Sentinel events, involving serious injury or death, reveal critical vulnerabilities in clinical practices. Nurses play a key role in identifying errors and contributing factors in such events. However, evidence on the effectiveness of nurse-guided RCA in improving compliance and corrective actions is limited.
Objective
The aim of our research is to deeply explore the experiences, roles, challenges, and strategies of nurses in guiding RCA. By concentrating on nurses’ guidance, we can provide in-depth insights into their unique contributions in the RCA process.
Methods
Twelve participants from a tertiary hospital in southeastern mainland China were selected for the study. A constructivist qualitative research method was used to collect views and opinions from the participants' perspectives through semi-structured face-to-face interviews, and content analysis was applied, the data was further interpreted using thematic analysis.
Results
A total of 12 RCAdirectors were included in this study. Analyses revealed four main themes and 11 sub-themes. The main themes were: (1) success in a demanding field requires exceptional skills and abilities (having comprehensive knowledge, empowering capabilities, demonstrating interest and engagement), (2) building strong interpersonal relationships between guides and team leaders (selecting mature and experienced team leaders, building trust and cooperation with team leaders, exerting the guiding role of team leaders in projects), (3) tailored communication strategies in nursing for effective leadership and safety enhancement (navigating complex hierarchies through tailored communication, fostering collaboration through targeted communication strategies, empowering teams through clear and adapted communication) (4) investing effort and overcoming obstacles are key to successful nursing-guided project implementation (investing time and effort in project implementation, addressing obstacles during project advancement).
Conclusion
We provide new evidence on the critical role of the care coach in RCA programmes, highlighting the importance of competence, communication, trust and collaboration in enhancing team dynamics and improving quality of care and safety outcomes.
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Implications for clinical practice
RCA guides should actively engage in RCA initiatives, leveraging their expertise to bridge clinical practice and organizational policies, enhancing safety measures effectively.
Building strong interpersonal relationships between guides and team leaders fosters trust, leading to improved communication, team cohesion, and more successful project outcomes.
Tailored communication strategies are essential for RCA guides to navigate complex hierarchies, facilitating collaboration and empowering teams in safety improvement efforts.
Introduction
Sentinel events, defined as unexpected occurrences involving death or serious physical or psychological injury, have a significant impact on patient safety and healthcare quality [1]. These events, though rare, often highlight critical vulnerabilities in clinical practices and processes, demanding a swift and thorough investigation to prevent recurrence. Emphasise that a proactive approach should be adopted in the healthcare system to increase resilience and adaptability in responding to threats to patient safety in a variety of contexts in order to achieve improvement success [2, 3]. RCA is a widely used methodology to investigate sentinel events, aiming to identify underlying system weaknesses, human errors, and process failures that contribute to adverse outcomes [4]. Traditionally, RCA is conducted by multidisciplinary teams, including physicians, managers, and quality improvement specialists [5].
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RCA as a continuous quality improvement tool plays an important intervention role in clinical practice [6]. Studies have shown that adherence and outcomes of intervention programs tend to be more significant when appropriate support is provided [7]. Clinical studies have also confirmed the effectiveness of nurse-guided clinical intervention programs in reducing the risk of pulmonary complications after cardiac surgery, shortening the length of hospitalization, and reducing patients' insomnia symptoms [8, 9]. In terms of efficacy and safety, nurse-guided intervention programs are not only no less effective than physician-directed treatments, but even better in some cases [10]. Thus, the role of nurse guidance in clinical interventions has been well validated. Nurses, being on the frontlines of patient care, possess invaluable insight into the daily operations of clinical workflows and patient interactions [11]. They not only identified errors but also helped in identifying contributing factors such as communication breakdowns, insufficient training, and staffing issues [12]. Nurses' insights have proven essential in ensuring a holistic analysis of incidents, leading to more effective corrective actions.
Direct observation, analysis, and implementation of interventions by experienced program members is often an appropriate approach in practice settings where sufficient time and manpower are available [5]. However, there is a lack of sufficient evidence that nurse-guided RCA analyses are effective in improving member compliance, increasing efficiency, and enhancing the implementation of corrective measures in the overall analysis of sentinel events.
