Trauma Experience Related to Organ Procurement Surgery From Deceased Donors on Attitude Toward Organ Donation: Mediating Effect of Coping Flexibility

Abstract

To examine the mediating role of coping flexibility in the relationship between traumatic experiences and attitudes toward organ donation among healthcare workers involved in organ procurement surgery. This was a cross-sectional study. Data were collected from 170 healthcare workers with experience in organ procurement surgeries for brain-dead patients at 4 hospitals in South Korea between June 16 and September 30, 2021. The study utilized questionnaires assessing traumatic experience, coping flexibility and attitude toward organ donation. Data were analyzed using the PROCESS macro (IBM SPSS Statistics 28.0). Coping flexibility significantly mediated the relationship between traumatic experiences and attitudes toward organ donation. Traumatic experiences related to organ procurement surgery negatively influenced coping flexibility, while higher coping flexibility was associated with more positive attitudes toward organ donation. Developing educational programs to enhance coping flexibility and regularly assess psychological well-being may improve healthcare workers’ attitudes toward organ donation and support their mental health after trauma exposure.

Keywords

tissue and organ procurement psychological trauma attitude

Introduction

Organ transplantation refers to the procedure in which an organ is removed from a donor patient and placed into the body of a recipient whose organ has lost its function and is likely to lose life because the organ cannot be recovered using current treatment methods.¹ Donation after brain death is a treatment wherein a patient diagnosed with brain death can donate organs to a person waiting for a transplant.¹ However, healthcare professionals who participate in organ procurement surgery for brain-dead donors face various emotions as they experience the process of dying.² Health professionals bear the professional responsibility of focusing on respecting and understanding the intentions of brain-dead donors or their families to donate organs.² However, some people may perceive that brain-dead donors are still alive because the donor’s skin is warm and biomarkers such as pulse and blood pressure remain normal; therefore, they may consider organ procurement surgery an act of violence against the donor.^2
-4 During this process, health professionals may experience trauma, including feelings of anger, emptiness, sadness, depression, and helplessness, while watching the donor’s death.⁵

Trauma to operating room nurses can occur during surgery on a severely traumatized patient, the death of a patient, or organ harvesting from a brain-dead patient.^6,7 Nurses experience anger, emptiness, sadness, depression, helplessness, and pain and may perceive the organ harvesting process as a tragic and surreal event,^5,8 feeling mentally and physically exhausted during organ procurement surgery.⁸ Furthermore, patients can experience painful sadness as they directly see the patient’s physical trauma and death amid tension and stress.⁹ This distress also affects attitudes toward organ donation, and nurses who participate in organ procurement surgery have negative attitudes toward organ donation.⁹ Trauma can remain a psychological wound not only at the time of experience but even after the event and can have a variety of effects on daily life; therefore, it is necessary to respond appropriately.¹⁰

Coping flexibility refers to the ability to respond flexibly to situations.¹¹ Coping flexibility includes trauma- and future-focused coping. People who can use both flexibly have a high level of psychological adjustment after a traumatic experience.¹¹ Coping strategies are important for resolving negative emotions experienced during organ harvesting surgery in brain-dead patients.^2,8,12 Coping plays an important role in psychological adaptation and recovery following traumatic experiences.¹³ If goal-oriented behavior is achieved using appropriate coping flexibility in the face of traumatic experiences,¹¹ a reduction in psychological dysfunction and improved health and social adjustment can be achieved.¹⁴ However, health professionals who participate in urgent organ procurement surgery do not have the time to recover from trauma¹⁵ and are sometimes limited in their ability to overcome trauma because of faulty coping mechanisms.⁸ Operating room personnel who participate in brain-dead organ harvesting are sometimes not prepared to address the patient’s death. Therefore, they experience pain or discomfort beyond normal emotions.^8,16 Some health professionals who feel a lack of respect for brain-dead patients during organ harvesting operations or who experience negative emotions sometimes show resistance to organ donation.⁸ Appropriate coping can increase professional responsibility and lead to positive attitudes toward organ donation.¹⁷ It is important for health professionals to empathize with the need for organ donation and to understand the correct information to cultivate a positive attitude, which can have a significant impact on the organ donation decision-making of brain-dead family members.^18,19

The conceptual framework of this study was based on the work of Regehr et al.⁹ The death and trauma experiences of healthcare professionals contributed to negative attitudes toward organ donation, and coping strategies could affect these attitudes. Therefore, this study aimed to verify the mediating effect of coping flexibility on trauma experiences related to organ procurement from brain-dead donors by healthcare professionals. The hypothesis to verify the objective of this study is as follows: Coping flexibility mediates the relationship between trauma experience and attitudes toward organ donation.

