Nursing students’ experiences of patient information protection during clinical practice: a qualitative study

Abstract

Background

Nursing students frequently access patient information during clinical practice and face ethical challenges in protecting patient information. This study aimed to explore and describe nursing students’ experiences of patient information protection during clinical practice.

Methods

A qualitative descriptive approach was employed to understand nursing students’ experiences of patient information protection. Using convenience sampling, twenty-three nursing students were recruited from four nursing schools in South Korea. Data were collected using semi-structured interviews and field notes until data were saturated. A qualitative content-analysis was conducted for data analysis. Rigor was ensured achieving four criteria including credibility, dependability, confirmability, and transferability.

Results

Four themes emerged from the data analysis. Nursing students experienced awareness of the importance of patient confidentiality, challenges of protecting patient information, inappropriate use of patient information, and need for more education about patient confidentiality.

Conclusions

Nursing students recognized gaps between their awareness and practice in terms of patient confidentiality. They reported the need for repetitive and case-based education on patient information protection. This study provides valuable data for developing strategies for patient information protection. Future research need to develop better pedagogical strategies to improve students’ protection of patient information during clinical practice.

Background

Healthcare providers have faced many ethical challenges in protecting patient information around the world. Nurses, as main healthcare providers, have direct access patient information, have a legal and ethical duty of confidentiality, and play an important role in protecting patient information [1–3]. Some studies [1, 3–5], however, have reported nurses’ unauthorized access to medical records, disclosure of patients’ information, and invasion of patients’ privacy, which might result in loss of trust, reputational damage, disciplinary action, legal action, loss of license, and penalties.

Nursing students, future healthcare providers, also frequently access patients’ health information during clinical practice [6–8]. Nursing students’ access to and collection of patient information have raised increasing ethical concerns about disclosure of patient information and breach of patient privacy [9]. Earlier studies [10–12] reported nursing students’ poor attitudes and poor practice related to patient information (privacy) protection. In this context, nursing educators who have ethical responsibilities and teach nursing ethics face many ethical challenge and resolve ethical problems in the clinical training for nursing students [13–16].

[Despite the importance, globally, there are only small number of qualitative studies [9, 17–19] regarding nursing students’ patient information protection. The earlier studies [9, 17–19[ perception focused on various aspects (perspective, view, experience, cultural viewpoint, and influencing factors) of patient confidentiality and privacy issues among nursing students with various study aims and questions. The studies [9, 17–19] were conducted in different four countries— Iran, South Africa, Brunei Darussalam, and Türkiye. Therefore, the earlier studies [9, 17–19] reported very various and mixed findings. Considering the importance of the confidentiality issue, further studies are required.

In Korea (ROK), nursing students are frequently exposed to patients’ health information (electronic medical records and paper-based information) in most clinical settings [6]. Nevertheless, education on patient information protection for nursing students in Korea varies widely depending on nursing schools and institutions, with no standardized guidelines [20]. To the best of our knowledge, there is no qualitative studies about nursing students’ experiences of patient information protection in Korea.

Given the lack of research and understanding about nursing students’ experiences of patient-information protection during clinical practice, further investigation is required. Therefore, this study aimed to explore and describe nursing students’ experiences of patient-information protection during clinical practice. The findings are expected to provide in-depth insights and understanding of students’ experiences and help nursing educators develop effective pedagogical strategies to strengthen ethics education for nursing students.

Methods

Research design

This study used a qualitative descriptive study design [21, 22], which is “the method of choice when straight descriptions of phenomena are desired” [21:339]. Qualitative description study emphasizes straightforward and richly detailed descriptions with low-inference and it explores poorly understood phenomena through the experiences that naturally emerge from participants’ accounts [21–25]. The method fitted well with the purpose of the study—straight descriptions of nursing students’ experiences regarding patient information protection in clinical practice from their perspectives.

Theoretical framework

Kolb’s experiential learning theory [26–28] was used to understand students’ experiences in this study. Experiential learning theory provides dynamic view of learning and learning cycle [28]. In experiential learning theory, learning is “the process whereby knowledge is created through the transformation of experience.” [26:38].