Based on the above research questions, the main objective of this study was to use qualitative analysis methods to explore how nurses can guide the implementation of RCA after an outpost event. Through in-depth analyses of the barriers and successes encountered by healthcare organisations in practice, we aim to propose a set of systematic guidelines to help healthcare teams conduct RCA more effectively. Ultimately, these guidelines will help to promote a culture of safety in healthcare, which will lead to fewer medical errors and improved patient safety.
Methods
Study design
We utilize a qualitative research approach that combines semi-structured and face-to-face interviews to explore the experiences, perceptions, and real-life pressures faced by healthcare quality improvement directors during the RCA process after sentinel events. Qualitative descriptive methods are typically utilized to explore individuals' experiences, cognitions, and inclinations towards specific phenomena [13]. Using qualitative descriptive methods allows for gathering rich viewpoints and opinions from participants' perspectives, thereby enhancing understanding of the phenomenon [14].
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Settings
The surveyed hospital is a tertiary general hospital in southeastern Zhejiang Province, mainland China. It has 1200 beds, enabling a comprehensive exploration of the research topic in a complex healthcare setting.
Participant recruitment
Purposive sampling along with a maximum variation strategy to identify and select participants who could provide rich and diverse insights into the researchphenomenon [15]. Maximum variation was achieved in terms of participants' gender, education level, occupation, position, work experience, and experience in guiding RCA projects, respectively. The inclusion criteria were as follows: (1) registered nurses, nurse managers, nurses in hospital administration, and nurses in quality management roles; (2) having certification in medicine; (3) having at least 3 years of experience guiding RCA projects within healthcare institutions; (4) having successfully guided at least two relevant projects; (5) being willing to fully cooperate throughout the study. Purposive sampling continued until thematic saturation was reached during data analysis. A total of 14 nurse guides met the inclusion criteria, 2 women were unable to complete the interview due to lack of interest and time conflicts.
Sample size
The sample size of this study was determined based on achieving conceptual saturation. This occurs when interviews reveal recurring themes without new significant concepts emerging, indicating that the collected information is sufficiently comprehensive and representative. In this study, saturation was reached after interviewing 12 RCA directors. At this point, there was consensus among coders on conceptual categories that encompassed key shared experiences. Therefore, additional interviews were deemed unnecessary to enhance understanding of the themes [16].
Ethical approval
Before the interviews, participants were fully informed about the anonymity and confidentiality of their information. They were also briefed on the study's methods, objectives, and their voluntary right to withdraw at any time. Participants confirmed their understanding of these aspects by signing an informed consent form. The study was approved by the Ethics Committee of Taizhou First People's Hospital, Zhejiang Province [Ethical Approval No. 2024-KY034-01] (see Supplement 1). All research procedures adhered to principles outlined in the Declaration [17].
Data generation
Individual interviews were conducted from August 1 to September 20, 2024, using a semi-structured interview guide. The development of this interview guide was based on our experience in specific research contexts and referenced relevant literature to ensure the scientific validity and relevance of the questions [11, 18, 19]. Open-ended questions were designed to promote in-depth dialog [20]. Two researchers with experience in qualitative research methods (LLH and HFC) field-tested the initial questions, which were subsequently modified based on feedback. In addition, experts in the field were consulted to ensure that the interview questions adequately answered the research questions. Ultimately, the interview guide was tested and revised in multiple rounds, following standard qualitative research procedures to ensure the validity and reliability of data collection (Supplement 2). The guide comprised five main questions, each further detailed with three sub-questions: "Role and background," "Challenges and difficulties," "Effective communication and collaboration," "Learning and growth," and "Impact and achievements." Following the main and sub-questions, participants were asked additional exploratory and follow-up questions.
The research team consists of 5 researchers, including 4 with qualifications and experience in qualitative research (LLH, HFC, JHY & WWH), and 1 with a PhD in research methodology (WWH). All five researchers serve as project directors for RCA in healthcare institutions. The interviews we conducted typically ranged from 45 to 85 min in length, average duration was 53 min. This time frame allowed for in-depth exploration of the participants' experiences, perspectives, and insights [14]. These interviews were carried out after multiple RCA activities. By collecting data from experiences of different RCA processes, we aimed to gather a more comprehensive and diverse range of insights.
