The Journal of Continuing Education in Nursing

Original Article 

Correlation Between Needs Satisfaction and Behavioral Intentions of Sexual Health Care

Li-Ya Tsai, RN, PhD; Chiou-Fang Liou, RN, PhD; Li-Hua Huang, RN; Cheng-Yi Huang, RN, PhD

Abstract

Background:

This study aimed to evaluate correlations between female nurses' needs satisfaction and behavioral intentions for providing sexual health care and to assess moderating effects of learning needs on that correlation.

Method:

A total of 300 female RNs were enrolled. Two validated instruments were used to collect information on participants' learning needs, needs satisfaction, and behavioral intentions for providing sexual health care.

Results:

Adjusted multivariable regression analysis revealed significant moderating effects of medium and low learning needs on correlations between needs satisfaction and behavioral intentions (medium learning needs: β = 0.282, 95% CI = 0.075, 0.490; p = .008; low learning needs: β = 0.293, 95% CI = 0.033, 0.553; p = .027), while no moderating effect was observed in those with high learning needs.

Conclusion:

Needs satisfaction was significantly correlated with behavioral intentions of sexual health care in medium and low learning needs groups. [J Contin Educ Nurs. 2020;51(10):457–464.]

Abstract

Background:

This study aimed to evaluate correlations between female nurses' needs satisfaction and behavioral intentions for providing sexual health care and to assess moderating effects of learning needs on that correlation.

Method:

A total of 300 female RNs were enrolled. Two validated instruments were used to collect information on participants' learning needs, needs satisfaction, and behavioral intentions for providing sexual health care.

Results:

Adjusted multivariable regression analysis revealed significant moderating effects of medium and low learning needs on correlations between needs satisfaction and behavioral intentions (medium learning needs: β = 0.282, 95% CI = 0.075, 0.490; p = .008; low learning needs: β = 0.293, 95% CI = 0.033, 0.553; p = .027), while no moderating effect was observed in those with high learning needs.

Conclusion:

Needs satisfaction was significantly correlated with behavioral intentions of sexual health care in medium and low learning needs groups. [J Contin Educ Nurs. 2020;51(10):457–464.]

The World Health Organization (WHO) defined sexual health as physical, mental, emotional, and social well-being that is associated with sexuality and sexual relationships, and highlighted the importance of a full range of sexual health care (WHO, 2006). Compared with other health professionals, nurses are more likely counseling and resolving various sexual health issues, such as adolescent sexual knowledge, hygiene of productive system, safe sex, and planning a pregnancy (Evans, 2013; Fennell, & Grant, 2019; Santa Maria et al., 2017; Propst et al., 2001). Therefore, the full range of sexual health care has been long suggested to be included in the curriculum for nursing education and training programs (Arikan et al., 2015; Gleeson & Hazell, 2017; Sung et al., 2016). However, evidence has revealed that patients' sexual health care needs, as well as the needs of nurses who provide such care, are often ignored in clinical nursing care and continuing education (McAuliffe et al., 2016). A systematic review revealed that nurses' knowledge deficit has been the main limitation affecting their ability to discuss sexual health care issues with patients, and that education can enhance nurses' knowledge and comfort level, helping them to face the provision of sexual health care more easily (Kotronoulas et al., 2009). Sexual health care training programs are shown to improve nurses' knowledge levels significantly and improve attitudes regarding the provision of sexual health care (Bauer et al., 2012). However, self-efficacy concerning sexual health care remains limited (Sung et al., 2016).

Sexual health care counseling provided to patients is also limited, and although nurses may be aware of patients' sexual issues, sexuality is still viewed as “too private an issue to discuss” (Arikan et al., 2015, p. 6). Consequently, nurses do not see sex education as something they need to handle as part of their profession, and they are reluctant to provide sexual health care services (Kolbe et al., 2016). Studies have reported that nurses' personal values regarding sexuality, lack of knowledge, lack of confidence and/or feelings of embarrassment, lack of communication skills, and lack of experience in the nursing community may hinder them from implementing sexual health care in clinical practice (Moore et al., 2013; Nicolai et al., 2013; O'Connor et al., 2019).