Participants

Using convenience sampling, participants were recruited by the first author. The first author contacted five nursing schools located in Seoul, Incheon, and Gyeonggi Province (South Korea) to invite participation in the study. Among them, four nursing schools expressed interest and were included. The first author met faculty members of the schools to provide detailed explanations of the study’s objective and procedure. With their help, nursing students who expressed interest and provided consent were recruited. The first author contacted 23 participants sequentially by phone, explaining the study’s purpose and process, obtaining their consent, and scheduling interviews at their convenient time and location. Recruitment continued until no new code and theme emerged. Finally, a total of 23 participants were included, and no refusal occurred. There was no relationship between authors and participants prior to study commencement. The first author was a doctoral student at one of the participating universities but she did not have any relationship with the participants prior to study commencement.

Participants were eligible if they met the following criteria: (a) were fourth-year students enrolled in nursing programs located in Seoul, Incheon, and Gyeonggi Province (Korea), and (b) had prior hospital-based clinical experience. Participants were excluded if they had previously participated in a qualitative study with a similar focus on patient information protection. This exclusion criterion was set to prevent potential bias that could arise from prior exposure to the study topic and procedures. A total of 23 nursing students participated in the first interview, and 18 of them proceeded to the second interview. The remaining five students were unable to participate in the second interview—four due to personal reasons and one because of illness.

Data collection

Data were collected from April to August in 2019. Interview questions were developed by two authors based on relevant studies and expert’ consultation (Table 1). The first author (female, PhD candidate in nursing, and nurse) had completed courses on qualitative research methodology and actively participated in qualitative research societies. The second author was a nursing professor (female, PhD in nursing, and nursing professor) who has taught qualitative research courses and had published many qualitative study articles. A pilot test was conducted with two nursing students to refine and modify the interview questions.

Table 1.

Qualitative interview guide

First interview questions

• Have you ever heard about patient information protection in the context of hospital clinical practice? • Have you received any education on patient information protection? • To what extent do you think patient information is protected in healthcare institutions? • Can you describe any experiences related to collecting patient information? • What do you know about the disposal of patient data after collection? • How do you manage and store patient information obtained during hospital clinical practice? • What challenges do you face in practicing patient information protection? • Have you ever witnessed (or heard) peers or healthcare professionals disclosing patient information? • Have you ever disclosed patient information personally during hospital clinical practice?

Second interview questions
• What do you think about the results of initial data analysis? • Is there anything else that you would like to add? • Tell me about your experience in participating in this study.

During the interviews, the author minimized verbal input and focused on actively listening to the participants’ responses. The first interviews included three components: obtaining written consent (10 min), completing a general questionnaire (five minutes), and an in-depth interview (average 55 min). The first interview was conducted in Korean by the first author and recorded using two digital recorders. The author used semi-structured and open-ended questions and continuously assessed whether the questions matched the intended research objectives.

During the first interviews, all participants underwent in-depth interviews their preferred locations, ensuring a quiet and comfortable environment (students’ training rooms). The first author took measures to minimize distractions and create a setting where participants felt at ease. With participants’ consent, two audio recorders were used simultaneously to ensure accurate data collection. The author was familiar with the operation of the recording devices to avoid any disruptions during the interviews. The first author wrote filed notes immediately after each initial interview session to avoid interfering with the interview process.

The first author conducted the second interviews to obtain participants’ feedbacks about the initial data analysis of the first interviews, clarify contrasting or contradictory data, and add participants’ in-depth and new reflections [29]. Out of the 23 first-interview participants 18 took part in the second interview, which was held at the same location as the first interview. The second interview focused on obtaining participants’ feedback on the analysis results, discussing any necessary modifications or additions, and clarifying uncertain aspects of their responses. The second interviews lasted approximately 10 ~ 15 min.

After completing the interviews, participants received a $20 honorarium in recognition of their time and contribution. A research assistant repeatedly listened to the recorded interviews and transcribed the entire content verbatim to ensure accuracy. The author carefully reviewed and verified the accuracy of all transcripts. The first-round interview data amounted to 263 pages and the second-round interview data was 61 pages (a total of 324 pages).

