Ms. Diane Nguyen is Clinical Applications Coordinator, VA Puget Sound Health Care System, and Drs. Zierler and Huong Nguyen are Associate Professors, University of Washington, Seattle, Washington.
The authors have no financial or proprietary interest in the materials presented herein.
Address correspondence to Diane N. Nguyen, MS, RN, Clinical Applications Coordinator, VA Puget Sound Health Care System, 1660 South Columbian Way, Mail Stop: S-118-NOD, Seattle, WA 98108; e-mail: Diane.Nguyen@va.gov.
Nursing education has transitioned from traditional methods of classroom instruction to the inclusion of technology in teaching to accommodate various learning needs and lifestyles (Ali et al., 2005; Cook et al., 2004; Jeffries, Woolf, & Linde, 2003; Johnston, 1997; Skiba, 2007). The integration of educational technology in nursing curricula has the potential to enhance nursing knowledge and skills. Examples of four emerging educational technologies include:
- Distance learning, defined as the delivery of course content from a distance using typewritten, voice, and video technology through the Internet via the World Wide Web (American Association of Colleges of Nursing [AACN], 1999).
- Simulation, defined as simulated clinical scenarios using life-size manikins or human patient simulators (Nehring & Lashley, 2004).
- Telehealth, defined as the delivery of health care and teaching to remote and rural communities through audio and video telecommunication (Sevean, Dampier, Spadoni, Strickland, & Pilatzke, 2008; Wakefield, Flanagan, & Specht, 2001).
- Informatics and computer fundamentals, defined in this article as the integration of computer knowledge and skills (McNeil et al., 2003).
These educational technologies embody information technology competencies that are fundamental to the roles and responsibilities of nurses and other health care professionals (Greiner & Knebel, 2003; Institute of Medicine, 2003). Focusing on faculty development and state-of-the-art training programs is essential to effectively teach faculty members how to use and integrate new technologies in their teaching and practice (Van Der Velde & Rawl, 2000). Therefore, nursing faculty must be trained to use educational technologies so that they can impart these technologies to students (Saba, 2001).
Several organizations, including the AACN (1997, 1998), the National League for Nursing (2005), and the Technology Informatics Guiding Educational Reform (TIGER) Initiative (n.d.) have encouraged the integration of information technology competencies into nursing education. The AACN (1998), the American Nurses Association (2001), and the Pew Health Professions Commission (Bellack & O’Neil, 2000) are among the organizations that have established recommendations and guidelines to incorporate information technology competencies into nursing education to enhance pedagogical strategies and prepare nursing students to become knowledgeable in new technologies in practice (Atack & Rankin, 2002; Billings, Skiba, & Connors, 2005; Cooper, Taft, & Thelen, 2004, Herdtner & Martslof, 2001; Kenny, 2002; McNeil et al., 2003; Sole & Lindquist, 2001).
Despite these guidelines and recommendations, the integration of information technology knowledge and skills in nursing curricula has been slow and inconsistent as indicated in a comprehensive review of empirical studies on nursing information technology in the past 15 years (Staggers, Gassert, & Curran, 2001). Limited data have been published on the different approaches to training faculty in the use of the technology for teaching. In the Pacific Northwest, a nursing technology collaborative was recently formed to expand the capacity of collegiate schools in the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region to integrate technology into nursing education and practice (Zierler, 2007).
The purpose of this study was to conduct a needs assessment for faculty training in integrating new technologies into nursing education to inform the development of faculty training programs. The primary aim of the study was to describe nursing faculty’s use, knowledge, and training needs associated with distance learning, simulation, telehealth, and informatics tools. A secondary aim was to examine both individual and institutional factors associated with use and knowledge of distance learning and simulation tools in nursing education.
Study Design and Population
This study used a descriptive, cross-sectional survey design to assess nursing faculty’s perceived knowledge, skills, and needs for training in the use of technologies for nursing education and practice. Nursing faculty who taught in accredited nursing programs across all levels (vocational, associate, baccalaureate, and graduate programs) in the WWAMI region were eligible to complete the anonymous Web-based survey. The study was approved by the university’s institutional review board.