Nursing education is designed to help nurses provide quality care to patients, and continuing education must maintain and improve the competencies already gained (Gaberson & Langston, 2017; Vasli et al., 2018). Continuing education for nurses facilitates learning within the workplace and empowers nurses to provide effective, high-quality, and safe care, thereby leading them to feel that they are valuable, competent, and capable of the best practices (Govranos & Newton, 2014; Nsemo et al., 2013). However, nurses' perceptions about continuing education include lack of satisfaction with time and scheduling of available educational classes, low applicability of the lectures, and no connection between their actual learning needs and conference outlines (Eslamian et al., 2015).

Among nurses who received limited sexual health care training in the clinical setting, which primarily focused on gender education or prevention of sexual harassment or assault, the knowledge they gained was typically obtained individually from the internet or books, and making decisions about accurate and appropriate education for patients was still challenging (Sung et al., 2016; Vasli et al., 2018). In keeping with the underlying premise of the reasoned action theory, which states that the satisfaction of needs contributes to individuals' related behavioral intentions (Ajzen, 1991), as well as the principles of the self-determination theory, which views needs as being able to stimulate individual self-motivation (Vansteenkiste et al., 2007), our goal was to explore the influence of nurses' learning needs on needs satisfaction through continuing education and the related effects on self-motivation regarding sexual health care. We hypothesized that nurses' learning needs for sexual health care as provided by continuing nursing education may have a moderating effect on the correlation between their needs' satisfaction and behavioral intentions. Therefore, the purpose of this study was to evaluate the correlation between nurses' needs satisfaction and behavioral intentions for providing sexual health care and to assess the possible moderating effects of levels of learning needs on that association.

Participants and Method

Study Design and Ethical Considerations

This study adopted a cross-sectional survey design and was performed in our hospital from November 2016 to April 2017. The inclusion criteria were female RNs working in the hemodialysis, rehabilitation, medical–surgical, obstetrics and gynecology, or psychiatric departments. All participants were recruited using convenience sampling. The study protocol was approved by the institutional review board of our hospital, and signed informed consent was obtained from all participants.

Questionnaire Distribution and Collection

During the monthly nursing staff meetings of various hospital units, the researchers explained the purpose of this cross-sectional study. Female RNs who were willing to participate in this study signed the informed consent. Each participant then received a sealable envelope and the questionnaires. Participants anonymously completed the demographic information and the questionnaires in their spare time, taking approximately 15 to 20 minutes. After placing the completed questionnaires into the envelope, the envelope was sealed by respondents. The researchers went to each hospital unit to collect sealed envelopes from respondents 2 weeks later.

Main Measure

Demographic Data and Nursing Experience in Sexual Health Care. Self-reported demographic information (i.e., age, marital status, religion, education level, nursing department, years of practice) and nurses' experience in sexual health care services were collected. The participants' sexual health care services experience included questions about listening attitude for patients' sexual health concerns, assessing patients' history of sexual health concerns, and providing a nursing care plan for patients' sexual health concerns.

Learning Needs for Addressing Patients' Sexual Health Concerns (LNAPSHC). The LNAPSHC questionnaire was used to collect information on nurses' learning needs relative to patients' sexual health care and nurses' learning needs satisfaction. A previous study (Tsai et al., 2013) validated the psychometric properties of this scale, reporting a Cronbach's alpha of .97. The LNAPSHC questionnaire comprises 24 items in three subscales: (a) sexuality in health and illness (6 items); (b) communication about patients' intimate relationships (9 items), and (c) approaches to sexual health care (9 items). Questions are scored on a 7-point Likert-type scale with endpoints of never need or almost never need (1) to always need or almost always need (7). In the current study, based on respondents' scores, we reported a Cronbach's alpha of .985 for total needs; .955 for the subscale sexuality in health and illness; .986 for the subscale communication on patients' intimate relationships; .983 for the subscale approaches to sexual health care; and .97 for needs satisfaction, suggesting that the scale had satisfactory psychometric properties (Tsai et al., 2013).

Nursing Interventions on Sexual Health (NISHC) Questionnaire

The NISHC (Huang et al., 2012) was used to assess participants' behavioral intentions for providing sexual health care. The NISHC survey is based on the PLISSIT model, which includes the categories of Permission, Limited Information, and Specific Suggestion. The scale comprises 19 items, including three levels of nursing interventions on sexual health care, corresponding to the three domains of permission, limited information, and specific suggestion. The NISHC is scored on a 7-point Likert-type scale that ranges from 1 = strongly impossible to 7 = strongly possible. Scores are calculated for the three domains of permission, limited information, and specific suggestion. A Cronbach's alpha of .96 for total score, as well as .93, .94, and .95 in three subscales, respectively, were founded (Huang et al., 2012). This study added the scores of the three domains as the total score for behavioral intention and reported a Cronbach's alpha of .975.