Data analyses
Manifest content analysis was employed to analyze and interpret the data, aiming to accurately describe informant statements and closely align with the text to represent observable elements [21]. An inductive approach was used to identify commonalities and differences in the data, progressing from specific textual details to a broader conceptual understanding [22]. We used the qualitative research analysis software QSR Nvivo 12.0 to organize and analyze the data. During the preparation phase, two researchers, LLH and HFC, meticulously reviewed the transcribed interview texts multiple times to familiarize themselves thoroughly with the data. They identified meaningful units within the text, which were groups of words or sentences that conveyed central concepts [23, 24]. In the organizing phase, these meaningful units were condensed into codes. The researchers discussed and debated the codes to ensure consistency and accuracy. Similar codes were merged into broader categories [23].
Initially conducted in Chinese, coding was later translated into English by LLH for peer review [25]. Principal investigators LLH & WWH, fluent in both languages, oversaw the translation process. Regarding conceptual saturation, we reached it when three coders observed that repeated participant responses did not yield new themes. We continued coding until no new significant concepts emerged [26]. We also constructed a thematic matrix using the coded data, which helped us visualize the relationships between different themes and sub-themes [26]. Each code was placed in the matrix, and we began to assess relationships. the decision-making process that led to the categorization “is part of”, “is associated with” “is caused of”. The research team refined the categorization through several iterative discussions. Additionally, selective citations for each theme were included to clearly delineate their boundaries and enhance the credibility of our findings [21].
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Findings
Demographic characteristics of interview participants
Twelve participants were selected based on information repetition during interviews, indicating that saturation was reached and no new themes emerged [27]. The demographic composition of the 12 participants includes three males and nine females, with ages ranging from 32.0 to 52.0 years (mean 41.2 ± 5.6 years) and an average work experience of 19.0 years (ranging 10.0 to 32.0 years). Among these participants, two have an associate degree, six have a bachelor's degree, three have a master's degree, and one has a doctoral degree. Of the 12 participants, nine hold management positions and three hold regular positions. Experience in directing RCA projects: five participants have directed more than five projects; 4 participants have directed three to five projects; and three participants have directed one to two projects. (Table 1).
Table 1
Presents a summary of the participants' demographic data (n = 12)
No
Gender
Age (years)
Education
Occupation
Position
Years of work experience
Experience in guiding RCA projects (number of projects)
G1
female
42
master's graduate
nursing management
head nurse
20
more than 5
G2
male
32
undergraduate
nursing management
head nurse
11
3 to 5
G3
female
45
college
nursing management
head nurse
27
more than 5
G4
male
37
undergraduate
clinical nursing
nurse
15
3 to 5
G5
female
40
undergraduate
nursing management
department head
18
3 to 5
G6
male
35
master's graduate
clinical nursing
nurse
10
1 to 3
G7
female
37
undergraduate
nursing management
head nurse
16
3 to 5
G8
female
37
undergraduate
clinical nursing
nurse
16
more than 5
G9
female
48
nursing management
nursing management
deputy hospital director
22
more than 5
G10
female
44
college
nursing management
head nurse
22
1 to 3
G11
female
45
master's graduate
nursing management
department head
19
1 to 3
G12
female
52
undergraduate
nursing management
nursing department director
32
more than 5
G Guide
Themes
We identified four main themes, each consisting of two to three sub-themes. For example, the theme development and coding process for theme 3 (Supplement 3). We have also created a more explicit link between the main themes and the sub—themes. By showing how the sub—themes support and elaborate on the main themes, we can better demonstrate the depth and complexity of our findings. The correlations between themes and sub-themes, which we described in a matrix of themes using []: is part of; = = : is associated with; = > : is cause of. With these correlations, we constructed a thematic framework (Fig. 1).
Fig. 1
Conceptual map based on experiences in directing the root cause analysis after a sentinel event []: is part of; = = : is associated with; = > : is cause of
×
Themes 1: success in a demanding field requires exceptional skills and abilities
The first theme lies in enhancing the core qualities and competencies of guides. In this sense, it covers having a broad range of knowledge, acquiring empowering skills and demonstrating a positive attitude towards engagement.
Having comprehensive knowledge
Comprehensive knowledge usually refers to the guide's in-depth understanding of the methods of conducting root cause analyses of adverse medical events, including theory, practice, skills, and relevant background knowledge. This knowledge enables a person to better analyse problems, make decisions and communicate effectively.