Several strategies were taken to improve response rates in this survey (Dillman, 2007). The WWAMI Nursing Technology Collaborative project director first alerted 43 directors of nursing schools (39 from Washington state and 1 each from Wyoming, Alaska, Montana, and Idaho) that a Web-based survey would be forthcoming and that they would be asked to distribute the announcement to their faculty. A formal e-mail letter with a hyperlink to the survey was sent to the directors a week later asking them to complete the survey and to forward the e-mail invitation to their faculty listserv. Three reminder e-mails were sent 2 weeks apart after the initial contact with the directors. The survey was administered from April to May 2009.
The survey, which was expected to take 30 to 45 minutes to complete, included the following four sections:
- Demographic and teaching characteristics.
- Current use of four technologies (distance learning, simulation, telehealth, and informatics).
- Perceived knowledge and skills for using the technologies.
- Training availability and needs.
The face validity of the survey was verified by the Collaborative project directors and other content experts on the Collaborative’s executive board.
Use of Technology. Participants were asked to use a 6-point Likert scale (1 = not at all, 2 = a few times, 3 = one time per month, 4 = two or three times per month, 5 = one time per week, and 6 = more than one time per week) to rate how often they used distance learning, simulation, telehealth, and informatics. The six response options were then collapsed into three categories (not at all, infrequent use [a few times to two to three times per month], and frequent [at least one time per week]) for ease of comparisons for the secondary aim of the study.
Knowledge and Skill Assessment. The respondents used Benner’s (1984) novice to expert professional development framework to assess their perceived knowledge and skills in the use of technology in nursing education. Participants rated their knowledge and skill as novice, advanced beginner, competent, proficient, or expert. A novice was defined as someone with no experience and required rules and guidance in performance. An advanced beginner was defined as someone with little experience and still required guidance by mentors with prioritization. A competent practitioner was defined as someone who could develop conceptual plans and identify situations of action as a whole but lacked speed and flexibility. A proficient practitioner was defined as someone who could interpret minor details and had a deeper understanding of the overall picture. An expert was defined as someone who no longer relied on rules or guidelines to guide performance but rather has an intuitive understanding of the situation from their experience (Benner, 1984). The proficient and expert responses were combined for ease of analysis for the secondary aim. In addition, because the responses for the knowledge and skills questions were similar (reflecting respondents’ perception of knowledge and skill levels as being synonymous), only findings for knowledge are included in this article.
Training Needs Assessment. Participants were asked to answer six yes/no questions about the support they received or desired to effectively teach using distance learning technologies, simulation, telehealth, and informatics. Participants were asked about four specific areas of support: administrative, financial, technical support, and curricular design. Administrative support included assistance and support from department administrators. Financial support included funds to purchase and maintain equipment and to hire and provide training to staff. Technical support included hiring technical support and on-call help for training and equipment maintenance, including hardware and software assistance. Curricular design support included the pedagogical frameworks for integrating various technologies in the nursing curriculum.
Descriptive statistics were used to describe the sample and responses to the technology use, knowledge and skills, and training needs assessments. Chi-square tests were used to examine how use and knowledge of distance learning and simulation technologies were associated with demographic and teaching characteristics and perceived institutional support. A p value ≤0.05 was considered significant. All statistical procedures were performed using Statistical Package for the Social Sciences (SPSS) software version 15.0.
A total of 197 surveys were completed; however, only 193 surveys were analyzed because 4 of the surveys were completed by non-nursing faculty. The majority of the respondents were women from the metropolitan areas of Washington state, older than age 50, and Caucasian. Most of the respondents were full-time faculty with a master’s or doctorate degree, and had a median of 10 years of teaching experience. In addition, most of the respondents held the position of instructor or lecturer and taught a combination of lecture and clinical courses in baccalaureate nursing programs (Table 1).
Table 1: Sample Characteristics (N = 193)
Use of Technology
Informatics and computer fundamentals was the most frequently used type of technology. This was followed by distance learning, telehealth, and simulation (Figure 1).
Figure 1. Use of Distance Learning, Simulation, Telehealth, and Informatics. Note. Infrequent = Fewer than Three Times per Month; Frequent = at Least One Time per Week.
Ratings of perceived knowledge paralleled the frequency of technology use (Figure 2). Sixty-five percent of the respondents reported being at least competent with the use of informatics and computer fundamentals, and 59% were competent with distance learning technologies. A majority of the respondents reported that they were novices or advanced beginners with their knowledge of simulation (70%) and telehealth (68%).