Data analysis

Inductive content analysis was used in this study. All interviews and fields notes were transformed into written text. Two authors conducted data analysis using the eight-step qualitative content analysis method [30]: (a) the unit of analysis was sentences in all the interviews, (b) two authors developed initial 15 categories and 50 codes, (c) category definitions and coding rules were pre-tested with three interviews, (d) reliability and validity were assessed through many repeated data analyses. ATLAS.ti 8.2 (Atlas.ti Scientific Software Development GmbH, Berlin, Germany, 2018) was used to facilitate data analysis (coding and data retrieval), (e) coding rules were revised and unclear or inconsistent codes were removed, (f) the revised category scheme was further pre-tested and refined with feedback from four nursing faculty, (g) all data were coded and patterns were identified to develop themes, resulting in four final themes, and (h) to assess reliability and validity, the authors reanalyzed the data multiple times until consistent results were obtained. Finally, four themes, nine subthemes, nine categories, and 27 codes were identified. Data analysis was discontinued when code and thematic saturation were achieved—no new code and theme emerged [31–33].

Four qualitative research experts (nursing professors) and one nursing doctoral student with experience of conducting qualitative research reviewed the findings and provided consultation. Finally, data analysis resulted in four themes, nine subthemes, nine categories, and 27 codes. Following the final data analysis, the second author, who is bilingual, translated the quotes and themes in English, and a professional bilingual editor reviewed the translation for accuracy.

Ethical considerations

This study was approved by Gachon University’s Institutional Review Board (NO 1044396-201903-HR-051-01). This study followed ethical principles of the Declaration of Helsinki. Both verbal and written informed consent were obtained from all participants. All participants’ information was handled with strict confidentiality to ensure anonymity. Participants’ names were replaced with numerical codes, and the data were securely stored on the author’s personal laptop with password protection to prevent unauthorized access.

Trustworthiness

Rigor was ensured following Lincoln and Guba’s criteria for trustworthiness, including credibility, dependability, confirmability, and transferability [34]. To enhance credibility, prolonged engagement in the field and member checking were conducted. The researcher created a comfortable interview environment to encourage participants to share their vivid experiences freely. The researcher actively listened during the interviews and used open-ended questions to allow participants to express their rich experiences. Furthermore, the analysis results of the first interviews were shared with 18 participants in the second interview, where feedback and opinions were collected. Additional feedbacks were obtained from four nursing professors and one nursing doctoral researcher. Dependability was achieved by conducting repeated data analysis and maintaining an audit trail. Reflexive notes were also written throughout the research process to document analytic decisions and support dependability.

Confirmability was enhanced by minimizing researcher bias and subjectivity and securing objectivity through ongoing consultation with four nursing professors specializing in qualitative health research. Thick description was used to ensure transferability. This study provided a detailed description of the study’s objectives, data collection methods, and analysis procedures to ensure applicability to other settings. To ensure the completeness and transparency of the research findings, this study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [35] and the Standards for Reporting Qualitative Research (SRQR) guidelines [36].

Results

Table 2 presents the nursing students’ general characteristics. Among the 23 students, 18 (78.3%) were female, and five (21.7%) were male. All students had received education on patient information protection, with 21 students (91.3%) having received the education from both at their nursing schools and in hospital. Table 3 summarizes the findings from the qualitative data analysis. Data from both the first and second interviews were analyzed, leading to the identification of 27 codes, nine categories, and four themes. The four themes included awareness of the importance of patient confidentiality, challenges of protecting patient information, inappropriate use of patient information, and need for more education about patient confidentiality.

Table 2.

General characteristics of participants

Characteristics	Categories	N
Age (year)	21~25	17
	25~30	6
Gender	Female	18
	Male	5
Religion	Protestant	5
	Catholic	3
	Buddhism	3
	No religion	12
	Other	0
PIP* education experience	Yes	23
	No	0
Provider of PIP Education	College only	2
	Hospital only	0
	Both college and hospital	21
	Other	0
Total PIP education time (year)	1 ~ 2 h	3
	2 ~ 3 h	18
	> 3 h	2

PIP patient information protection

Table 3.

Themes and subthemes

Themes	Subthemes
Awareness of the importance of patient confidentiality	Received education on patient information protection
	Recognize the need for patient information protection
	Make conscious efforts to protect patient information
Challenges of protecting patient information	Challenging environment of protecting confidentiality Accessing patient records out of personal curiosity
Inappropriate use of patient information	Unauthorized use and retention of patient information
	Sharing assignment materials with other students
Need for more education about patient confidentiality	Need for repetitive education about patient confidentiality
	Need for case-based education about patient confidentiality

Awareness of the importance of patient confidentiality

Many nursing students mentioned that they had received education and recognized the importance of patient information protection as important responsibility. In addition, many students knew that patient information should never be disclosed so they made conscious efforts to protect patient information. This theme was illuminated by three subthemes— ‘received education on patient information protection’, ‘recognize the need for patient information protection’, and ‘make conscious efforts to protect patient information’.

