Introduction
The general health and well-being of people worldwide is becoming more and more strongly correlated with mental health (MH). The World Health Organization estimates that there has been a 13% upsurge in the frequency of mental health illnesses and drug use disorders. This is further demonstrated by the realization that an increasing proportion of those with mental illnesses are obtaining care via the medical system. Of the approximately one billion individuals who are thought to be suffering from mental illness, the great majority are not believed to be receiving help nowadays. For instance, just 30% of persons with depression obtain mental health treatment, and 71% of those with psychosis globally lack access to psychological treatment [1].
It is often known that individuals who are experiencing mental illness have poorer physical health and are more likely to become physically ill [2]. Nursing students face several problems in the present complicated health care system, and sufficient clinical training is necessary to give every learner the opportunity to advance their information and competencies [3]. One of the main factors pushing the usage of simulation in undergraduate clinical courses to enhance student learning possibilities is the challenge of finding a sufficient number of high-quality clinical experiences within congested healthcare institutions.
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In nursing schools, the use of simulation sessions has increased as a result of the COVID-19 outbreak. Due to limitations on in-person encounters, simulated experiences have become a popular means of giving nursing students practical experience [4]. Simulated patients and the teacher serve as educational facilitators in simulations, which are dynamic, learner-centered instructional methods. Students can exhibit higher levels of self-motivation, produce original ideas, and solve complex clinical scenarios at an advanced level via simulations [5]. In a safe setting that closely resembles real life, simulation offers a favorable educational atmosphere that is centered on giving students the chance to experiment and investigate presumptions, improve social competence, and cultivate the mental and motor abilities necessary for subsequent years [6].
In a range of clinical scenarios, simulation has been utilized to nurture certain competences and capacities that are essential to modern nursing. Dynamic learning bundles, scenarios, mid-to-high fidelity dolls, interactive performers, programs, and role-playing are some of the delivery modalities for simulation [7]. The field of mental health nursing is one where simulation has been proven to be beneficial [8]. Nursing students must use the concepts of interpersonal therapy and a nurse-patient connection throughout their undergraduate mental health practicum, which can be difficult and anxiety-inducing [9]. In addition to helping learners acquire compassion for individuals with mental health conditions, simulations offer a secure environment in which they can engage in interpersonal relationships, collaboration with other professionals, peer review, and obtain patient input [10]. According to reports, simulation increases students’ assurance and sense of pleasure while interacting with patients [11, 12]. From the standpoint of the patient, mental health simulations enhance cultural competency, improves patient safety, and fosters more efficient and organized nurse-patient interaction [13]. Furthermore, during their time in school, nurses have indicated that they would want to be exposed to more simulation [14].
Without a question, gaining experience working with patients is a crucial component of preparing a licensed nurse. On the other hand, the demands of contemporary curriculum have prompted concerns about how to give pupils a more uniform, regulated learning environment. Utilizing actors who simulate patients with specific medical disorders in their portrayals of complaints is one strategy that resulted from this requirement. The approach has drawn interest in various disciplines of medical training since the earliest reports of the methodical use of such “standardized” or “simulated” patients (SPs) date back to the 1960s [15]. Dealing with SPs expands on a number of adult educational topics. The idea of experiential learning, which is based on a series of direct expertise, introspective thinking, conceptual thinking, and engaged experimentation, has been used by many writers to justify the didactic method [16]. The learning process can be shaped and enhanced by input from clinicians and other learners, as well as by interactions with them. Furthermore, case-based learning—which is popular in medical training and helps with the transition from theoretical understanding to clinical judgment and practice—is usually incorporated into the usage of SPs. Because of this, the approach can be used to teach increasingly difficult clinical competencies [17].
The use of SPs is very intriguing to incorporate into mental health topics because of a few factors. Research has demonstrated that the approach is effective for imparting psychopathology, interpersonal skills, and other therapeutic competencies that are critical to the field of mental health [18‐20]. From the standpoint of their career function as actors as well as their role as patients, these performers can offer input. Ideally, the type of controlled critique actors offer can improve the students’ capacity for self-reflection, an essential skill in the field of mental health. Without putting the patient or the pupils in risk, teachers can expose their students to a wide range of psychopathological disorders and even permit interaction with severe manifestations. Ultimately, using SPs in the classroom is seen as an engaging and stimulating experience that may spark students’ interest in the subject. Therefore, employing SPs in mental health education might help address the serious issues with the field’s lack of recruiting [21].