Figure 2. Perceived Knowledge of Distance Learning, Simulation, Telehealth, and Informatics. Note. Adv. Beg = Advanced Beginner; Prof/Exp = Proficient/expert.
Support and Training Available to Teach with Technology
Respondents reported that they received the most training from their institutions on distance learning tools (80%), followed by informatics and computer fundamentals (54%), simulation (52%), and telehealth (18%) (Table 2). The majority of respondents reported that technical support was available to them for the use of distance learning tools (92%); fewer respondents reported having support for the use of simulation, telehealth, and informatics. Respondents reported far less curricular design and pedagogical support than any of the four technologies (22% to 56%). Sixty-nine percent of the respondents felt a need for training with distance learning; a similar percentage reported a need for training in simulation (69%) and informatics (68%), and fewer with telehealth (49%). The majority of respondents reported that technical (90%), financial (67%), curricular design (60%), and administrative (55%) support would be needed from their institution for them to use these technologies for teaching.
Table 2: Support and Training Available to Faculty to Teach with Technology (N = 193)
Factors Associated with Use and Knowledge of Distance Learning Tools
Faculty age was not associated with frequency of use of distance learning tools (p = 0.25) (Table 3) nor was perceived knowledge of distance learning tools (p = 0.75) (Table 4). However, doctorally prepared faculty and those teaching at the university level were more likely to use distance learning frequently and to perceive their knowledge as proficient or expert (Tables 3 and 4). Financial (p = 0.01) and technical support (p = 0.05) as well as training (p < 0.01) for distance learning were associated with greater use of distance learning tools; administrative and curricular design support (p > 0.05) were not associated with use of distance learning tools (Table 3). Technical support (p = 0.03) and training (p < 0.01) were associated with greater knowledge of distance learning tools, whereas financial (p = 0.26), administrative (p = 0.94), and curricular design (p = 0.70) support were not (Table 4).
Table 3: Factors Associated with Use of Distance Learning Tools (N = 193)
Table 4: Factors Associated with Perceived Knowledge of Distance Learning Tools (N = 193)
Factors Associated with Use and Knowledge of Simulation Tools
Faculty age, education, and teaching institution were not associated with frequency of use or knowledge of simulation tools (p > 0.05) (data not shown). Availability of training (p = 0.03) for simulation was associated with greater use, whereas financial, technical, administrative, and curricular design support were not (p > 0.05). Greater knowledge of simulation was associated with administrative support (p = 0.04) but not with financial, technical, or curricular design support, or training (p > 0.05).
The main findings of this study were that: 1) more than half of the respondents were frequent users of distance learning and informatics (computer fundamentals) tools; 2) ratings of perceived knowledge and skills paralleled frequency of technology use, with two thirds of respondents who were at least competent with distance learning and informatics tools; 3) training and technical support for distance learning tools were highest, yet a large percentage of respondents still felt a need for additional training in using these tools; and 4) availability of training as well as financial and technical support were associated with greater use of distance learning tools.
Nursing Faculty’s Use, Knowledge, and Training Needs
Of the four educational technologies, the first finding from this study indicated that distance learning and informatics and computer fundamentals tools had the most frequent users. Earlier studies demonstrated that both distance learning (AACN, 1999; Ali, Hodson-Carlton, & Ryan, 2002; Avery, Cohen, & Walker, 2008; Billings et al., 2005; Jacobsen, 2006; Lewis & Price, 2007; Mills, 2007; Mills & Hrubetz, 2001; Oermann, 2004) and informatics and computer fundamental tools (Elfrink et al., 2000; McNeil & Odom, 2000; McNeil et al., 2003) were taught in undergraduate and graduate nursing courses, whereas the integration of telehealth or telemedicine was recommended for graduate students in health informatics courses to prepare them for their future roles in the field (Demiris, 2003). Simulation pedagogy was found in both undergraduate (Hoffmann, O’Donnell, & Kim, 2007; Kardong-Edgren, Starkweather, & Ward, 2008; Nehring & Lashley, 2004; Oermann, 2004) and graduate nursing courses (Theroux & Pearce, 2006), and is typically taught in the simulation laboratory by specialized faculty (laboratory preceptors) (Kardong-Edgren et al., 2008). However, simulation education has been underused related to resource allocation and complexity of use (Jones & Hegge, 2007; King, Moseley, Hindenlang, & Kuritz, 2008; Nehring & Lashley, 2004). Therefore, the lack of use and knowledge of telehealth and simulation found in this study may be attributed to these reasons.