Statistical Analysis

In the current study, categorical variables are presented as counts and percentages, while continuous variables are presented as means and standard deviation (mean ± SD). Nurses' learning needs were stratified into three groups of low, medium, and high levels. Pearson correlation analysis was used to evaluate the associations between need satisfaction and behavioral intention in the different learning needs groups. Univariate linear regression models were performed to assess the associations of behavioral intention with participants' learning need groups, needs satisfaction, demographics, and sexual health care experience. The moderating effects of different learning needs groups on the associations between needs satisfaction and behavioral intention were evaluated. The multivariable regression model was adjusted for variables that were significant in the univariate regression model. All p values were two-sided, and p < .05 was considered statistically significant. All statistical analyses were performed using IBM SPSS® statistical software version 22 for Windows.

Results

Participants' Characteristics

In the current study, 316 questionnaires were distributed and 300 valid samples were returned (response rate = 94.9%). Among 300 participating female nurses, 27.7% were ages 21 to 25 years, the majority (79%) had Bachelor's degrees, 60% worked in medical or surgical units, 32.3% had worked for more than 10 years, 63% were not married, and 53% had no specific religion. Regarding nurses' sexual health care experience, 42% of respondents had never expressed active listening attitude toward patients' sexual health concerns, 47% had never assessed patients' history of sexual health concerns, and 94% had never provided a nursing care plan for patients' sexual health concerns (Table 1).

Participant CharacteristicsParticipant Characteristics

Table 1:

Participant Characteristics

Correlations Between Needs Satisfaction and Behavioral Intentions for Sexual Health Care in the Three Learning Needs Groups

The respondents were divided into three groups based on their values of learning needs for continuing nursing education: low (≤ 4; n = 90), medium (5, n = 107), and high (> 5; n = 103). The associations between needs satisfaction and behavioral intentions in the separate learning needs groups were as follows: mean scores of needs satisfaction in high, medium, and low learning needs groups were 4.64 ± 1.28, 4.02 ± 0.91, and 3.45 ± 0.79, respectively. The mean scores of behavioral intentions for high, medium, and low learning needs groups were 3.97 ± 1.29, 3.44 ± 0.98, and 2.82 ± 1.09, respectively. Pearson correlation analysis revealed significant correlations between needs satisfaction and behavioral intention in medium and low learning needs groups (medium learning needs: r = .255; low learning needs: r = .256), whereas no significant correlations were observed between needs satisfaction and behavioral intentions in the high learning needs group (r = .102). Figure 1 depicts the relationships between nurses' behavioral intentions and needs satisfaction regarding sexual health care in continuing education. Specifically, the slopes for low and medium learning needs groups (red and green lines) were similar but were different from that of the high learning needs group (Figure 1).

Associations between needs satisfaction for continuing education on sexual health care and behavioral intentions stratified by learning needs (low, medium, and high groups).

Figure 1.

Associations between needs satisfaction for continuing education on sexual health care and behavioral intentions stratified by learning needs (low, medium, and high groups).

Impact of Learning Needs and Needs Satisfaction on Behavioral Intentions Regarding Sexual Health Care in Continuing Education

Univariate linear regression analyses revealed that behavioral intentions correlated significantly with learning needs, needs satisfaction, religion, nurses' work units, expressing active listening attitude towards patients' sexual health concerns, assessing patients' sexual health problems, and developing a care plan for patients' sexual health concerns (Table 2). Table 3 shows the moderating effect of the different levels of learning needs on the associations between nurses' needs satisfaction and behavioral intentions related to providing sexual health care. After adjusting for significant variables identified in univariate regression analysis, multivariable regression analysis revealed significant positive moderating effects of medium and low learning needs groups on the associations between needs satisfaction and behavioral intentions (medium learning needs: β = 0.282, 95% CI = 0.075, 0.490, and p = .008; low learning needs: β = 0.293, 95% CI = 0.033, 0.553, p = .027), whereas no moderating effect was observed in the high learning needs group (Table 3).