Methods

Study Design

This is a cross-sectional descriptive study that investigated the mediating effects of coping flexibility on the impact of trauma experience on attitudes toward organ donation among healthcare workers who participated in brain-dead procurement surgery for organ harvesting. This study has followed the relevant EQUATOR guidelines.

Study Participants and Setting

Data were collected from 4 territorial hospitals from the 16th of June to the 30th of September 2021. The researcher explained the purpose and methods of the study. The participants were informed that there would be no disadvantage or risk during the study period and that they could stop participating at any time. After informed consent was obtained, 192 questionnaires were distributed to those who voluntarily agreed to participate.

The participants included scrub nurses, circulating nurses, surgical physician assistants, anesthesiology nurses, organ transplant coordinators, surgeons and assistants, and anesthesiologists. The number of samples required for the multiple regression analysis was 150, with 18 predictors. The sample size was calculated using the G*Power 3.1.9 program with a .05 significance level, a power of 0.80, and an effect size of 0.15.¹⁴ Anticipating a dropout rate of approximately 20%, 192 copies of the questionnaire were distributed, and 190 copies were collected, of which 170 copies were used for the final analysis, excluding 20 copies that responded insincerely.

Instruments

The self-report questionnaire consisted of items on general characteristics (15 items), trauma experience (22 items), coping flexibility (20 items), and attitudes toward organ donation (20 items).

General Characteristics

The general characteristics of the participants were sex, age, religion, marital status, education level, occupation, and clinical career.

Trauma Experience

Trauma experiences related to brain-dead organ procurement surgery refer to the psychological trauma that health professionals may experience during surgery. Trauma experience was measured using the revised version of the Impact of Event Scale (IES) developed by Weiss and Marmar²⁰ and Horowitz et al²¹ The subdomains were hyperarousal (six items), avoidance (6 items), intrusion (5 items), sleep disturbance, emotional numbness, and dissociation symptoms (5 items). For the 22 questions, each item was measured on a five-point Likert scale ranging from ‘not at all’ (0 points) to ‘a lot’ (4 points). The Cronbach’s alpha at the time of development²¹ was .78, and the reliability was .95 in this study.

Coping Flexibility

Coping flexibility was measured using the Perceived Ability to Cope with Trauma (PACT) Scale developed by Bonanno et al.¹¹ The subfactors include trauma focus (8 questions) and forward focus (12 questions). The ability to perform actions and strategies for a traumatic event was evaluated using a seven-point Likert scale ranging from ‘not at all able’ (1 point) to ‘extremely able’ (7 points). At the time of development, the Cronbach’s alpha coefficients for the reliability of trauma-focused coping flexibility and forward-focused coping flexibility in the subdomains were .79 and .83,¹¹ respectively; those in this study were .91 and .93, respectively.

Attitudes Toward Organ Donation

Attitudes toward organ donation were measured using an instrument developed by Yu²² and modified and supplemented by Choi.²³ The subfactors were composed of emotional aspects (7 items), cognitive aspects (6 items), and behavioral aspects (7 items), ranging from ‘strongly agree’ (1 point) to ‘strongly disagree’ (5 points), for a total of 20 questions. In previous studies, the Cronbach’s alpha coefficients for reliability were .67 and .77,^22,23 respectively; in the present study, the Cronbach’s alpha coefficient was .80.

Data Analysis

The PROCESS macro (version 3.1), developed by Hayes²⁴ in IBM SPSS Statistics 28.0, was used to analyze the collected data. The P-value was considered significant at .05, and the specific method was as follows: The general characteristics of the subjects are presented in terms of frequency and percentage using descriptive statistics. The differences in variables (trauma experience, coping flexibility, and attitudes toward organ donation) according to general characteristics were analyzed using statistical methods such as the independent t test, one-way analysis of variance (ANOVA), and Scheffe test. Traumatic experience, coping flexibility, and attitudes toward organ donation related to brain-dead organ procurement surgery are presented as the mean and standard deviation, range, and minimum and maximum values, respectively. Pearson’s correlation coefficient was used to analyze the correlations between traumatic experience, coping flexibility, and attitudes toward organ donation. The PROCESS macro was used to analyze the mediating effect of coping flexibility on the relationship between trauma and attitudes toward organ donation. The statistical significance of the mediating effect was verified with a 95% confidence interval (CI) by performing bootstrap analysis with a process macro of 5000 iterations.