The second finding of this study demonstrated that the knowledge and skill paralleled with two thirds of faculty who were competent correlates with the increase in the use of distance learning and informatics and computer fundamentals in recent years. In a study by Mills (2007), the rate of enrollment in distance learning courses increased for master’s and post-certificate master’s nursing students to 70% in 2005 (2 years after the program evaluation period) compared to 13% at the beginning of the study in 1997. Regarding the use of informatics and computer fundamentals, a study by McNeil et al. (2003) assessed the use of informatics and computer fundamentals in nursing practice and education among 266 baccalaureate and graduate nursing faculty in the United States via an online survey. The findings indicated that 73% (n = 194) of respondents perceived the nurses in their region were using information technology in practice (McNeil et al., 2003). From the same group, 81% (n = 213) of respondents predicted that the need for nurses to use information technology in practice would increase either greatly or somewhat in the next 3 years (McNeil et al., 2003). Although the studies demonstrated an increased use of distance learning and informatics and computer fundamentals, earlier studies reported less perceived knowledge of distance learning and informatics and computer fundamentals, contrary to the second finding of this study.
Individual and Institutional Factors
Similar to the third finding, a study by Ali et al. (2005) demonstrated that although faculty taught online, they perceived their knowledge as advanced beginner or competent. This finding suggests that more training is needed to increase faculty knowledge. The study by McNeil et al. (2003) reported a lower level of knowledge in informatics and computer fundamentals, with the majority of nursing faculty perceiving themselves as novice and advanced beginners in informatics and computer fundamentals. Because more than 50% of the respondents reported using informatics and computer fundamentals in the courses they taught, this validates the increased need to educate and train nurses to be more knowledgeable in these skills.
The fourth finding that financial and technical support was associated with greater use of distance learning tools is consistent with another study that reported financial and technical issues were barriers in the attainment of informatics and computer fundamentals competencies among nursing students (Fetter, 2009). Financial barriers, referred to as the lack of resources, included costs, such as updates to modify or add new information technologies equipment and support to health agencies (Fetter, 2009; Hersh, 2002). Earlier studies also suggested that funding may be a barrier in integrating distance learning education (Ali et al., 2005) and informatics and computer fundamentals (McNeil et al., 2003). These findings should prompt nursing administrators and leaders to allocate their resources to include the integration of informatics (including computer fundamentals and clinical informatics) competencies in nursing programs. The findings should also encourage the development of faculty training programs in educational technologies, such as distance learning and informatics, and provide the necessary resources, tools, and support to ensure positive faculty outcomes (Bonk & Dennen, 2003; Mancuso-Murphy, 2007).
The importance of training faculty in the use of educational technologies for nursing education and practice is supported by the literature (Billings, 1995; Van Der Velde & Rawl, 2000). Faculty workload should be evaluated when developing a training program in the use of educational technologies. The literature shows that distance learning pedagogy requires more class preparation and facilitation time than traditional face-to-face classes, with an average of 22.5 hours per week dedicated for each online course (Morris, Buck-Rolland, & Gagne, 2002) for managing course assignments and providing support to student learning (Cravener, 1999; Morris et al., 2002).
However, the integration of distance learning in nursing education may also serve as a possible solution to the current nursing shortage by providing online classroom instruction to more students and increasing student enrollment (Oermann, 2004; Mancuso-Murphy, 2007). For distance learning integration to succeed and relieve faculty workload, technical support (Ali, Hodson-Carlton, & Ryan, 2004; Hodson Carlton, Siktberg, Flowers, & Scheibel, 2003; O’Neil, Fisher, & Newbold, 2004; Oermann, 2004; Roberts, 1998) and instructional design (Bonk & Dennen, 2003; Oermann, 2004) are necessary to help educators maintain and deliver course content. Ali et al. (2005) discussed the importance of developing a continuing education program in distance learning pedagogy. Although a study to train faculty in the use of distance learning or informatics was not found, a recent study by King et al. (2008) was used to display a faculty training program in the use of simulation or human patient simulators. The results of the Web-based survey of 34 associate degree in nursing faculty found that most nursing faculty (n = 21, 62%) had no prior hands-on training and 73% (n = 25) had not attended an educational program on the use of human patient simulators. Also, the majority of nurses (n = 32, 94%) reported that they would increase the use of human patient simulators if they attended training programs. Participants expressed a more positive attitude regarding the use of human patient simulators after training. The findings suggest that there was limited use of human patient simulators, but with training, faculty may gain confidence in the use of human patient simulators. This positive training example may be applied to other educational technologies. A further study to assess a training program for distance learning or informatics would be helpful to evaluate the effectiveness of the training in the use of these educational technologies.
