The Journal of Continuing Education in Nursing

Original Article 

Improving LGBTQ Cultural Competence of RNs Through Education

Tyler Traister, DNP, RN-BC, OCN, CHPN, NPD-BC, CNE, CTN-A

Abstract

Background:

The health of lesbian, gay, bisexual, transgender, and/or queer (LGBTQ) people is a national health priority. A barrier to culturally congruent LGBTQ care is the lack of knowledge about LGBTQ people. LGBTQ people face significant health disparities. This study established an understanding of the knowledge and attitudes of RNs about LGBTQ people and the impact of an educational intervention.

Method:

RNs received a 1-hour educational intervention. Pre- and posttests were administered to establish baseline knowledge and attitude, as well as effectiveness.

Results:

A statistically significant impact on the nurses' knowledge of LGBTQ health (p < .0001) happened after the intervention. Qualitative responses from nurses showed an overwhelming desire to have LGBTQ education for their nursing practice.

Conclusion:

Implications for practice include implementing LGBTQ cultural competence into initial and ongoing educational training for RNs within health care organizations and improved nursing care of LGBTQ people. [J Contin Educ Nurs. 2020;51(8):359–366.]

Abstract

Background:

The health of lesbian, gay, bisexual, transgender, and/or queer (LGBTQ) people is a national health priority. A barrier to culturally congruent LGBTQ care is the lack of knowledge about LGBTQ people. LGBTQ people face significant health disparities. This study established an understanding of the knowledge and attitudes of RNs about LGBTQ people and the impact of an educational intervention.

Method:

RNs received a 1-hour educational intervention. Pre- and posttests were administered to establish baseline knowledge and attitude, as well as effectiveness.

Results:

A statistically significant impact on the nurses' knowledge of LGBTQ health (p < .0001) happened after the intervention. Qualitative responses from nurses showed an overwhelming desire to have LGBTQ education for their nursing practice.

Conclusion:

Implications for practice include implementing LGBTQ cultural competence into initial and ongoing educational training for RNs within health care organizations and improved nursing care of LGBTQ people. [J Contin Educ Nurs. 2020;51(8):359–366.]

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) people face significant health disparities in the United States (Traynor, 2016). The National Institutes of Health (NIH) declared LGBTQ communities a health disparity population in 2016 and included LGBTQ health in Healthy People 2020 (Perez-Stable, 2016). Evidence indicates that LGBTQ people have less access to health care and carry a higher burden of certain diseases such as HIV/AIDS, depression, and cancer (Perez-Stable, 2016). What causes these health disparities and barriers to care is not fully understood, and the NIH has called for more research to understand these challenges better. Previous research conducted by the NIH has shown that LGBTQ people living in communities with high levels of prejudice toward LGBTQ people have a shorter life expectancy of up to 12 years on average, when compared with those living in more accepting communities (Perez-Stable, 2016). An area of research priority that was highlighted by the NIH for LGBTQ health is understanding the knowledge and attitudes of health care providers about LGBTQ health.

Within nursing curricula and research, heterosexual bias exists that diminishes culturally competent LGBTQ nursing care (Strong & Folse, 2015). Research and content published on LGBTQ health was almost nonexistent in the top 10 nursing journals between 2005–2009, with only 0.16% of nursing articles including content about the subject of LGBTQ health during this time frame. (Lim et al., 2015; Strong & Folser, 2015). In the United States, approximately 3.5% or 9 million people identify as LGBTQ (Gates, 2017). The Department of Health and Human Services found that the LGBTQ population is at an increased risk of suicide, depression, HIV infection, sexually transmitted diseases, obesity, and alcohol and drug abuse (Traynor, 2016). LGBTQ people do not have unique health disparities; instead, generations of systematic discrimination, stigmatization, and marginalization created them. One of the most substantial barriers to culturally congruent LGBTQ care is the lack of knowledge about LGBTQ people and possible negative attitudes among nurses and other health care providers (Strong & Folse, 2015). Without knowing LGBTQ people and their care, nurses are unable to deliver culturally competent care to this population.

Understanding LGBTQ

The term LGBTQ is an acronym for lesbian, gay, bi-sexual, transgender, and queer. The “LGB” of the acronym refers to sexual orientation. The “T” refers to transgender or gender-nonconforming people, whereas the “Q” can represent either a person's sexuality or gender identity (American Psychological Association [APA], 2017). Identity and sexual orientation are not the same things. However, both reflect “gender norm transgression” and share an intertwined social and political history (APA, 2017).