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However, evidence is still not robust enough regarding the effectiveness and significance of this learning modality from the students’ perspectives, who are the key stakeholders in the educational process. Existing studies often focus on the technical aspects of SP interactions or their effectiveness in skill acquisition, rather than the subjective experiences and perceptions of the students themselves. This gap highlights the need to explore the emotional, cognitive, and social dimensions of using SPs in mental health education, which can provide insights into how these experiences influence students’ learning and future practice. This is especially important in the middle eastern context, where there is a dearth of literature on the employment of SPs in nursing education and specifically mental health nursing. Thus, understanding how SP interactions shape students’ learning can lead to improved educational practices that foster critical thinking, empathy, and communication skills essential for practicing mental health nursing in the Lebanese context which poses challenges to discussions on various mental health topics. Therefore, the aim of this study was to explore the experience of undergraduate nursing students’ in engaging with SPs in a mental health course.
Theoretical framework
The educational technique utilized in this work for the construction of the standardized patient simulation experience was based on the experiential learning theory, which was first recognized by DA Kolb, RE Boyatzis and C Mainemelis [22] and then refined by TH Morris [23]. This approach requires critical thinking, practical engagement, contextually-specific abstract thinking, and contextually rich tangible experience on the part of the students [23]. The use of SPs creates a realistic and immersive learning environment where student nurses can actively participate in patient interactions. This aligns with the “concrete experience” stage of the DA Kolb, RE Boyatzis and C Mainemelis [22] model, allowing students to engage directly with scenarios that mirror real-life clinical situations. Moreover, experiential learning Theory emphasizes the importance of reflection on experiences. In the context of mental health education, reflecting on interactions with SPs enables students to consider their emotions, biases, and responses, which is essential for developing empathy and understanding in patient care. Thus, the theory’s focus on abstract conceptualization allows for the integration of theoretical knowledge with practical experiences. This is crucial in mental health education, where understanding psychological concepts is as important as the application of skills in practice.
Three realistic scenarios, such as individuals displaying depression, mania, and schizophrenia, were employed. These are scenarios that the students would regularly encounter in the mental health clinical environment. The students fully engaged in a simulation activity during a single in-person learning day. In the training session, actors playing mentally ill patients performed as real patients. The objective was to simulate an entire hospital shift while giving learners the chance to experiment with therapeutic interaction, communication, and mental health assessment techniques [24]. Gibbs’ Reflective Cycle served as the framework for the organized discussion that took place after each simulation activity [25].
Methods
Research design
The investigators used a descriptive qualitative design for the current investigation. It serves as a means of explaining encounters in simple language [26]. According to M Sandelowski [26], a qualitative descriptive approach aims to accurately describe events and the manner in which participants interpret those events. Presenting information that clarifies the where, what, and who of the events or occurrences under investigation is the aim. As a result, it is clear that this method applies to inquiries that aim to accurately represent phenomenon without providing a more thorough explanation or justification [27]. The current study aimed to explore the standardized patient simulation experiences that nursing students had during the mental health course. Because of the qualitative research framework’s flexibility, the study was guided by the notions of Husserlian descriptive phenomenology [28]. Constructivism therefore offers the research’s epistemic framework, which takes into account a number of realities and explores participants’ viewpoints through their social interactions with their environment [29]. This article was produced in accordance with the Consolidated Criteria For Reporting Qualitative Research (COREQ) guidelines.
Setting and sample
The study was conducted at a large private higher education institution in Lebanon that is connected to many university hospitals in the country and provides an internationally recognized three-year bachelor’s degree in nursing. All the students registered in the psychiatry and mental health course were required to attended the simulation session prior to the commencement of clinical practice. However, the students were informed beforehand that participation the study was completely voluntary. A purposive sampling design was adopted to recruit nursing students for in-depth qualitative interviews. Recruitment continued until data saturation was reached at 19 students. For the students to be eligible to participate, they had to be senior students, actively registered in the bachelor nursing program at the approached higher education institution, completed their required clinical hours, were not enrolled in another program as a double major, did not graduate from any other undergraduate or post-graduate major, did not receive a technical degree in nursing, and were not enrolled in the nursing bridging program (technical to bachelor acceleration). Maximum variation sampling was performed in an effort to try to capture the variety of viewpoints held by students. This allowed for a deeper understanding of the subject under investigation. This meant including students from various ages and gender identities.