These findings need to be interpreted within the context of two key limitations. The first limitation included the imprecise and overlapping operational definitions across the four educational technologies. For instance, the term informatics and distance learning may be described as encompassing “computer knowledge and skills” (McNeil et al., 2003). The reason for the different meanings may be associated with the various subcategories of informatics, such as bioinformatics, biomedical and health informatics, consumer health informatics, imaging informatics, research informatics, public health informatics, and clinical informatics (Shortliffe, 2006). Hersh (2009) discussed the different meanings of informatics and health information technology with the hope of reaching an agreement or consensus for clarifying those terms.
Similarly, the term distance learning has several interpretations and synonyms that are used interchangeably, such as online education, online learning, distance education, Web-based instruction (Bangert & Easterby, 2008; Lahaie, 2007; Lewis & Price, 2007; Mancuso-Murphy, 2007; Mills, 2007), and pedagogical instruction via asynchronous (delayed communication such as online discussion boards, e.g., World Wide Web Course Tools [WebCT], Blackboard, and Moodle) and synchronous (real-time interaction such as Web-conferencing, e.g., Connect Pro Live) methods divided by location and time (Carnevale, 2003; Kreideweis, 2005; Mancuso-Murphy, 2007). Telehealth and distance learning both included the use of audio and video communications. Informatics, which was operationally defined as the integration of computer knowledge and skills (McNeil et al., 2003) was actually a component of all four technologies. Thus, the article was primarily focused on distance learning and simulation technologies data because distance learning is a term that is more broadly used and simulation is distinctive and separate from the other educational technologies.
The second limitation was the small sample size from the five WWAMI states. Among the WWAMI states, surveys were sent to 39 nursing schools in Washington state (which included vocational, associate, baccalaureate, and graduate nursing programs), and 4 nursing schools in the other WWAMI states (1 university-level nursing school in each state of Wyoming, Alaska, Montana, and Idaho that only included baccalaureate nursing programs) (Zierler, 2007). Therefore, the findings may inaccurately reflect the target population and misrepresent nursing faculty from Wyoming, Alaska, Montana, and Idaho.
The integration of information technology competencies is crucial in nursing education and practice. To adequately prepare current and future nurses, faculty development and training in the use of educational technologies is necessary. A needs assessment survey identified the use, knowledge and skills, and training needs for using distance learning technologies, simulation, telehealth, and informatics. The findings indicated that the majority of respondents used distance learning and informatics and computer fundamentals most frequently, and were novice to competent users. The knowledge level suggests more training is needed to increase their knowledge level to proficient and expert users. In addition, support and training factors, such as financial and technical support, are needed to adequately provide nursing faculty with the knowledge and support needed to teach with distance learning tools and informatics and computer fundamentals. Further study in the use and knowledge of the four educational technologies and clarification of terms would be helpful in developing course content and training workshops when planning and developing course content. Ultimately, distance learning technologies and informatics and computer fundamentals are more specific to individual faculty and are tools that they use in education and practice. Therefore, the greatest impact would be if training programs focused on the use of technology tools that make work easier for faculty members (informatics and computer fundamentals) and meet the needs of students (distance learning tools).