“To effectively mentor others, one's own competencies need to be strong first, including broad knowledge, problem solving and analytical skills, so that one can better drive the team” (G5). “The knowledge of the guide should be comprehensive; if your knowledge level is lower than that of the group members, then the opinions you give will lack value” (G11).
Empowering capabilities
Guides are effective at supporting and motivating others to help them improve their skills, increase their confidence and foster growth. This includes providing resources, feedback and opportunities for team members to reach their greater potential in their work.
“The project mentor is in a sense a manager and needs to know how to empower and give rights to the team members to enhance their initiative in checking and implementing improvement measures” (G6). “Empowering team members appropriately, so that they can feel a sense of achievement in the process, which will stimulate their interest and sustain their commitment” (G10).
Demonstrating interest and engagement
The guide actively participates in team and organisational activities, demonstrating enthusiasm for the work and team goals. This attitude not only motivates others but also enhances team cohesion.
“It is not necessary to be perfect, but one should do the best one can within one's ability and try to move in the best guidance possible” (G6). “I believe that since I have taken over a project, I should be determined to do it well and achieve project success through learning and growth in order to gain greater rewards and win the recognition of my team members” (G7).
Themes 2: building strong interpersonal relationships between guides and team leaders
This main theme emphasises establishing effective partnerships with team leaders. In this sense, it also includes selecting mature and experienced team leaders, building trust and cooperation with team leaders, and leveraging the team leader's mentoring role in the project. Together, these factors contribute to the success of the partnership and the smooth progress of the project.
Selecting mature and experienced team leaders
Mature leaders are more comfortable dealing with complex situations and conflicts. In addition, experienced team leaders usually have a higher level of emotional intelligence and expertise, and are better able to understand and support the goals and decisions of the directors.
“The team leader needs to have some communication skills, preferably as a manager of the department. That way, after communicating on behalf of the team, it will be easier for us as mentors to follow up with project coaching, and the execution will go smoother” (G9). “The team leader should have some foundation in the use of hospital quality management tools and be able to effectively assume responsibility for cross-departmental communication, especially in hospital-level improvement projects” (G5).
Building trust and cooperation with team leaders
When trust exists between the director and the team leader, the team leader is more willing to accept the director's advice and actively participate in the decision-making process. In addition, trust reduces the occurrence of misunderstandings and enables teams to be more united in finding solutions to challenges.
“As the project moves forward, the mentor usually communicates with the team leader first, who then assigns tasks to the team members. This approach helps the team as a whole to work together more smoothly” (G5). “The team leader serves as a bridge of communication, and it is especially important to build trust between the mentor and the team leader” (G7).
Exerting the guiding role of team leaders in projects
When the team leader is active in providing direction during the project, the director is more likely to feel the value of the collaboration, leading to increased trust.
“If the group leader is willing to invest time and work closely with the mentor, the improvement project is 70 per cent successful” (G1).“To effectively utilise the team leader's driving role, one needs to tap into their motivation points” (G11).
Themes 3: tailored communication strategies in nursing for effective leadership and safety enhancement
This central theme that underscores the importance of adapting communication to navigate complex organizational structures. This is reflected in three key sub-themes: the need for tailored communication to overcome hierarchical barriers, fostering collaboration through customized communication, and empowering teams by addressing individual needs.
In the findings section, we have expanded on the “is part of” “is associated with” and “is caused of” relationships. For example, the sub—theme like “Fostering collaboration through targeted communication strategies” is part of the main themes “Tailored communication strategies in nursing for effective leadership and safety enhancement”. We have also created a more explicit link between the main themes and the sub—themes (is associated with). By showing how the sub—themes “Navigating complex hierarchies through tailored communication” support and elaborate on the main themes “Tailored communication strategies for effective leadership and safety improvement”, we can better demonstrate the depth and complexity of our findings. We also have explained how the presence or absence of targeted communication strategies affects the overall RCA process. If lack of “Tailored communication strategies in nursing for effective leadership and safety enhancement” is caused of “Understanding the experience of nurse-directed RCA after the Sentinel incident”, we have illustrated this with examples from the interviews. This will help readers understand the causal relationships and how they contribute to the overall theme.
Navigating complex hierarchies through tailored communication
Tailored communication helped overcome barriers posed by organizational layers, enabling RCA guides to engage various team members at different levels effectively.