Received education on patient information protection

Most students stated that they had received education on patient information protection from their nursing schools and hospitals before beginning their hospital clinical practice. They frequently used expressions such as “important” and “must be protected” regarding patient information. Additionally, many participants emphasized that patient information should never be disclosed in public places and protecting patient information is a critical responsibility.

Before starting clinical practice, we received orientation training at school and the hospital. I think our school’s students are well aware of the importance of patient information protection and recognize the necessity of adhering to it. (Participant 6)

I received education on patient privacy protection at the hospital. I learned that discussing patient-related matters in elevators or public buses, even without mentioning real names, was strictly prohibited. I believe protecting patient information is a critical responsibility. (Participant 11)

Recognize the need for patient information protection

Many students recognized that exposing patient information constitutes an invasion of patient privacy and the privacy breaches could lead to unfair consequences for patients. They emphasized that patient information protection is essential to prevent such harm.

If I were a patient, I would feel like my privacy was violated. It would be like exposing something I wanted to keep secret. (Participant 20)

If my personal information were exposed without my consent, I would feel bad. From a patient’s perspective, it would be an invasion of privacy. In some cases, patients sue hospitals over privacy breaches. As someone could suffer from such incidents, I strongly believe that privacy protection is necessary. (Participant 1)

Make conscious efforts to protect patient information

Several students mentioned that some hospitals provided students worksheet including patient name, registration number, and diagnosis, where they recorded vital signs during clinical practice. Nursing students stated that they made conscious efforts to dispose of these documents properly before leaving the hospital, ensuring that patient information was not taken outside the hospital.

One thing I actively tried to do was to dispose of the worksheet including patient list properly before leaving the hospital. I made sure to put it in the disposal bin before finishing my shift. (Participant 8)

Some hospitals printed out vital sign sheets, which include patient names, registration numbers, and even primary diagnoses. I remembered making sure to dispose of them in the nurses’ station disposal bin before going home. (Participant 3)

Challenges of protecting patient information

Most students pointed out that multi-bed rooms and open structure of nurses’ station made it difficult to protect patient information. Some students revealed that they accessed patients’ medical records out of personal curiosity. This theme included two subthemes—and ‘challenging environment of protecting confidentiality’ and ‘accessing patient records out of personal curiosity’.

Challenging environment of protecting confidentiality

Many (seventeen) students pointed out that inappropriate ward structure and nurses’ station layout created an environment where practicing protection of patient information was difficult. They highlighted that multi-bed rooms allow other patients and caregivers to overhear confidential conversations, posing a challenge to patient information protection. Additionally, students mentioned that the open structure of nurses’ stations made it difficult to protect patient information and confidential conversation.

I think the ward structure is a major problem. In rooms with four or six people, I tried to talk quietly, but the conversations between the medical staff and the patient—even personal medical things— could still be heard by everyone in the room. When I talked to a patient, I sometimes felt embarrassed because other patients in the room could hear everything. (Participant 13)

During rounds in a multi-bed room, I heard caregivers in the next bed talking about the conversation the doctors had just had. They said things like, “Call the caregiver quickly! If the patient gets the injection, they’ll lose their hair!”—all the while the patient was right there listening. (Participant 19)

The nurses’ station itself is an environment where it’s difficult to protect information. It’s an open space, so we can hear everything the doctors and nurses are discussing. They even hold discussions after rounds, but at the same time patients were walking in the hallway for exercise. (Participant 7)

Accessing patient records out of personal curiosity

Students admitted that out of curiosity, they and their peers accessed patient records without permission. Students mentioned that they felt curious and interest when they encountered rare disease cases and read the patients’ medical histories. Students’ curiosity and interest led to searching patient information and violating regulations of patient information protection.

I think it’s out of curiosity. When my friends say, “That patient has an interesting medical history,” I get curious too and end up looking it up myself…. (Participant 22)

Since we are still students, seeing rare diseases that we don’t usually encounter makes us curious. We say things like, “It’s interesting!” “Is this real?” and … searching for more information. At the time, we didn’t even realize we were violating patient privacy regulations. (Participant 5)

Inappropriate use of patient information

Many students admitted their unauthorized collection and retention of patient information for case assignments and future assignments without properly disposing of it. Also, they revealed their experiences of sharing assignment materials with juniors, seniors, and peers. Students also told their discussions about patient cases which led to unintentional disclosure of patient information.