Univariate Regression Analysis of Behavioral Intentions for Sexual Health Care

Table 2:

Univariate Regression Analysis of Behavioral Intentions for Sexual Health Care

Moderating Effects of Different Learning Needs Groups on Associations Between Needs Satisfaction and Behavioral Intentions

Table 3:

Moderating Effects of Different Learning Needs Groups on Associations Between Needs Satisfaction and Behavioral Intentions

Discussion

The current study focused on the sexual health care experience of female RNs in Taiwan who had received previous continuing education on sexual health care. We sought to measure both their learning needs associated with sexual health care, as well as the possible moderating effect of their learning needs on the correlation between needs satisfaction and behavioral intentions related to providing sexual health care. Significant correlations were found between needs satisfaction and behavioral intentions in the groups with medium and low learning needs, whereas no significant correlations were observed between needs satisfaction and behavioral intentions in the high learning needs group. These results indicate that participants with higher learning needs will also have higher needs satisfaction and stronger behavioral intentions to provide sexual health care services in their clinical work.

To best understand the results of the current study, we need to first understand the definitions of the main areas of inquiry—nurses' learning needs, needs satisfaction, and behavioral intentions as related to sexual health care. The learning needs of nurses refers to what they expect to learn from continuing nursing education about sexual health care. To investigate nurses' learning needs about sexual health care, we divided the participants into groups with high, medium, and low levels of learning needs, finding that the low and medium levels of learning needs had the most influence on the relationship between nurses' needs satisfaction and their behavioral intentions. Needs satisfaction refers to the extent to which continuing nursing education on sexual health care is able to satisfy nurses' ability to provide sexual health care counseling. Behavioral intentions, in turn, represent nurses' self-motivation to provide sexual health care services in their clinical work. The influence of learning needs on nurses' needs satisfaction and behavioral intentions was demonstrated definitively in our results, showing that most nurses did not actively express their openness, or positive attitudes, to patients' sexual health issues encountered in clinical care. Even in the process of collecting medical history, patients' sexual concerns were rarely evaluated. Nurses who provided sexual health interventions represented only 6% of our sample, consistent with previous studies that noted the limited participation of nurses in sexual health care services (Moore et al., 2013; Nicolai et al., 2013; O'Connor et al., 2019; Tsai et al., 2013).

Several studies have reported that nurses lack a proactive attitude toward initiating care for patients' sexual health issues, and that both personal and contextual factors tend to limit their willingness to address patients' sexual health concerns in everyday clinical practice (Moore et al., 2013; Nicolai et al., 2013; Tsai et al., 2013). Although nursing professionals seem to recognize that sexual health is within the scope of nursing care and also have identified a need for continuing education to support incorporating sexual health care services into practice (Propst et al., 2001), working nurses characteristically do not see that providing sexual health care services is something to be practiced within their profession (Kolbe et al., 2016). Although nurses do consider the evaluation of patients' sexual health to be part of holistic care (Evcili & Demirel, 2018; Hendry et al., 2018), they appear to be reluctant to deliver this aspect of care themselves (Benoot et al., 2018; Moore et al., 2013; Nicolai et al., 2013; O'Connor et al., 2019). In theoretical psychology, the intention–behavior gap helps to explain why people do not always do what they intend to do, and closing that gap and promoting the desired behavior requires that people must initiate, maintain, and then close the pursuit of the behavior goal (Sheeran & Webb, 2016). If we apply this strategy to nurses who must prepare to deliver sexual health care to patients, realizing their intentions will likely require specific, sexual health-oriented learning that satisfies their learning needs.

In this study, the low to medium scores for learning needs related to sexual health care indicated that participants were not well satisfied with the continuing education provided on sexual health care. This corresponds to the results of previous studies in which nurses had received limited education or training regarding sexual health care (McAuliffe et al., 2016), along with the fact that training needs analysis is missing in current nursing continuing education (Holloway et al., 2018). Examining the knowledge, skills, and attitudes of nurses is necessary to identify the professional practice gaps in prioritizing and satisfying the learning needs of nurses in clinical practice (Bindon, 2017). Given that sexual health is a noted public health issue worldwide, strategies to improve the sexual health of all population groups must include good practices, good communication and education, and competent professional implementation (Gauci & Azzopardi-Muscat, 2017), which obviously requires the adequate preparation of health care professionals to administer sexual health care (Holloway et al., 2018). Participants in the current study who had medium and low levels of learning needs for sexual health care reported positive learning needs satisfaction toward their behavioral intentions for sexual health care. This trend suggests that satisfying nurses' learning needs for continuing education on sexual health care will help to improve their behavioral intentions toward sexual health care. However, challenges still exist in current nursing education programs, including that nurses continue to report that the obligation to attend classes and the lack of any meaningful connection between the educational courses and their actual needs decreases their motivation to enroll (Eslamian et al., 2015). Existing sexual health care training modules for building their professional capacity were focused on the biology of sex and attitudes toward sexuality (Karimian et al., 2018), or instead were focused on gender education or prevention of sexual harassment or assault (Sung et al., 2016). Apparently, nurses did not feel that these particular topics prepared them to address patients' sexual health care needs in everyday clinical practice.