"Tailored communication allows me to speak directly to team members at all levels, breaking down the silos that often exist in large organizations" (G7). "Being a nurse first allowed me to approach team members at different organizational levels with empathy and clarity, tailoring my message to make sure everyone felt heard and engaged in the RCA process." (G8).
Fostering collaboration through targeted communication strategies
By adapting communication styles to suit different team members, RCA guides were able to build trust and create an open dialogue, which in turn facilitated smoother teamwork and cooperation in safety improvement initiatives.
"By tailoring my communication to the specific needs of each team, I can build trust and encourage open conversations, which are crucial for fostering collaboration" (G2). "When I adjust my approach to fit the communication style of each team member, it creates a more inclusive environment, leading to better teamwork and stronger cooperation in our safety initiatives" (G4).
Empowering teams through clear and adapted communication
RCA guides noted that tailored communication not only improved team coordination but also empowered individual team members. By addressing each member’s unique concerns and providing targeted guidance, RCA guides enabled teams to take a more proactive role in safety improvement efforts.
"When I communicate in a way that addresses each team member's specific concerns, it gives them the confidence to take ownership of their role in safety improvements"(G2). "By adapting my communication to the unique needs of individuals, I empower them to actively contribute and make informed decisions, which drives our collective efforts in safety enhancement" (G12).
Themes 4: investing effort and overcoming obstacles are key to successful nursing-guided project implementation
The theme demonstrates how guides can focus on key aspects of project management and implementation. On the one hand, there is a need to devote sufficient time and effort to the implementation of the project; on the other hand, there is a need to address obstacles to project progress in a timely manner. Together, these two aspects contribute to the success of a project.
Investing time and effort in project implementation
The director was able to identify and resolve potential problems in a timely manner through continuous monitoring and evaluation to ensure that the project progresses according to the intended schedule.
“Promoting a project requires a sustained investment of time and energy, and as long as the director does not slacken off, it will ultimately succeed” (G10).
In addition, investing energy can also motivate team members’ participation and responsibility, thus improving overall execution.
“RCA events often trigger resistance for people in the relevant frontline departments, who do not take the initiative to expose the problem; only the active participation of the director can invariably enhance the sense of responsibility of other people” (G6).
Addressing obstacles during project advancement
By identifying and responding to obstacles in a timely manner, directors can avoid project delays and ensure efficient use of resources. Actively responding to obstacles can provide the team with opportunities to learn and grow, enhancing the ability to meet future challenges.
“In my opinion, the hardest part of moving forward with the RCA improvement project is the root cause analysis; if enough information cannot be collected, the subsequent steps will be difficult to move forward” (G5). “Countermeasure implementation can face obstacles, particularly in cross-departmental collaboration, but smooth resolution serves as great encouragement for team members.” (G7).
Discussion
Clinical implications
This study delved into the experiences, roles, challenges, and strategies of nurses in guiding RCA. By concentrating on nurses’ guidance, we can provide in-depth insights into their unique contributions. The primary themes identified include the enhancement of core competencies, establishing effective partnerships with team leaders, tailored communication strategies, and investing effort and overcoming obstacles. Guides who possess comprehensive knowledge and empower their teams through engagement create an environment conducive to motivation and cohesion. Furthermore, effective partnerships with experienced team leaders foster trust and collaboration, ultimately enhancing project outcomes. Notably, thorough preliminary preparation and adept communication skills emerged as crucial for resolving differences and establishing consensus, which are integral to effective project management.
The implications of this study are significant for both academic and practical spheres. Academically, it contributes to the existing body of knowledge on project management by outlining specific director competencies that enhance team dynamics and project success. Practically, the findings serve as a guide for organizations seeking to improve their project management practices through director training and development programs. By emphasizing the importance of communication, trust, and preparation, organizations can foster more effective leadership and ultimately drive project success [28].
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Clinical practices
In comparing our findings with the existing literature, it is clear that the role of nurse—guides in RCA has been underestimated in the broader discourse on healthcare quality improvement [27, 28]. While many studies primarily focus on the contributions of physicians [29, 30]. Our research highlights how nurse—guided through their direct patient care experiences, can significantly influence safety protocols and quality initiatives. This perspective is crucial, as nurses often serve as the frontline guardians of patient safety and are uniquely positioned to identify systemic issues that contribute to adverse events [31].