Unauthorized use and retention of patient information

Many (sixteen) students admitted that, during clinical practice, they engaged in the unauthorized collection and retention of patient information for case presentation assignments. They revealed using unauthorized methods such as taking screenshots of computer screens or writing down information on their laptop. Furthermore, they often kept the collected patient information for future assignments, with some retaining it rather than properly disposing of it.

I didn’t do it myself, but I saw my friends taking screenshots of computer screen of patient information… to prepare their case presentation assignments because writing everything down manually increases the risk of missing important details and it’s impossible to obtain detailed information in such a short time. (Participant 19)

Although we were not allowed to write down patient information…we ended up writing the information on our laptops. We don’t discard it immediately and keep it for later use because the information might have been useful for future assignments. (Participant 18)

Sharing assignment materials with other students

Many (fifteen) students repeatedly mentioned the term “sharing” when describing how they exchanged patient information without patient consent. They admitted their experiences of sharing assignment materials with juniors, seniors, and peers. Students also mentioned that they often discussed patient cases with each other while preparing assignments, inadvertently disclosing patient information.

Sometimes juniors ask for assignment materials, and it’s hard to refuse. If they are new to clinical practice and struggling with their first case conference, we naturally help them. I also had received help from seniors when I was a junior, so sharing materials seems to be a common practice. (Participant 20)

In my school, clinical practice and coursework rotate. So, when my friends finished clinical practice first, I asked them what kind of patients were there, which patient to choose for the case study, and through the discussions, we ended up sharing assignment materials about patients with each other. (Participant 12)

Need for more education about patient confidentiality

Most students revealed that their forgetfulness, uncertainty, and lack of understanding regarding the patient information protection. Students stated that additional training, repeated reminding, and case-based detailed education made them more conscious about patient information protection. So, they expressed their needs for repetitive and case-based education to improve their understanding and practice of patient information protection.

Need for repetitive education about patient confidentiality

Nineteen students stated that they tended to forget what they had learned in the orientation so additional training and repeated reminding made them more conscious about patient information protection. So, they expressed their needs for repetitive education about patient information protection both at school and in the hospital.

I think it would be very helpful to receive repeated education every time we go out for clinical practice. Since we spend one month at school and the next month in the hospital for practicum, we tend to forget what we had learned in the orientation. (Participant 7)

Each hospital had different protocols, and some head nurses provided additional training in hospitals that emphasized patient information protection. Since we were repeatedly reminded at school and in the hospital, it made us more conscious about protecting patient information. I hope they provide repetitive education so that nursing students are not careless in protection of patient information. (Participant 14)

Need for case-based education about patient confidentiality

A large number of students revealed that their uncertainty and lack of understanding regarding the patient information protection. They mentioned that case-based education would help them better understand and implement patient information protection. They expressed their needs of reinforcing case-based education regarding patient information protection.

As nursing students, we are unsure about how much information we are allowed to collect and discuss. Case-based education would help clarify these boundaries and improve our understanding of patient information protection. (Participant 12)

I think they need to reinforce case-based education. Honestly, as students, when we hear about real cases of someone violating patient privacy, it makes us more cautious and more likely to follow the rules. (Participant 1)

Discussion

This study explored nursing students’ experiences of patient information protection during clinical practice. According to Kolb’s experiential learning theory [26–28], experience is the important foundation of learning and having experience is the first stage of learning cycle. This study found that nursing students experienced the awareness of the importance of patient confidentiality, challenges of protecting patient information, inappropriate use of patient information, and need for more education on patient information protection during their clinical practice.

In this study, nursing students described their ‘awareness of the importance of patient information protection,’ which was similar to the result of earlier study [17], offering deeper insight into how nursing students perceive and value patient confidentiality in clinical practice. Most students in this study had received education on patient information protection, which is similar to the results of previous studies [6, 37].

This study revealed that although nursing students recognized the importance of patient information protection through education, they reported that patient confidentiality was breached due to personal curiosity and structural limitations in the ward environment. Also, given the importance of code of ethics for nurses [38], there is a strong need to develop and evaluate ethics education programs tailored to future nurses (nursing students) regarding patient information protection. This finding highlights the urgent need to improve clinical environments to facilitate better implementation of patient information protection for nursing students as well as nurses. Hospitals must take continuous action to improve the environments of wards where implementing patient information protection is difficult.