To overcome these issues, clinical continuing nursing education must play a key role in training nurses in effective sexual health training programs that provide comprehensive coverage of the psychological, social, and biological aspects of sexuality, and nurses have confirmed that these identified training needs are especially relevant for their sector (Holloway et al., 2018). Topics need to include skills focused on addressing patients' sexual health concerns, assessment of patients' needs, and communication and information on sexuality related to patients' health status, as well as information on referral, counseling, and treatment for sexual dysfunction (Propst et al., 2001; Sung et al., 2016). Tsai et al. (2013) suggested that the three important aspects of learning needs are sexuality in health and illness, communication about patients' intimate relationships, and approaches to sexual health care. To make continuing education programs more effective, nurses' expectations for continuing education, equivalent to their learning needs, must be considered, including their personal perspectives and those of the institutions in which they work (Ni et al., 2014).

Our study results are in accord with the reasoned action theory, which states that the attitudes about specific behaviors, such as satisfaction of needs, actually contributes to the related behavioral intentions (Ajzen, 1991). Our results are also compatible with the self-determination theory, which states that needs are regarded as an intrinsic motivation to stimulate individual self-motivation and personality integration (Vansteenkiste et al., 2007). When needs are satisfied, the positive results of behavior are strengthened, as shown in other studies supported by these long-held theoretical concepts (Bindon, 2017; Flannery, 2017; Vansteenkiste et al., 2007). Considering that motivation and competence are essential in bringing about behavioral change (Flannery, 2017), clinical continuing nursing education must provide a supportive learning environment to ensure that nurses are educated in the cultivation of knowledge and the development of attitudes and self-efficacy concerning sexual health care (Sung et al., 2016). To achieve effective learning, nursing education must develop competency-based curricula featuring specialty knowledge of sexual health-related issues (Cappiello et al., 2017). Continuing education programs for nurses also must incorporate sufficient practice time and direct instruction, such as that in the PLISSIT model, which can serve as a guide for consistent nursing practice (Sung et al., 2016). Finally, a recent review and meta-analysis concluded that clinical nursing educational interventions that are designed to support evidence-based practice also hold the promise for improving patient outcomes (Wu et al., 2018). Although this may seem like a lofty goal, it is worth keeping in mind for the future of continuing nursing education.

Limitations

This study has several limitations, including that data were collected from a small convenience sample of nurses working in a single university hospital, which limits the generalizability of the study findings. The cross-sectional design limits the inference of cause and effect and cannot be used to analyze behavior over a given time period. Furthermore, we did not collect personal data regarding individual sexual health or related history that may have the potential to distort responses to questionnaires. Additional study with a larger sample of nurses from multiple institutions is needed to confirm results of this study.

Conclusion

Low- to medium-level learning needs for sexual health care have significant moderating effects on associations between nurses' needs satisfaction and behavioral intentions for providing sexual health care. Higher learning needs appear to be associated with higher needs satisfaction and stronger behavioral intentions. Results of this study may be useful to nursing supervisors in the development of continuing education programs that will satisfy nurses' learning needs appropriately. Because sexual health is a global public health issue, and patients have sexual health issues related to their health status, continuing nursing education is essential to transfer knowledge, skills, and attitudes in an appropriate training context that will translate into providing sexual health care for patients.