Lesbian (“L”) is a woman who is physically, romantically, or emotionally attracted to another woman. Gay (“G”) is a term used to describe men who are attracted to other men; however, some women wish to identify as a “gay woman.” Bisexual (“B”) describes a person who has attractions to people of the same or opposite gender. Bi-sexual people experience these attractions in different degrees throughout their lifetime, and many bisexual people describe this as a spectrum. Transgender (“T”) is an umbrella term used for those whose gender identity and/or their gender expression differs from their assigned sex at birth. The “Q” in LGBTQ can be used by someone who identifies themselves as queer or as questioning. Queer is a term that is seeing a resurgence among LGBTQ youth and adolescence. They use it when they feel their identity is more than being lesbian, gay, bisexual, or transgender, or when they feel that there is not a term to adequately describe their sexual or gender identity. Questioning can used when a person is questioning their sexuality or gender identity (APA, 2017).

Literature Review

Cultural Competence

Cultural competence arose as a critical concept in the literature. The researcher included and considered the following terms as a variation of cultural competence: culturally congruent care, cultural safety, and transcultural nursing care.

The classic work of Campinha-Bacote's theory of cultural competence provides the foundation for this study. In her process of cultural competence, Campinha-Bacote discussed several key constructs of cultural competence: awareness, knowledge, skill, encounters, and desire (Campinha-Bacote, 2002). If one of these critical constructs is missing from the journey to cultural competence, nurses will not be able to deliver care that is culturally congruent with the populations served. With the scarcity of LGBTQ content in nursing education and curricula, faculty are unable to provide nurses with the baseline knowledge to care and interact with LGBTQ people. Without this knowledge, nursing can perpetuate the health disparities faced by this population. For nursing to create a culturally competent workforce, LGBTQ content must be incorporated into nursing education programs.

Knowledge and Attitude

Perhaps the most significant barrier to LGBTQ culturally competent care is the lack of provider knowledge. The invisibility of LGBTQ nursing research is evident in that from 2005 to 2009, only eight of 5,000 articles published by the top 10 nursing journals focused on LGBTQ health (Lim et al., 2015; Strong & Folse, 2015). To break it down further, of those eight articles, six were qualitative studies and two were quantitative research, mostly authored outside of the United States (Johnson et al., 2012).

New evidence on LGBTQ health research in nursing from 2009 to 2017 shows slow growth on the topic. Researchers found that from 2009 to 2017, 0.19% (or 33 articles) of literature in the top 20 nursing journals focused on sexual minority health (Jackman et al., 2019). This dearth of information on LGBTQ in top nursing research journals sends a message that the topics of LGBTQ health are not crucial to nursing research or that they represent a “niche” topic that many nurses do not need to know (Jackman et al., 2019). Much of the available nursing research on LGBTQ health focuses on lesbian and gay populations, with limited discussion and insight into transgender and gender-nonconforming populations. Another limitation to the available nursing research on LGBTQ health is that much of the research focuses on HIV and AIDS, despite a small percentage of the LGBTQ population living with HIV or AIDS (Johnson et al., 2012).

In the nursing education realm, 79% of nurse educators felt that LGBTQ health and issues are important to teach students; however, another study found that 72% of nurse educators surveyed felt that they were not prepared to teach about LGBTQ issues (Carabez et al., 2015a).

LGBTQ content must be incorporated into the classroom and clinical education for nursing students, such as ingrained in simulations, case studies, nursing care plans, test questions, and elective courses (Lim & Borski, 2015). Universities and nursing schools recruit and retain diverse faculty that are openly LGBTQ to bring multicultural perspectives and education into the classroom and clinical setting (Lim & Borski, 2015).

In the literature, limited studies have evaluated the effectiveness of the improvement of knowledge and attitudes regarding LGBTQ care after an educational intervention. One study (Strong & Folse, 2015) that examined nursing students had statistically significant increases in mean scores after their educational intervention on LGBTQ health for nursing students. For further research, this study should be expanded to examine current practicing nurses and the impact of such interventions longitudinally.

