - original draft, writing - review & editing. Shu-Ying Fu: Software, validation, formal analysis, resources, data curation, writing - review & editing. Tai-Chu Peng: Validation, resources, data curation, writing - review & editing, supervision.

Author Conformation

All authors have participated in (a) conception and design, or analysis and interpretation of the data; (b) drafting the article or revising it critically for important intellectual content; and (c) approval of the final version.

This manuscript has not been submitted to, nor is under review at, another journal or other publishing venue.

The authors have no affiliation with any organization with a direct or indirect financial interest in the subject matter discussed in the manuscript

Funding

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

Ethical Considerations

Ethical approval was granted by the Research Ethics Committee of Hualien Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation (IRB111-229-B).

Declaration of Competing Interest

The authors declare that they have no conflict of interest to declare.

Footnotes

All authors have read and agreed to the published version of the manuscript.

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