Recruitment and data collection
The study team sent the invitation to the students individually via their emails. A high response rate was guaranteed by the invitation letter’s concise and straightforward language, which included a description of the study’s purpose and importance as well as any potential benefits and relevance. After responding to the invitation, the students were recruited in person by a post-graduate student at the approached university. This enabled the mediation of any power imbalance between the study team and the students, which has the potential of affecting the students’ decision to provide their consent. Furthermore, the recruiter clarified the expected time commitment from participants as well as the confidentiality and anonymity of the interview process. This reduced ambiguity and barriers to participation. Finally, the recruiter notified those students who had not responded and provided their contact information so they may ask any questions. Students who expressed interest in participation filled out a written informed consent form, and a convenient, private one-on-one interview was set up. The period of data collection extended from April 2024 to June 2024.
Standardized patient simulation scenarios
The scenarios utilized during the standardized patient simulations were developed collaboratively by faculty members and clinical instructors at the psychiatric unit of the affiliated hospital. Each scenario was crafted to encompass various mental health conditions, requiring students to engage in therapeutic communication, conduct mental state examinations, and apply their theoretical knowledge in practice. Scenarios included interactions with patients exhibiting symptoms of depression, mania, and schizophrenia,. The SPs were trained individuals who portrayed patients with specific mental health conditions. They were provided with detailed scripts that outlined their backgrounds, symptoms, and the context of the interactions, ensuring consistency and realism in the simulations. This training enabled SPs to deliver authentic responses to students’ questions and interventions, thereby enhancing the learning experience. By engaging in these scenarios, students were able to practice critical skills in a supportive and controlled environment, facilitating experiential learning. Following the standardized patient simulations, the semi-structured interviews were conducted to gather students’ reflections on their experiences.
Interviews
Considering that the principle researcher held a faculty position at the approached university, she refrained from conducting the interviews. Instead, a research assistant who is a Ph.D. student, with extensive training on qualitative inquiry engaged in in-depth interviews with the students. This further mediated any potential power imbalances that might affect the responses of the students. The interviews were conducted in each student’s naturalistic setting in accordance with their individual schedules in order to ensure the comfort of the respondents. The interviewer used reflexivity and dressed appropriately while showing respect for the students’ culture and without coming across as threatening. Throughout the conversation, the interviewer deliberately bracketed any preconceived ideas and recorded them in the field notes. The duration of each interview was between 45 and 60 min, during which the interviewer had one-on-one conversations with the students to make sure they were comfortable expressing their thoughts and experiences completely. After breaking the ice, the interviewer restated the basic objective of the discussion. They assured the responders that the conversations would remain confidential and anonymous and validated the permission for the sessions to be audio recorded. During the interviews, field notes were taken in order to record any nonverbal cues and situational information that would be important for the inquiry. The choice was made to use the interview guide created by RA Krueger and MA Casey [30], which included questions for introduction, transition, and major points. At the end of the interview, the students were given closing questions and, if needed, additional inquiries. Every student was given the same set of questions in order to maintain uniformity of data (Table 1).
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Table 1
Interview questions
Introduction Question | What are your thoughts on having a career in mental health nursing? |
|---|---|
Transition Question | How do you describe your experiences caring for mentally ill patients at the clinical site? |
Key Questions | What do you think about the use of simulation in the nursing program? |
What do you think about the use of simulation in the mental health nursing course? | |
How was your experience with the standardized patient simulation in the mental health nursing course? | |
Final prompt | Do you have anything further to say ? |
Probing Questions | Could you give us a better description? |
Could you provide us with a better description? |
Data analysis
After hearing the audio recordings many times, the interviewer meticulously transcribed the conversations. The respondents’ names were securely concealed through the use of pseudonyms; thus, both explicit and implicit identifiers were removed from the transcripts. Owing to the Arabic language utilized in the interviews, the written transcripts were translated into both Arabic and English by two sworn translators. After that, the transcripts were sent to another expert so they could evaluate how accurate the translation was. After then, the transcript analysis was passed to the study team. NVivo was used to organize the data and generate initial codes. The technique employed was the seven stages of inductive theme analysis: reading through the transcripts, labeling significant words, generating interpretations, organizing and thematically grouping, providing comprehensive explanations, and verifying the outcomes with the involved students. Analyst triangulation was employed to contest the team members’ assumptions and bolster the data-driven findings. Important themes were identified through in-depth data analysis, where each team member coded independently. After that, the three came together, discussed the findings, and resolved any disagreements. The transcripts were reviewed several times to ensure the investigators grasped the students’ perspectives. Each quotation was then followed by an illustrative phrase that emphasized the actual value of the information offered. After classifying, rearranging, and combining these concepts into qualitative themes, the researchers examined the themes to see how accurately they captured the phenomena they were studying.