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Sample Characteristics (N = 193)
|Demographic and Teaching Characteristics||n(%)|
| ≤50 years||62 (32)|
| >50 years||130 (68)|
| Female||183 (94)|
| Male||9 (6)|
| Caucasian||179 (92)|
| Hispanic||1 (1)|
| African American||1 (1)|
| Native American||2 (2)|
| Asian/Pacific Islander||9 (4)|
|Area of residence|
| Rural||50 (26)|
| Metropolitan||142 (74)|
|State in which faculty teach|
| Washington||148 (77)|
| Wyoming||8 (4)|
| Alaska||8 (4)|
| Montana||19 (10)|
| Idaho||9 (5)|
|Level of education|
| Baccalaureate||10 (5)|
| Master’s||103 (54)|
| Doctorate||79 (41)|
| Dean or director||7 (4)|
| Associate/assistant dean||5 (3)|
| Professor||20 (10)|
| Associate professor||27 (14)|
| Assistant professor||56 (28)|
| Instructor or lecturer||77 (41)|
| Community or technical college||48 (26)|
| University||144 (74)|
| Part-time||39 (22)|
| Full-time||153 (78)|
|Experience as an educator (years)|
| Median (range)||10 (1 to 41)|
|Nursing program that faculty teacha|
| ADN/LPN||48 (24)|
| BSN||99 (50)|
| MS||35 (18)|
| MN||58 (29)|
| PhD/DNP||39 (19)|
| Lecture||142 (72)|
| Clinical||119 (60)|
| Skills laboratory||63 (15)|
Support and Training Available to Faculty to Teach with Technology (N = 193)a
|Design and pedagogical support||56%||45%||22%||44%|
|Perceived training need||69%||69%||49%||68%|
|Faculty perception of support needed to teach with technology|
| Curricular design||60%|
Factors Associated with Use of Distance Learning Tools (N = 193)
|Demographic and Teaching Characteristics||Use of Distance Learning Toolsn(%)||pValue|
|Not at All||Infrequenta||Frequentb|
| ≤50 years (n = 61)||17 (28)||14 (23)||30 (49)|
| >50 years (n = 131)||28 (21)||22 (17)||81 (62)|
| Baccalaureate (n = 15)||8 (53)||1 (7)||6 (40)|
| Master’s (n = 95)||25 (26)||20 (21)||50 (53)|
| Doctorate (n = 81)||12 (15)||15 (18)||54 (67)|
| Community or technical college (n = 47)||18 (38)||8 (17)||21 (45)|
| University (n = 144)||26 (18)||28 (19)||90 (63)|
| Yes (n = 105)||22 (21)||20 (19)||63 (60)|
| No (n = 87)||23 (26)||15 (17)||49 (56)|
| Yes (n = 129)||23 (18)||21 (16)||85 (66)|
| No (n = 63)||22 (35)||14 (22)||27 (43)|
| Yes (n = 116)||28 (24)||17 (15)||71 (61)|
| No (76)||17 (22)||18 (24)||41 (54)|
| Yes (n = 165)||29 (18)||32 (19)||104 (63)|
| No (n = 14)||6 (43)||3 (21)||5 (36)|
| Yes (n = 132)||19 (14)||21 (16)||92 (70)|
| No (n = 33)||14 (43)||10 (30)||9 (27)|
Factors Associated with Perceived Knowledge of Distance Learning Tools (N = 193)
|Demographic and Teaching Characteristics||Perceived Knowledge of Distance Learning Toolsn(%)||pValue|
| ≤50 years (n = 61)||10 (16)||17 (28)||20 (33)||14 (23)|
| >50 years (n = 131)||16 (12)||37 (29)||39 (30)||38 (29)|
| Baccalaureate (n = 15)||4 (27)||4 (27)||6 (40)||1 (6)|
| Master’s (n = 94)||13 (14)||37 (39)||26 (28)||18 (19)|
| Doctorate (n = 81)||9 (11)||13 (16)||26 (32)||33 (41)|
| Community or technical college (n = 51)||7 (13)||24 (47)||14 (28)||6 (12)|
| University (n = 143)||19 (13)||31 (22)||47 (33)||46 (32)|
| Yes (n = 105)||15 (14)||31 (30)||31 (30)||28 (26)|
| No (n = 86)||11 (13)||23 (27)||28 (32)||24 (28)|
| Yes (n = 129)||17 (13)||37 (29)||35 (27)||40 (31)|
| No (n = 62)||9 (15)||17 (27)||24 (39)||12 (19)|
| Yes (n = 115)||17 (15)||29 (25)||37 (32)||32 (28)|
| No (n = 76)||9 (12)||25 (33)||22 (29)||20 (26)|
| Yes (n = 164)||16 (10)||48 (29)||47 (29)||53 (32)|
| No (n = 14)||4 (28)||5 (36)||5 (36)||0 (0)|
| Yes (n = 132)||8 (6)||42 (32)||36 (27)||46 (35)|
| No (n = 33)||12 (36)||4 (12)||16 (49)||1 (3)|