Ethical Considerations

This study was approved by the Institutional Review Board (IRB) of Ulsan University Hospital (Approval No: 2021-04-009). Prior to study initiation, the research purpose, methods, anticipated benefits, and potential risks were fully explained to all participants. Written informed consent was obtained from all participants before data collection, ensuring their voluntary agreement to participate. The consent process included the protection of participants’ personal information, the option to refuse participation, and the assurance that collected data would be used solely for research purposes. Furthermore, the research data were stored securely for 3 years after the study’s completion, after which all documents were shredded and permanently deleted.

Results

Differences in Variables According to the General Characteristics of the Subjects

Most participants were female (87.6%), and the largest age group included participants in their 20s (38.8%). Of all the participants, 64.7% declared no religion, and 68.2% held a bachelor’s degree. The most common occupation of the participants was operating room nurses (58.8%), and only 10 (5.9%) doctors participated in the study.

As a result of verifying the differences in variables according to general characteristics, coping flexibility significantly differed based on age (t = 3.13, P = .046), marital status (t = −2.92, P = .004), occupation (t = 4.19, P = .003), and clinical career (t = 3.92, P = .010). There were significant differences in marital status (t = −2.55, P = .012) and occupation (F = 11.48, P < .001) regarding attitudes toward organ donation (Table 1).

Table 1.

Differences of Variables According to the General Characteristics of Subjects (N = 170).

Variables	Categories	n (%)	Trauma experience			Coping flexibility			Attitude toward organ donation
Variables	Categories	n (%)	Mean ± SD	t or F	P (post hoc)	Mean ± SD	t or F	P (post hoc)	Mean ± SD	t or F	P (post hoc)
Gender	Male	21 (12.4)	0.53 ± 0.66	0.74	0.470	9.01 ± 3.29	−0.16	0.878	3.55 ± 0.45	1.38	0.170
	Female	149 (87.6)	0.42 ± 0.47			9.13 ± 2.30			3.41 ± 0.44
Age (years)	20-<29	66 (38.8)	0.38 ± 0.50	1.04	0.356	8.54 ± 2.18	3.13	0.046^*	3.38 ± 0.40	0.53	0.589
	30-<39	64 (37.6)	0.44 ± 0.43			9.44 ± 2.61			3.46 ± 0.48
	≥40	40 (23.5)	0.53 ± 0.58			9.54 ± 2.40			3.43 ± 0.45
Religion	None	110 (64.7)	0.44 ± 0.47	0.62	0.606	8.89 ± 2.55	1.32	0.269	3.43 ± 0.45	0.06	0.980
	Christian	29 (17.1)	0.39 ± 0.47			9.89 ± 1.98			3.41 ± 0.49
	Catholic	9 (5.3)	0.64 ± 0.99			9.02 ± 2.35			3.39 ± 0.30
	Buddhist	22 (12.9)	0.42 ± 0.40			9.24 ± 2.35			3.40 ± 0.39
Marital status	Unmarried	88 (51.8)	0.40 ± 0.44	−0.96	0.338	8.60 ± 2.25	−2.92	0.004^*	3.34 ± 0.40	−2.55	0.012^*
	Married	82 (48.2)	0.48 ± 0.55			9.66 ± 2.51			3.51 ± 0.47
Education level	Diploma	32 (18.8)	0.37 ± 0.37	0.56	0.574	8.82 ± 2.43	2.70	0.070	3.34 ± 0.40	1.57	0.210
	Bachelor	116 (68.2)	0.44 ± 0.49			8.98 ± 2.28			3.42 ± 0.45
	≥Master	22 (12.9)	0.51 ± 0.69			10.21 ± 2.98			3.56 ± 0.45
Occupation	OR nurse	100 (58.8)	0.41 ± 0.48	1.10	0.360	8.81 ± 2.39	4.19	0.003^*	3.30 ± 0.38^a	11.48	<0.001^*
	Anes. nurse	33 (19.4)	0.44 ± 0.40			8.93 ± 1.70			3.41 ± 0.40^b		(a,b < c)
	GS nurse	12 (7.1)	0.60 ± 0.65			8.49 ± 2.47			3.62 ± 0.46
	Coordinator	15 (8.8)	0.60 ± 0.67			10.94 ± 2.90			3.99±0.52^c
	Doctor	10 (5.9)	0.26 ± 0.38			10.75 ± 2.74			3.61 ± 0.18
Clinical career (years)	1-<5	46 (27.1)	0.38 ± 0.47	0.98	0.402	8.38 ± 2.04^a	3.92	0.010^*	3.43 ± 0.36	0.90	0.448
	5-<10	57 (33.5)	0.39 ± 0.45			9.05 ± 2.47		(a < b)	3.38 ± 0.49
	10-<15	21 (12.4)	0.57 ± 0.63			10.48 ± 2.34^b			3.56 ± 0.52
	≥15	46 (27.1)	0.49 ± 0.51			9.30 ± 2.57			3.41 ± 0.42