Trustworthiness and credibility
The five-step trustworthiness criteria—credibility, dependability, confirmability, transferability, and authenticity—established by EG Guba and YS Lincoln [31]were employed in order to ensure the rigor of the findings. The conclusions have more credibility now that member-checking has been used. We were able to determine whether or not the created themes and explanations still correctly represented the opinions of the participants by providing them to the students. The reliability of the data analysis process was enhanced by the participation of several coders. This contested the assumptions made by the researchers and verified that the results were substantiated by the words of the respondents. Establishing an audit trail from the raw data and field notes—which included observations, impressions, remarks, procedural notes, and the underlying assumptions of analytical inferences—increased dependability and confirmability. Improved transferability was achieved by outlining the characteristics of the sample and giving comprehensive explanations of the participant perspectives. Apart from the comprehensive explanations, the inclusion of quotes from participants in the results aids in a true and impartial portrayal of the variety of personal perspectives. The idea of authenticity highlights the need of providing participants with a voice, encouraging distinct perspectives, and motivating action through the dissemination of study findings. The value of utilizing standardized patient simulation in nursing education is brought to light by the study’s findings. This is supposed to spark conversation and lead to subsequent actions that will promote additional study in this field.
Ethical considerations
The approached university provided clearance to conduct the study and approval from Beirut Arab University Institutional Review Board (IRB number: ECO-R-301). All participants provided written consent after being informed that taking part in the research is completely optional and that declining to participate would not have any negative consequences. On several occasions, the students were also assured that their participation would remain private and that nobody’s personal data would be utilized in any publications intended for public consumption. To protect their privacy, each responder was given a pseudonym, and the recorded answers have been made anonymous and encrypted. The password-protected folder holding the transcriptions and recordings was only accessible by the study team.
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Results
Characteristics of the respondents
The sample of the study was made up of 19 senior nursing students in total, where 12 (63%) where identified as females, and 7 (37%) identified as males. The average age of the participants was 21.34 ± 1.7 years.
Qualitative findings
Practicing therapeutic communication and mental state examination
In the context of interviews, students articulated their belief in the essential role that SPs played in their learning process. They emphasized how interacting with SPs provided a crucial platform for honing their skills in therapeutic communication. They recounted moments of active listening, empathetic responses, and keen observation during these simulated encounters. Through these interactions, students discovered the importance of creating a nurturing environment where patients felt heard and understood. For instance, one of the students said, “…I used to think communication was just words, but the session showed me it’s also about the unspoken cues—the way someone holds themselves, their tone. It’s a whole language on its own…” (S13). Another student also shared a similar experience, “…SPs taught me that communication is not just a skill; it’s an art. It’s about building a connection, understanding emotions, and creating a space where someone feels truly heard…” (S2). Moreover, students shared how the structured scenarios with SPs allowed them to practice conducting mental state examinations effectively. They described navigating through assessments of thought processes, mood variations, and perceptual cues, gaining confidence in evaluating a patient’s mental well-being. For example one student said, “…those scenarios were like puzzles…trying to piece together someone’s mood and thoughts…it was challenging, but each time I got a bit better at understanding the whole picture…” (S7). Another anecdote was, “…I learned that assessing someone’s mental well-being requires sensitivity and empathy. It’s about looking beyond the obvious and delving into the nuances of their emotions and thoughts… it’s about understanding their inner world, which isn’t always visible on the surface…” (S18).
Readiness for clinical placement
The students’ accounts revealed how students felt a sense of empowerment and preparedness after engaging with SPs. They described feeling more equipped to navigate the complexities of psychiatric care, having honed their ability to listen actively, respond empathetically, and assess mental states with sensitivity and insight. For instance, one of the students said, “…I used to be anxious about interacting with real psychiatric patients, but after practicing, I feel more at ease…It’s like they helped me find my footing before the actual clinical training…” (S1). Another student also shared, “…Those interactions with SPs were eye-opening. They made me realize that effective communication and empathy are key in psychiatric care, and now I feel more prepared to face these challenges in the clinicals…” (S14).