Another study (Gendron et al., 2013) that examined the effects of cultural competence training on health care professionals about LGBTQ people found that the participants reported feeling more knowledgeable and culturally competent about LGBTQ issues after the intervention; however, they are unsure whether it had any impact on deep-seated beliefs about the LGBTQ population. Another limitation that they discuss in their study understands that people will respond in a socially desired manner because they knew that the intervention's purpose was to impact their views (Gendron et al., 2013). This type of bias could potentially affect the reliability and validity of the results.

Communication

One aspect of communication that is vital to the nurse–patient relationship and can affect the overall health of a patient is their ability to disclose sexual or gender identity comfortably. In one study, 79% of the sample disclosed their sexual identity to their oncologist or provider treating their cancer, and only 47% disclosed their identity to surgeons. More than half (52%) of the individuals in the study disclosed themselves after correcting heterosexual assumptions of the provider, and less than 15% reported that their providers asked general questions that elicited disclosure (Kamen et al., 2015). From the results of this study, providers must create safe and inclusive spaces for LGBTQ patients so that they feel empowered to disclose their sexual identity.

For LGBTQ older adults, communication and disclosure play a more significant role. Approximately 89% of LGBTQ older adults in long-term care believed that staff would discriminate against an LGBTQ resident, and 53% believed that staff would abuse or neglect a resident if they identified as LGBTQ (Moone et al., 2016). Many believe that part of the fear of disclosure by LGBTQ older adults and others is because medical providers believe that they “treat everyone the same” and that they “do not ask anyone about sexual orientation or gender identity” (Moone et al., 2016). However, this type of communication approach can lead to significant health disparities and poor outcomes, including significant feelings of isolation (Moone et al., 2016).

When assessing a patient's sexual orientation or gender identity status, the nurse must be cognizant of their body language and their responses to the patient. Sometimes nurses or providers can have feelings or thoughts of discomfort, shock, embarrassment, and/or awkwardness when patients disclosed their sexual or gender identity and sexual practices (Cahill et al., 2014; Moone et al., 2016). Nurses may feel uncomfortable in certain situations that may be foreign to them and that they have not encountered previously. To help build rapport and communication with the patient, nurses should own their discomfort with the patient, as this shows them that they are willing to “go there” (Cahill et al., 2014).

Nurses, providers, and facilities must also ensure that their facilities, forms, and policies communicate inclusivity to the LGBTQ population. In one study (Carabez et al., 2015b), nurses were interviewed about the use of gender-inclusive forms. Their results highlighted that only 5% of respondents used gender-inclusive forms, 44% did not know about gender-inclusive forms, 37% did not understand what a gender-inclusive form was, and 14% confused gender with sexual orientation. Their study was conducted in the San Francisco Bay Area, which has one of the largest and most prominent LGBTQ communities than any other U.S. geographical area (Carabez et al., 2015b).

Method

Methodological Type and Design

A descriptive correlational study with a cross-sectional design and pretest–posttest was used for this study. RNs received a 1-hour educational intervention. Pre- and post-tests were administered to establish baseline knowledge and attitude, as well as effectiveness. The study was approved as exempt by the following Institutional Review Boards: Allegheny Health Network, University of Pittsburgh, Carlow University.

Setting

The population of the study was a convenience sample of employed RNs (N = 111) who worked in four different hospitals in the Pittsburgh metropolitan region.

Procedures

Recruitment of participants took place via flyers and email correspondence from the nursing education departments of each hospital. Each hospital had set up their date and time for the educational intervention.

At the beginning of the education session, nurses received a packet containing informed consent documents, a demographics survey, and the pretest containing the three survey tools. After the educational intervention, participants completed the posttest containing the three survey tools for postintervention data.

Intervention

This project implemented an educational intervention to improve the attitudes and knowledge of nurses about LGBTQ people. The intervention was titled “LGBTQ Cultural Competence for Registered Nurses.” The author delivered the presentation via a lecture to the attendees. It comprised 28 slides organized into three sections: definitions and terminology, health disparities faced by the population, and communication practices. The research team created all this information through the information available from the Fenway Institute. The length of the intervention lasted approximately 60 minutes and included the pretest, intervention presentation, and the immediate posttest, as well as some time for questions and discussion. The educational intervention was delivered by the author, whose doctoral studies focus on LGBTQ nursing care and has taught on the subject to local nursing programs, health care organizations, and various national presentations.