This study showed that nursing students collected, retained, and shared patient information for assignments without maintaining patient confidentiality. In this study, students expressed uncertainty regarding the boundaries of permissible patient information collection and discussion, which have been reported in earlier study [9]. Most students in this study emphasized the need for repetitive education and case-based education to strengthen their understanding and maintaining of patient information protection. The findings revealed that nursing students perceived a gap between their awareness and actual clinical practices. The knowledge (theory)-practice gap in clinical learning has been a serious issue in nursing education.

Nursing faculty and clinical instructors hold roles and responsibilities for ensuring that nursing students adhere to patient confidentiality guidelines and professional ethical codes during clinical practice. Some earlier studies [13–16] reported nursing educators’ ethical challenges and problems in clinical educaton for nursing students. To strengthen education on patient information protection among nursing students, collaborative and actionable strategies between healthcare institutions and universities are required [20, 37]. Nursing faculty and clinical instructors should provide clear ethical guidance and support ethical conduct across all aspects of students’ clinical practice [13–16]. Furthermore, continuous monitoring, constructive feedback, consistent education system at both the school and hospital are needed to improve students’ protection of patient confidentiality for preventing patient-information breaches in clinical settings. In addition, clinical training settings need to adhere to ethical codes and guidelines, continuously provide ethical clinical education, improve ethical culture, and evaluate the ethical outcomes. Furthermore, government agencies and healthcare organizations responsible for patient information protection must strengthen and regularly update relevant regulations and guidelines to keep pace with the rapidly evolving digital healthcare environment.

Future research need to focus on the development and evaluation of effective education programs on patient information protection for nursing students using mixed method research. This study found nursing students’ strong need of repetitive and case-based educational programs. Kolb [26–28] proposed that learning is dynamic cyclical process and emphasized the importance of ‘reflecting on the experience’ in the learning cycle. Therefore, future studies need to develop educational program including critical reflection, critical thinking, simulation, and role playing to improve nursing students’ ethical competence and ethical behavior in clinical learning.

Limitations

This study has some limitations. Data were collected in a single Asian country using convenience sampling, participants were limited to fourth-year nursing students, and the majority of them were female. Given the cultural diversity and varying clinical experiences of nursing students globally, cautions are needed when generalizing these findings to other students in other countries. In addition, all interviews were conducted in Korean, and then quotes and themes were translated into English. Despite authors’ best efforts, translation issue in cross-language may be a limitation in terms of linguistic and cultural context.

Implication for nursing education

This study revealed that nursing students perceived a gap between their awareness and actual clinical practice in terms of patient information protection. Most students in this study emphasized the need for repetitive education and case-based education to improve their understanding and practice of patient information protection. This study suggested that future research need to develop better pedagogical strategies to strengthen patient information protection for future nurses.

Conclusion

This study found that although nursing students received education on patient information protection both before and during clinical practice and acknowledged its importance, they faced challenges in maintaining patient confidentiality due to personal curiosity and challenging clinical environments. Additionally, their inappropriate use and sharing of patient information for academic assignments revealed a significant gap between knowledge and practice in clinical learning. Nursing students emphasized the need for repetitive and case-based education to protect patient information in clinical practice. Furthermore, they highlighted the importance of regular and continuous training throughout clinical placements to reinforce ethical awareness and regulatory compliance. Future research is required to focus on the development and evaluation of more effective and various educational programs to strengthen nursing students’ competence for patient information protection. In addition, government agencies and healthcare institutions need to make sustained efforts to strengthen and refine ethical regulations and guidelines of patient confidentiality in line with advancements in digital technology.

Author’ contributions

YP, a major contributor, performed conceptualization, research design, data collection, data analysis, data interpretation, writing (original draft preparation), revision, translation, and final approval of manuscript. EK conducted the selection of methodology, data analysis, data interpretation, writing (reviewing and editing), validation, translation, and final approval of the manuscript. All authors read and approved the final manuscript.

Funding

No funding.

Data availability

Data can be shared upon responsible request to the first author.

Declarations

Ethics approval and consent to participate

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Ethical approval for this study was obtained from the Institutional Review Board of Gachon University, South Korea (IRB No.1044396-201903-HR-051-01). Written informed consent was obtained from all participants prior to their inclusion in the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.