Note. SD = standard deviation; OR = operating room; Anes. = anesthesia recovery room; GS = general surgery.

P < .05.

Characteristics of Organ Procurement Surgery in Brain-Dead Patients

The number of participants who underwent organ procurement from brain-dead patients was 30.0% (51 people) 1 to 5 times, 23.5% (40 people) 20 times or more, 22.9% (39 people) 5 to 10 times, 15.9% (27 people) 10 to 15 times, and 7.6% (13 people) less than 15 to 20 times. A total of 53.5% (91 people) responded that they had experienced an ethical dilemma related to organ harvesting. A total of 51.8% (88 people) responded that they had relevant knowledge about the brain death determination procedure, which was similar to the 48.2% (82 people) who said they were not sure. Regarding ethics education, 53.5% (91 people) responded that they had completed it; however, educational experience related to organ donation (30.0%; 51 people) and coping with psychological trauma (15.9%; 27 people) was low.

More than half (76.5%; 130 participants) responded that they felt different emotions when participating in organ procurement surgery than when participating in other surgeries. The described emotions, including duplicate responses, were as follows: 40.0% (62 people) responded that they felt ‘sadness, condolence, pity, depression’ for the deceased. Next, they responded that they felt ‘reverence, nobility, awe, respect’ (25.1%; 39 people) and ‘gratitude’ (12.9%; 20 people). Other answers included ‘vain and empty’ (8.4%; 13 people) and ‘scary, burdensome, and tense’ (3.9%; 6 people). A total of 71.2% (121 people) responded that there was a change in their mindset according to the age of the brain-dead patient, and 85% (96 people) responded that they felt ‘pity, compassion, sadness, and depression’ when the age of the brain-dead person was younger.

Levels of Trauma Experience, Coping Flexibility and Attitudes Toward Organ Donation

Traumatic experience related to organ procurement surgery was rated at 0.44 ± 0.50 points, and coping flexibility was 9.11 ± 2.43 points. The average score for organ donation was 3.42 ± 0.44 points (Table 2).

Table 2.

Levels of Trauma Experience, Coping Flexibility and Attitude Toward Organ Donation (N = 170).

Variables	Mean ± SD	Range	Min	Max
Trauma experience	0.44 ± 0.50	0-4	0	3.05
Hyperarousal	0.24 ± 0.47	0-4	0	3.00
Avoidance	0.43 ± 0.60	0-4	0	3.00
Intrusion	0.72 ± 0.63	0-4	0	3.00
Sleep disturbances, emotional numbness and dissociation symptom	0.40 ± 0.52	0-4	0	3.20
Coping flexibility	9.11 ± 2.43	2-14	3.00	14.00
Trauma focus	4.57 ± 1.22	1-7	1.50	7.00
Forward focus	5.27 ± 1.02	1-7	2.00	7.00
Attitude toward organ donation	3.42 ± 0.44	1-5	2.60	4.75
Emotional aspect	3.26 ± 0.45	1-5	2.00	4.57
Cognitive aspect	3.91 ± 0.59	1-5	1.50	5.00
Behavioral aspect	3.18 ± 0.65	1-5	1.57	5.00

SD = standard deviation.

Correlations Among Study Variables

Trauma experience showed a significant negative relationship with coping flexibility (r = −.16, P = .043), but there was no significant relationship with attitude toward organ donation (r = −.01, P = .928). Coping flexibility showed a positive relationship with attitudes toward organ donation (r = .31, P < .001; Table 3).

Table 3.

Correlations Among Study Variables (N = 170).