Instruments and Variables

The knowledge and attitudes of the RNs were measured utilizing three validated tools—the modified Attitudes Toward Lesbians and Gay Men (ATLG) scale; the Attitudes Toward Lesbian, Gay, Bisexual and Transgender Patients (ATLGBTP) scale; and the Knowledge of Lesbian, Gay, Bisexual, and Transgender People (KLGBT) questionnaire. These tools had been modified by Strong and Folse (2015), and permission was granted to use the tools. Strong and Folse (2015) validated these tools with undergraduate nursing students in their doctoral research study “Assessing undergraduate nursing students' knowledge, attitudes, and cultural competence in caring for lesbian, gay, bisexual, and transgender patients.”

The first tool, the modified ATLG, consists of a 9-item 5-point Likert scale. Participants responded to their attitudes and cultural competence for LGBTQ people. The 5-point Likert scale consisted of 5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, and 1 = strongly disagree. Items within the scale gauged the participants' attitudes on whether they found LGBT people as “plain wrong,” “disgusting,” and a “natural expression of sexuality or gender identity.” The ATLG scale has been found to be reliable in previous research studies, with a Cronbach's alpha of > .85 among college samples. The reliability of the modified ATLG scale was established with a Cronbach's alpha of .95 (Strong & Folse, 2015).

The ATLGBTP scale was a 6-item 5-point Likert scale and allowed for the written elaboration of the research participants. The scale assessed the participant's cultural competence and attitudes towards LGBTQ people. Another area of analysis was whether their nursing curriculum incorporated LGBTQ content into the curriculum. Additionally, it provided two questions for a narrative response from the participants. This scale was also evaluated previously for the level of reliability that was established in a previous research study by Strong and Folse (2015), with a Cronbach's alpha of .54. The low number of items on this scale could affect the reliability of the ATLGBTP; therefore, the results should be interpreted with caution.

The KLGBT questionnaire is a 15-item true-or-false questionnaire. The research team designed the questionnaire in the research study by Strong and Folse (2015). Reliability for this scale was established through the Kuder–Richardson Formula 20. The reliability coefficient for the KLGBT was an alpha of .54. With those results, results from this scale should also be interpreted with caution.

Data Analysis

Descriptive statistics were used to analyze the demographics of the study participants (mean, standard deviation, and range). These calculated the variables of age, years of experience of the RN, education level, sexuality, exposure to LGBTQ individuals, and their reported scores on the attitude's subscales and knowledge scores.

Results

Demographics

The population of the study was a convenience sample of RNs (N = 112) who were actively employed as a registered staff nurse by four different hospitals in the southwestern Pennsylvania metropolitan region. There was one participant who completed only the demographic portion of the study packet and was not included in the final statistical analysis. The age ranges of the sample were 18 to 24 years (n = 9, 8.04%), 25 to 39 years (n = 33, 29.46%), 40 to 54 years (n = 38, 33.93%), 55 to 64 years (n = 31, 27.68%), and 65 years and older (n = 1, 0.89%). The majority (44.64%) of the sample had more than 21 years of RN experience; other experience levels represented within the sample included 0 to 3 years (18.75%), 4 to 6 years (9.82%), 7 to 10 years (11.61%), 11 to 15 years (7.14%), and 16 to 20 years (8.04%). Most of the sample size reported having a baccalaureate degree (40.18%) or a master's degree or higher in nursing (39.39%). Those with an associate's degree or diploma in nursing comprised 20.54% of the respondents (Table 1).

Number of Nurses by Age, Years of Experience, Level of Education, and Sexual Orientation (N = 112)

Table 1:

Number of Nurses by Age, Years of Experience, Level of Education, and Sexual Orientation (N = 112)

The sample population primarily identified as heterosexual (92.86%), less than 3% of the size as homosexual, less than 2% as bisexual, and 2% preferred not to answer. The reported sexual orientations in this study's sample size were congruent with a national sampling done by the Gallup Poll showing 4.1% of Americans who identified as LGBTQ (Gates, 2017) (Table 1).

Respondents also reported varying levels of personally knowing someone who identifies as LGBTQ. Many had a friend (73.87%), family member (42.34%), or coworker (63.96%) who identified as LGBTQ, and less than 2% of respondents did not personally know anyone (Table 2).