Realistic and safe environment to practice
Within this theme, students articulated how the SP sessions mirror real-world healthcare settings, offering a high-fidelity experience that closely resembles the challenges and dynamics they will encounter in clinical practice. The authenticity of these scenarios allowed students to apply their theoretical knowledge in a practical context, honing their clinical skills and decision-making abilities in a controlled yet realistic setting. For instance, one of the participants reflected, “…I appreciate how it mimics real-life scenarios. It’s like a dress rehearsal for the clinical environment, giving me a chance to apply my knowledge and skills in a setting that feels authentic and immersive…” (S5). Another student had a similar opinion, “…their ability to embody different roles and scenarios authentically enhances my learning experience…their responses and emotions make the scenarios feel genuine, allowing me to practice communication and clinical skills in a way that closely mirrors what I’ll encounter in real healthcare settings…” (S11). Moreover, students emphasize the importance of the safe learning environment provided by simulations. This safety net allows them to make mistakes, receive feedback, and refine their approaches without the risks associated with actual patient care. It fosters a culture of continuous improvement and self-reflection, enabling students to build confidence and competence as they progress through their training. For example, one of the shared experiences was, “…provides a safe learning space where I can experiment, get feedback, and improve without the fear of making errors that could harm patients… valuable opportunity to refine my skills and be supported through it…” (S19). Another student also said, “…these simulations gives me the freedom to explore different approaches and learn from each interaction without the pressure of real-life consequences…” (S4).
Obtaining real-time feedback
The participating students further expressed the value of receiving real-time feedback during their interactions with standardized patients. This feedback serves as a crucial tool for self-assessment, enabling students to gauge their performance, identify areas for growth, and make adjustments in real-time. One of the shared perspectives was, “…I appreciate the immediate feedback from the actor patients and instructors. It gives me insights into my performance, empowering me to enhance my performance in real-time and become a more effective healthcare provider…” (S16). Another student also said, “…It enables me to reflect on my actions, make corrections on the spot, and continuously refine my abilities to deliver quality healthcare…” (S8). The students focused on the importance of immediate feedback in helping them understand the impact of their communication, clinical reasoning, and decision-making in a simulated clinical setting. For example, one student said, “…Their comments on my communication style, clinical decisions, and reasoning really make me see where I’m doing well and where I can improve. It’s like a personalized roadmap…” (S3). Another student also said, “…The critiques and advice I receive during our simulated clinical scenarios push me to think deeper about how I approach patient care…” (S1).
Enhancing confidence and reducing anxiety
The final emergent theme focused on the perceived influence the using standardized patients simulations has on the emotional and psychological well-being of nursing students. During the interviews the students described a new found sense of confidence in their skills and in themselves as healthcare providers. They indicated that they developed a deeper understanding of patient care dynamics. This hands-on experience allowed students to bridge the gap between theory and practice, transforming abstract concepts into tangible actions and decisions within a controlled and supportive environment, which made them more assured about the interventions they are rendering. For instance, one of the students said, “…I got to practice what we learned in class and it made more sense like this…I felt like I am capable of actually making a difference in the patients’ life…I feel much more confident about my role and my competency …” (S15). Another student also said, “…psychologically I feel at ease…I feel like I can and I will…” (S11). The students also reflected on how the SP sessions relieved their anxieties regarding dealing with complicated patient cases. They felt that they are more resilient and able to adapt with the dynamic and unpredictable landscape of mental healthcare delivery. For instance, one of the students said, “…It has provided a low-pressure setting to practice and receive feedback, which has alleviated my anxiety about clinical scenarios. I now feel more prepared and confident…” (S18). Another student also said, “…these interactions have helped me overcome my fears and uncertainties about dealing with patients…” (S4).