Variables	Trauma experience	Coping flexibility
Variables	r (p)
Coping flexibility	−.16 (.043)^*
Attitude toward organ donation	−.01 (.928)	.31 (<.001)^*

P < .05.

The Mediating Effect of Coping Flexibility on the Relationship Between Traumatic Experience and Attitudes Toward Organ Donation

The data were analyzed to verify the mediating effect of coping flexibility (M) on the effect of trauma (X), which is related to organ procurement surgery, on attitudes toward organ donation (Y). Age, marital status, job group, and career status showed significant differences in trauma experience and attitudes toward organ donation when controlled for in the analysis. The results showed that while traumatic experience had a significant negative effect on coping flexibility (X on M, B = −0.94, P = .011), it had no significant effect on the path to attitude (X on Y, B = 0.01, P = .970). Coping flexibility had a significant positive effect on attitudes toward organ donation (M on Y, B = 0.04, P = .005). To verify the significance of the indirect effect, partial mediation of the path was repeatedly extracted 5000 times for bootstrap analysis. The mediating effect through coping flexibility was significant because the 95% bias-corrected bootstrap CI value of the indirect effect of the path from trauma experience to attitude toward organ donation by coping flexibility did not contain a value of 0 (−0.0823, −0.0045; Table 4 and Figure 1).

Table 4.

Mediating Effect of Coping Flexibility in the Relationship Between Trauma Experience and Attitude Toward Organ Donation (N = 170).

Pathway	Estimate	SE	95% CI		P	R ²	F (p)
Pathway	Estimate	SE	Lower	Upper	P	R ²	F (p)
Direct effect X on M	−0.94	0.36	−1.66	−0.22	.011	0.17	2.98 (0.001)^*
Direct effect M on Y	0.04	0.01	0.01	0.07	.005	0.27	4.94 (<0.001)^*
Direct effect X on Y	0.01	0.06	−0.12	0.13	.970	0.27	4.94 (<0.001)^*
Total effect X on Y	−0.03	0.06	−0.16	0.09	.595	0.24	4.45 (<0.001)^*
Indirect effect	−0.0362	0.0203	−0.0823	−0.0045

Note. All variables were mean centered.

SE = standard error; M = mediator; X = independent variable; Y = dependent variables; CI = confidence interval.

P < .05.

Figure 1.

Mediation model among trauma experience, coping flexibility, and attitude toward organ donation.

Discussion

This study was conducted to identify the mediating effect of coping flexibility in trauma experiences related to brain-dead organ procurement surgery on attitudes toward organ donation and to provide interventions to prevent psychological trauma among health professionals. Organ procurement surgery is a complicated procedure because healthcare professionals from various recipient hospitals participate in it. According to the Transactional Theory of Stress and Coping model,²⁵ when individuals experience psychological stress, how they cope with it, and how they appraise the stress (cognitive appraisals) occur as interdependent processes. Organ procurement surgery can be perceived as a stressful situation for healthcare professionals. The study results showed that approximately 40% of the participants expressed sadness, condolences, and disappointment. In particular, this finding was similar to that of previous studies, where participants reported more sympathy when the donor was younger.²⁶ As such, the age of the donor or experiencing moral and ethical dilemmas can pose challenges, especially when explaining organ donation issues to the family of the brain-dead donor. The way an individual copes with traumatic events plays a significant role in psychological adaptation.²⁵ Therefore, how healthcare professionals evaluate and manage the stress associated with participation in organ procurement surgery can determine their emotional responses and attitudes toward organ donation.

It was found that trauma experience had a significant negative effect on coping flexibility, which is in line with a previous study,⁸ that reported the importance of healthcare professionals who participate in organ procurement surgery in deceased donors using coping strategies to resolve the trauma they experience.⁸ However, no significant results were found regarding the direct effect of traumatic experience on attitudes toward organ donation. This differs from previous studies in which trauma experiences were shown to act as antecedents influencing attitudes toward organ donation,⁹ and health professionals who experience negative emotions during the organ procurement process become passive or develop a negative attitude toward organ donation.^5,8 This difference is thought to be due to the limitations of the instrument used to measure trauma in this study, which was limited to including only the symptoms related to exposure to organ procurement surgery in deceased donors and evaluating them as stressors. Furthermore, an individual’s or their family’s willingness to donate organs is influenced by factors such as related knowledge and religious beliefs.^27,28 In this study, approximately half of the participants reported that they lacked relevant knowledge and experienced ethical dilemmas. A lack of knowledge about brain death is one of the factors affecting perioperative nurses’ sadness and can cause ethical dilemmas due to organ procurement surgeries.⁸ Therefore, it is believed that the religious beliefs of each study participant and their knowledge as healthcare professionals regarding the procedures for organ transplantation in brain-dead donors likely influenced their attitudes toward organ donation. Therefore, there is a possibility that the medical staff’s traumatic experiences were omitted. In addition, attitudes toward organ donation worsened when coping flexibility decreased. This finding is similar to that of study,⁸ which revealed that a lack of ability to cope with the stress caused by brain-dead organ harvesting can exacerbate negative attitudes toward organ donation.