Number of Nurses with Lesbian, Gay, Bi-Sexual, Transgender, and/or Queer Encountersa (N = 111)

Table 2:

Number of Nurses with Lesbian, Gay, Bi-Sexual, Transgender, and/or Queer Encounters (N = 111)

Attitudes

Baseline attitudes were established with the pretest, with a posttest comparison for effectiveness. A two-sample t test was performed to measure the difference and impact of the pretest–posttest scores. Individual scores ranged from 1 (strongly negative) to 5 (strongly positive) for each of the subscales, with mean scores showing a somewhat positive attitude toward LGBT people and feelings of cultural competence (Table 3).

Two-Sample t Test of Nurses' Mean Attitude Scores on Lesbian, Gay, Bisexual, and Transgender Cultural Competence

Table 3:

Two-Sample t Test of Nurses' Mean Attitude Scores on Lesbian, Gay, Bisexual, and Transgender Cultural Competence

The first research question was to establish the baseline attitudes of RNs about LGBTQ people. The mean scores of the participants show a somewhat positive attitude (3.86) toward LGBTQ people, as well as a feeling of cultural competence.

The second research question was to evaluate the impact of an educational intervention on their attitudes. For this study, a result was statistically significant when the p value was less than .05. There was a slight increase in the mean attitudes between pretest and posttest. However, none of them were statistically significant (p = .30).

Knowledge

The 15-item true-or-false test was administered before and immediately after the intervention. The knowledge portion of the posttest had an 88% completion rate (n = 98 of 111.).

The participants had a strong baseline knowledge about LGBTQ health (M = 14.18, SD = 1.16). After the intervention, their knowledge levels increased to 14.76 (SD = 0.70) and showed a statistically significant increase in their knowledge from the educational intervention (p < .0001) (Table 4).

Two-Sample t Test of Nurses' Mean Knowledge Scores on LGBT Cultural Competence

Table 4:

Two-Sample t Test of Nurses' Mean Knowledge Scores on LGBT Cultural Competence

Responses

In addition to the quantitative findings, RN participants wrote one take-away message from the educational intervention. Only one written comment was perceived as unfavorable by the research team: “We are moving further away from the Bible every day.”

Other responses that the nurses had about the educational intervention and their awareness of LGBTQ include:

  • Necessary to get past personal bias first.
  • How to respectfully ask patients personal questions about their sexual orientation and gender identity.
  • Importance of learning about the sensitivity and health care needs of LGBTQ patients.

Many of the participants echoed these comments. Themes that arose from their narrative comments include gaining a new awareness for the importance of sensitive patient communication, understanding the difference between gender and sexuality, the need for nursing and health care to provide more education, as well as the necessity of understanding our own biases. Many of the participants also included that they wish they had received education about LGBTQ people in either nursing school or their nursing orientation.

Discussion

The purpose of this study was to examine the baseline knowledge and attitudes and level of cultural competence among RNs in a metropolitan area and the impact of an educational intervention. Cultural competence consists of five constructs: cultural awareness, cultural knowledge, cultural skill, cultural encounters, and cultural desire (Campinha-Bacote, 2002). There is a direct relationship between the level of competence of health care providers and their ability to provide culturally responsive health care services (Camphinha-Bacote, 2002).

The study highlighted the effectiveness of an educational intervention on knowledge. To further assess the impact of the intervention on the attitudes of RNs, longitudinal research is warranted. Although the study did not have a statistically significant effect on attitude, perhaps providing nurses with the cultural awareness and knowledge of LGBTQ people can help to improve their skills and care of LGBTQ people. Another concept for discussion is that nurses might see it is necessary to change their actions to deliver culturally competent care but not their beliefs (Wyckoff, 2019). Further research is warranted to examine the gap between nurses' behaviors and their attitudes toward LGBTQ people.

The study identified that most respondents had personal encounters with LGBTQ people (e.g., coworkers, families, friends), with less than 2% of the study population not having an encounter with someone who identified as LGBTQ. Regional and national studies would be beneficial to further examine the relationship between a person's attitude about LGBTQ people and their encounters with that population.