Discussion
Simulation has been acknowledged for a long time as a very useful method for improving the professional abilities needed in patient care [32]. It is becoming increasingly clear that simulation may help people acquire a variety of general and transferrable competencies, or non-technical abilities. One of these essential abilities is therapeutic interaction, which is acknowledged as a fundamental ability for medical practitioners [33]. Developing therapeutic interpersonal abilities in addition to the clinical competence in mental state evaluation (MSE) was the main goal of the simulated session. According to the results of our study, the simulation provided a useful chance to practice communication skills such as attentive listening, compassion, and building connections [34]. Parallel with our research, E Kavuran, N Türkoğlu, H Al-Nuqaidan and M Fawaz [35] observed an increase in students’ perception of patient-centered care. These abilities are crucial for fostering pleasant patient-provider interactions, developing trust, and encouraging patient-centered care. Health care workers should be able to use and refine these abilities in a safe and encouraging setting through simulation-based education without having to worry about endangering patients. The respondents recognized this safe space, and it has been noted in previous research as being crucial to guaranteeing the simulation’s effectiveness and beneficial effects as well as its ability to be used in real-world settings [36]. The current project put into practice a simulation with a realistic foundation. Our technique was developed in response to mounting data that shows learning both practical and interpersonal skills is more effectively achieved in simulations that are more genuine, especially when using standardized patient simulations [37, 38]. The students expressed a rise in confidence subsequent to their pre-placement chance to participate in simulations. These advantages included a reduction in the prevalent unfavorable preconceptions frequently connected to mental health as well as a decrease in anxiety and comfort prior to executing their training in the mental health environment [39]. The individuals also reported feeling more capable and competent. Before being exposed to the actual world of a clinical assignment, the students recognized the importance of having the chance to unravel prejudices and concerns via reflection and debriefing in a safe learning setting following the simulation. Similar results have been recently documented [40, 41], where simulation was claimed to have helped reduce mental health training anxiety. Students had the chance to fully immerse themselves in the task, contemplate, and grow as the day went on, thanks to the interactive nature of the exercise, which needed them to dedicate a full day to navigating through a series of situations and reviews in a rapid order. For now, this comprehensive full-day experience is only available as part of the mental health aspect of this bachelor curriculum. As educators, we have empirically witnessed a natural course of student growth that has given them the chance to securely collaborate with mental health clients later on during their clinical placement. In other bachelor level nursing simulation scenarios where nurses provide emergent care, there is a great deal of opportunity to incorporate elements of mental health nursing practice at the intersection of holistic care. Our findings showed that all students, not just those who expressed an interest in pursuing a career in mental health nursing, seemed to benefit from the realistic standardized patient simulation when it came to caring for patients with mental health problems. There is a persistent dearth of published studies on standardized patient simulation’s demonstrated efficacy as means of instruction and learning and its influence on practice, especially in the long-run, despite the numerous possible didactic and clinical advantages of simulation that students have described both before and after the simulation. In order to determine if students have applied their newly acquired knowledge in the real world, including higher order level of thinking, the simulation experience may additionally involve follow-up sessions after placement in the workplace. This makes such studies imperative.
Limitations
Considering that our study is qualitative in nature, we are not interested in generalizing the findings but rather in their transferability. One limitation of our study, is that it has been conducted in one private university in Lebanon. This compromises the transferability of the results to the wider population of nursing students, especially from different cultures. More studies should be conducted in order to build a more robust body of evidence. However, one strength in our sampling design was the use of maximum variation sampling which helped us attain an internally heterogenous and externally homogenous sample, thus enabling the portrayal of nuanced perspectives by the students. Yet, another limitation was the short period of the simulation experience. application of standardized patient simulation extended for only one day, which may have limited the full experience of the students and hindered exploring the phenomenon more in-depth. A future study is recommended piloting a full-blown SP program in mental health nursing in order to get a deeper understanding.
Conclusion
The results of this study corroborate the available data showing that nursing students who participate in mental health standardized patient simulation as part of their bachelor nursing education experience favorable outcomes. There have been prior reports indicating that learners benefit from this simulation’s interactive nature. But there haven’t been many reports of this design that are exclusive to mental health education. The ability to further enhance the efficacy of the simulation experience is made possible by the growing emphasis on immersion in simulation with standardized patients.
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Acknowledgements
All authors of this study extend their appreciation to the Researchers Supporting Project Number (RSPD2024R880), King Saud University, Riyadh, Saudi Arabia.
Declarations
Ethical approval and consent to participate
All participants provided written consent after receiving thorough details about the study. The work described has been carried out in accordance with The C ode of Ethics of the World Medical Association (Declaration of Helsinki) for experiments involving humans. Beirut Arab University Institutional Review Board approval was acquired (IRB number: ECO-R-301).
Consent for publication
Not applicable.
Conflict of interest
The authors declare that they have no competing interests.
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