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Participant Characteristics

VariableTotal, N = 300a
Demographics
Age (years)31.2 ± 6.7
  21–2583 (27.7%)
  26–3067 (22.3%)
  31–3570 (23.3%)
  > 3580 (26.7%)
Married
  No189 (63%)
  Yes111 (37%)
Religion
  No religion159 (53%)
  Buddhism and Taoism125 (41.7%)
  Western religions16 (5.3%)
Education level
  Associate or less36 (12%)
  Bachelor237 (79%)
  Master27 (9%)
Working units
  Medicine/Surgery180 (60%)
  Chronic units (Rehabilitation and Hemodialysis)83 (27.7%)
  Gynecology/Obstetrics19 (6.3%)
  Psychiatry18 (6%)
Working experience (years)8.1 ± 6.3
  0–264 (21.3%)
  3–548 (16%)
  6–1091 (30.3%)
  >1097 (32.3%)
Sexual health care experience
Express active listening attitude toward patient's sexual concerns
  Never126 (42%)
  Seldom123 (41%)
  Sometimes or more51 (17%)
Assess patient's sexual concerns in history taking
  Never141 (47%)
  Seldom119 (39.7%)
  Sometimes or more40 (13.3%)
Provide a nursing care plan for patient's sexual concerns
  Never282 (94%)
  Seldom18 (6%)
  Sometimes or more0

Univariate Regression Analysis of Behavioral Intentions for Sexual Health Care

VariableUnivariate

Coefficient [95% CI]p Value
Learning needs groups (Ref: Low ⩽ 4)a
  Medium0.625 [0.328, 0.923]a< .001a
  High (> 5)1.148 [0.848, 1.447]a< .001a
Needs satisfactiona0.328 [0.218, 0.439]a< .001a
Age (Ref: 21–25)a
  26–30−0.087 [−0.457, 0.283].644
  31–350.197 [−0.169, 0.562].292
  >350.177 [−0.176, 0.530].325
Partnered (Ref: No)a0.221 [−0.048, 0.491].108
Religion (Ref: Western religion)a
  No−0.592 [−1.180, −0.004]a.048a
  Folk religion−0.348 [−0.944, 0.247].252
Education (Ref: Associate)a
  Bachelor−0.280 [−0.681, 0.122].172
  Master0.199 [−0.372, 0.771].494
Working units (Ref: Psychiatry)a
  Medical/Surgical−0.800 [−1.348, −0.251]a.004a
  Chronic units−0.481 [−1.058, 0.095].102
  Gynecology/Obstetrics−0.292 [−1.021, 0.438].433
Working experience (Ref: 10 years)a
  0–2 years−0.148 [−0.512, 0.217].427
  3–5 years−0.094 [−0.494, 0.305].643
  6–10 years−0.105 [−0.436, 0.225].531
Express listening attitude for patient's sexual concerns (Ref: No)a0.607 [0.351, 0.863]a< .001a
Assessing patient's sexual problems (Ref: No)a0.611 [0.358, 0.864]a< .001a
Develop a care plan for patient's sexual concerns (Ref: No)a0.591 [0.044, 1.137]a.034a

Moderating Effects of Different Learning Needs Groups on Associations Between Needs Satisfaction and Behavioral Intentions

VariableaUnivariateMultivariableb


Coefficient (95% CI)p ValueCoefficient (95% CI)p Value
Moderating effects of separate learning needs groupsa
Needs satisfaction in the high needs group (> 5)0.268 (0.158, 0.377)a< .001a0.040 (−0.118, 0.197).623
Needs satisfaction in the medium needs group0.199 (0.070, 0.328)a.003a0.282a (0.075, 0.490).008a
Needs satisfaction in the low needs group (≤ 4)0.061 (−0.091, 0.213).4320.293 (0.033, 0.553)a.027a
Authors

Dr. Tsai is Associate Professor, Post-Baccalaureate Program in Nursing, College of Nursing, School of Nursing, Asia University, Dr. Liou is Assistant Professor and Dr. Huang is Assistant Professor, Department of Nursing, Chung Shan Medical University and Chung Shan Medical University Hospital, and Mr. Huang is Vice Director, Chung Shan Medical University Hospital, Taichung City, Taiwan.

This work was funded by the Ministry of Science and Technology, Taiwan (MOST 104-2629-B-040-001).

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Cheng-Yi Huang, RN, PhD, Assistant Professor, Department of Nursing, Chung Shan Medical University, 110 Sec.1, Jianguo N. Road, Taichung, 40201, Taiwan; email: huangcy@csmu.edu.tw.

Received: January 21, 2020
Accepted: May 04, 2020

10.3928/00220124-20200914-07

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