Limitations

The study focused on the knowledge, attitude, and cultural competence of RNs in a metropolitan region in southwestern Pennsylvania using a convenience sample. The findings added to the body of literature about the need for educational interventions. The study had a total of 111 participants complete the pretest, with 100% completion of the attitudes portion of the posttest and 88% completion rate on the knowledge portion of the posttest. However, the use of a convenience sample limits the generalizability of the findings from the study. The use of a cross-sectional research design also does not allow for longitudinal measurement and study of changes in knowledge, attitudes, and cultural competence over time. With voluntary participation, nurses who had a more favorable attitude on LGBTQ people might have been more likely to consider participating in the study and engaging in the educational intervention, which may have influenced the findings of the study. The metropolitan area where the study was conducted could allow for regional variances among the participants regarding knowledge and attitude, which could have also influenced the study's results.

Conclusions

The results of this study added to the body of literature about the need for educational interventions and the role of the provider's attitude and knowledge and LGBTQ health. The outcomes of this study show that although nursing has somewhat positive attitudes about LGBTQ people, further research is warranted for the generalizability of such findings. Through an educational intervention, nurses were able to gain more knowledge about LGBTQ people so that they could better provide them with culturally competent care in the clinical setting. The study has furthered the understanding of LGBTQ cultural competency within nursing and the healthcare setting.

Nurses are the guardians of public and individual health in our society. Providing care with dignity and respect are central tenets to the nursing profession. As our society continues to diversify, nursing education and practice must prepare current and future nurses to deliver culturally congruent health care to diverse and complex patient populations. This study has shown that nurses desire to learn about LGBTQ people and want to provide them with culturally competent care. Incorporating LGBTQ content into nursing curriculums, programs, and research will help to create a culturally competent nursing workforce capable of providing quality care to LGBTQ people.

References

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Number of Nurses by Age, Years of Experience, Level of Education, and Sexual Orientation (N = 112)

Variablen
Age (years)
  18–249
  25–3933
  40–5438
  55–6531
  >651
Nursing experience (years)
  0–321
  4–611
  7–1013
  11–158
  16–209
  ⩾2150
Level of education
  Diploma/ASN23
  BSN45
  MSN/DNP/PhD44
Sexual orientation
  Heterosexual104
  Homosexual3
  Bisexual2
  Prefer not to answer2
  Other1

Number of Nurses with Lesbian, Gay, Bi-Sexual, Transgender, and/or Queer Encountersa (N = 111)

Variablen
Significant other3
Neighbor24
Acquaintance43
Family Member47
Coworker/peer71
Friend82
Other2
I do not know anyone2

Two-Sample t Test of Nurses' Mean Attitude Scores on Lesbian, Gay, Bisexual, and Transgender Cultural Competence

SubscaleNMeanSDt Test Statisticp Value95% CI Difference in Means (Post–Pre)
Attitude: Gay0.63.53−0.15, 0.30
  Pretest1113.860.86
  Posttest1103.930.82
Attitude: Lesbian0.83.41−0.13, 0.31
  Pretest1113.840.84
  Posttest1103.930.82
Attitude: Bisexual1.22.23−0.09, 0.36
  Pretest1113.710.84
  Posttest1103.850.84
Attitude: Transgender0.90.37−0.11, 0.31
  Pretest1113.870.80
  Posttest1103.960.78
LGBT cultural competence0.92.36−0.05, 0.15
  Pretest1113.940.37
  Posttest1103.990.38
Attitude: Total1.03.30−0.07, 0.24
  Pretest1113.860.58
  Posttest1103.940.59

Two-Sample t Test of Nurses' Mean Knowledge Scores on LGBT Cultural Competence

InterventionNMeanSDt Test Statisticp Value95% CI Difference in Means (Post–Pre)
Pretest11114.181.164.38< .0001*0.32. 0.83
Posttest9814.760.70
Authors

Dr. Traister is Unit Director, Department of Nursing, University of Pittsburgh Medical Center Shadyside, Pittsburgh, Pennsylvania.

The author has disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Tyler Traister, DNP, RN-BC, OCN, CHPN, NPD-BC, CNE, CTN-A, Unit Director, Department of Nursing, University of Pittsburgh Medical Center Shadyside, 5230 Centre Ave., Pittsburgh, PA 15232; email: traistert@upmc.edu.

Received: June 05, 2019
Accepted: March 26, 2020

10.3928/00220124-20200716-05

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