The mediating effect of coping flexibility on the relationship between trauma and attitudes toward organ donation was significant. Flexibility refers to the optimal adjustment ability using various coping strategies for traumatic events.²⁹ This study showed that it is important to use coping flexibility to reduce the trauma experienced by healthcare workers participating in organ procurement surgery for deceased donors to avoid negatively affecting their attitudes toward organ donation. Operating room nurses reported that due to staffing shortages, they not only do not have time to care for donors after the organ procurement process but also have to participate in other surgeries without time to rest or take care of their own emotions.¹⁷ Because health professionals’ negative attitudes can be passed on to others, appropriate coping strategies are necessary.⁹ To resolve the negative emotions of healthcare professionals, it is important to express and consider the feelings of colleagues, and professional support is necessary.^2,17 Fortunately, perioperative nurses may feel sad after the procurement process but may use coping strategies to adjust their professional roles.²⁶ However, in this study, the healthcare professionals had little experience with educational training in organ donation. There are few professional support programs within the operating room, and no time is available to resolve trauma.¹⁷ Therefore, it is essential to develop educational and counseling programs aimed at improving coping flexibility. These programs could include strategies such as resilience training to enhance individuals’ ability to bounce back from adversity, peer support groups to provide emotional support and shared experiences, and mindfulness-based stress reduction techniques to help healthcare professionals manage stress and improve emotional regulation in high-pressure situations.

The study has several limitations. First, it was conducted in a single region, which limits the generalizability of the findings. Second, individual cultural, religious, and personal beliefs, as well as personal experiences (eg, trauma), may have influenced the study variables. Third, since data were collected from 4 different hospitals, the policies and procedures at each hospital could have affected the participants’ experiences. Additionally, while the IES and PACT scales were selected because they are well-established tools specifically designed to assess the psychological burden and coping mechanisms in individuals exposed to traumatic events, they were not specifically developed for the unique and specific context of organ procurement surgery. These limitations should be considered when interpreting the findings.

Conclusion

This study found a significant relationship between the trauma experiences of healthcare professionals involved in brain-dead organ procurement surgery and their coping flexibility. However, no direct correlation was identified between trauma experiences and attitudes toward organ donation. Coping flexibility was positively associated with attitudes toward organ donation and was found to mediate the relationship between traumatic experiences and attitudes. However, the cross-sectional design of this study limits the ability to infer causality between trauma experiences, coping flexibility, and attitudes toward organ donation. This limitation should be acknowledged, and future research should consider longitudinal or experimental studies to establish causal relationships. Based on these findings, we propose the following recommendations for future research: First, the instruments used in this study did not fully capture the trauma experiences of healthcare professionals involved in brain-dead organ procurement surgery. Therefore, future studies should develop more specific tools to assess these experiences. Second, since the current study did not encompass various aspects of trauma related to organ procurement surgery, further research should include additional variables to explore this issue from multiple perspectives.

Footnotes

Acknowledgements

This manuscript is based on a part of the first author’s master dissertation from University of Ulsan.

ORCID iD

Sangjin Ko

Ethical Considerations

The study was approved by the Ethical Review Committee of the Ulsan University Hospital (IRB No: 2021-04-009). Prior to study initiation, the research purpose, methods, anticipated benefits, and potential risks were fully explained to all participants.

Consent to Participate

Written informed consent was obtained from all participants before data collection, ensuring their voluntary agreement to participate.

Author Contributions

Geonyoung Kim: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Resources, Software, Validation, Visualization, Writing – Original Draft Preparation. Sangjin Ko: Conceptualization, Funding Acquisition, Investigation, Methodology, Project Administration, Resources, Software, Supervision, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing. All authors reviewed and approved the final version of the manuscript.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Data cannot be shared due to ethical, legal, or commercial restrictions.

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