Some researches discuss the importance of physicians in fostering a culture of safety, but they largely overlook the insights that nursing leadership can bring to the table [32]. Our study addresses this gap by emphasizing that nursing leaders possess essential knowledge about patient interactions, care processes, and operational workflows, which can enrich RCA initiatives. By actively engaging in RCA, nurse -can bridge the gap between clinical practice and organizational policy, ensuring that safety measures are both practical and effective.
Turner and Müller [33] emphasize that a guide’s engagement and comprehensive knowledge significantly influence project success, aligning with our findings on the necessity of guide competencies. Their research supports the idea that a guide's proactive involvement is crucial for steering projects effectively, particularly in complex environments. Moreover, some researchers highlight the critical role of trust in enhancing team performance and collaboration [34]. A theme that resonates with our emphasis on building effective partnerships between guides and team leaders. This alignment underscores the importance of interpersonal relationships in project management, suggesting that guides who invest in cultivating trust are more likely to achieve favorable project outcomes.
There are studies provide insights into the dynamics of team building, emphasizing that effective leadership practices guidly correlate with improved team performance [35]. Our findings support this perspective by illustrating how guides who prioritize communication and collaboration foster better team cohesion and motivation. Many existing studies focus on theoretical frameworks or specific leadership styles [36, 37]. But this research contributes practical dimensions that offer actionable insights for guides. For example, our emphasis on the necessity of thorough preparation and communication skills as vital components of effective project management extends beyond traditional leadership theories, highlighting a more hands-on approach that directors can adopt.
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Furthermore, the work of Gittell on leader-member exchange emphasizes that strong relationships between leaders and team members can enhance team dynamics and performance [38]. Our findings align with this notion, reinforcing that nurse guides must cultivate trust and rapport with their teams to drive successful RCA initiatives. By fostering an environment of mutual respect and open communication, nurse guides can empower their teams to engage more fully in safety improvement efforts.
Additionally, Venier examine the importance of teamwork and collaboration in healthcare settings, arguing that effective communication among team members is key to successful RCA implementation [39]. While their focus on multidisciplinary teams is relevant, our research specifically highlights the nuances of nursing teamwork and the unique challenges faced by nursing leaders. For example, nursing leaders often navigate complex hierarchies and may encounter barriers in communication with other departments [40]. This dynamic necessitates tailored approaches to facilitate collaboration, which our study elucidates by examining the specific competencies and communication strategies required for effective nursing leadership in RCA.
While existing studies have made significant strides in understanding leadership roles in healthcare quality improvement, there remains a substantial need to elevate the discussion surrounding nursing leadership [41]. Our findings not only underscore the importance of nursing leaders in RCA processes but also advocate for a more inclusive approach that recognizes the unique contributions of all healthcare professionals. Future research should aim to investigate these dynamics further, ensuring that nursing perspectives are integrated into safety and quality improvement frameworks. This shift is vital for creating a holistic approach to patient care that ultimately enhances safety and outcomes in healthcare settings.
Limitations
This study also has certain limitations. First, the study primarily relies on qualitative data from a specific set of case studies, which may limit the generalizability of the findings. Second, the research does not address how varying organizational contexts or cultures may influence the identified themes, which could provide a more nuanced understanding of the director's role across different environments. Third, how do different leadership styles among directors affect the effectiveness of team collaboration? Future research could explore the interplay between director characteristics and team dynamics in various organizational contexts. Fourth, due to time constraints, we were unable to determine the exact change in director experience.
Finally, longitudinal studies that track director performance over time could yield valuable information on the sustainability of the identified competencies.
Conclusion
This study highlights the critical role of nurse guides in enhancing RCA initiatives through in-depth knowledge of patient care, operational workflow, and effective communication. By actively engaging in RCA, nurse guides are able to link clinical practice to organisational policy, building trust and collaboration between teams. Our findings emphasise that good interpersonal relationships, inclusive discussions and tailored guidance approaches are essential for guiding in complex healthcare environments.
Acknowledgements
The authors gratefully acknowledge all employees who participated in this study.
Ethical guidelines
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. All methods were carried out in accordance with relevant guidelines and regulations.
Declarations
Ethics approval and consent to participate
These procedures were approved by the Ethics Committee of Taizhou First People's Hospital, Zhejiang Province [Ethical Approval No. 2024-KY034-01] before any data collection took place. Informed consent was obtained from all individual participants included in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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