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Positive Effect of Narcissism on Employees’ Whistleblowing: The Role of Felt Accountability and Ethical Environment

Authors Zhan X, Jie Y

Received 14 September 2023

Accepted for publication 15 December 2023

Published 23 December 2023 Volume 2023:16 Pages 5225—5235

DOI https://doi.org/10.2147/PRBM.S440348

Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Dr Gabriela Topa



Xuemei Zhan,1 Yuan Jie2

1School of Business Administration, Jimei University, Xiamen, 361021, People’s Republic of China; 2Department of Public Administration, Party School of C.P.C Jiangsu Committee, Nanjing, 210009, People’s Republic of China

Correspondence: Yuan Jie, Email [email protected]

Purpose: This study aims to develop a model to explore the effect of narcissism on whistleblowing through felt accountability and to examine the moderating role of organization’s ethical environment on this relationship.
Methods: The study was a two-wave study involving MBA students. Two surveys were distributed to individuals who work full time at two different times (roughly two weeks apart). A total of 261 individuals completed both questionnaires. Hierarchical linear regression analyses were conducted using SPSS 22.0 to test the hypotheses.
Results: The results supported the prediction that felt accountability mediates the positive relationship between narcissism and whistleblowing. The findings also showed that the indirect effect of narcissism on whistleblowing through felt accountability was stronger when individuals perceived organizational environment to be unethical.
Conclusion: The study contributes to our understanding of the bright side of narcissism by combining it with research on whistleblowing and explicates how and when narcissistic individuals engage in whistleblowing.

Keywords: narcissism, whistleblowing, felt accountability, ethical environment

Introduction

Cases of organizational scandals, as observed from the US companies Enron and WorldCom to Chinese enterprises, such as Kangmei and Luckin Coffee, have struck the business community in recent years. Fraud, corruption, and other unethical acts threaten an organization’s reputation, financial performance, and sustainability.1,2 However, they are often observed by one or a small number of individuals and may avoid existing institutional controls.3,4 Thus, the whistleblower may provide valuable information to help minimize wrong doing and improve organizational effectiveness.4–8

Unfortunately, not all observed wrongdoing has been reported.4 Observers who expect that they will suffer retaliation from the management are less likely to act.6 Research has explored the antecedents of whistleblowing. These studies have focused on both external factors like ethical culture and climate and internal factors like gender, age, and value orientation, as drivers to whistleblowing.9,10 However, the effect of personality as a precursor to whistleblowing has not been fully discussed.11 Here, we focus on the role of narcissism in reporting wrongdoing, showing that whistleblowers’ motives may result from “narcissism moralized” and self-enhancement. Narcissism is an individual difference characterized by (over)confidence, extroversion, dominance, high self-esteem, attention seeking, but also unwillingness to take criticism, grandiosity and aggressiveness.12–14 Previous research has suggested that narcissism is correlated with deceit12–15 and counterproductive work behaviors.16,17 Despite the dark side of narcissism, research has also found the bright side of narcissism. For example, narcissistic individuals perform more change-oriented organizational citizenship behavior,18 display dominance and assertiveness,19 and they generally have good performance under pressure.20 Narcissists adopt bold and risky approach to take on challenging tasks so that they can get social admiration. Because whistleblowing is characterized as a proactive behavior that requires initiative, assertiveness, and taking charge,6,21 we expect that narcissistic persons are more likely to blow the whistle. To date, however, researchers pay little attention to narcissism in this context.

We use trait activation theory to explain how and when narcissism leads to whistleblowing. According to trait activation theory22(Tett and Guterman, 2000), the effect of personality traits on behavior depends on the correlation between situation and trait. When a situation activates a personality trait, that trait links to behavior more strongly. Whistleblowing is considered as a situation that provides narcissistic employees an opportunity to reinforce their self-perceived role as a moral crusader or organizational savior by taking responsibility.

The relationship between narcissism and whistleblowing has not yet been strongly established. We contribute to the theoretical and empirical literature in two ways. First, the literature lacks the mechanism through which narcissism is related to whistleblowing. We provide a theoretical framework by hypothesizing that the link between narcissism and whistleblowing is mediated by feelings of accountability. Felt accountability refers to the extent to which employees feel they need to explain their actions to a salient audience. Narcissists seek to maintain moral self and avoid criticism from others, which heightens their feelings of accountability and tendency to blow the whistle. This part of our model allows us to explore the mechanism that narcissism motivates whistleblowing. Thus, we extend the current thinking on whistleblowing by examining the mediating effect of felt accountability on the relationship between narcissism and whistleblowing.

Second, the study examines the role of ethical environment on the relationship between narcissism and whistleblowing mediated by felt accountability. According to social information processing theory,15 how individuals perceive their environment determines appropriate and acceptable behavior, especially in uncertainty situations.23 In organizational settings, ethical environment impacts employees’ decisions regarding whistleblowing. Employees who work in an organization with an ethical code of conduct are more likely to blow the whistle.23–26 The possibility that ethical environment is likely to influence the relationship between felt accountability and whistleblowing may also explain why previous studies have shown inconsistent relationships between felt accountability and extra-role behaviors.27–30

The theoretical model is shown in Figure 1. We examine the model using data obtained from MBA students in the study. We finally discuss the implications of the findings from the theory and research aspects.

Figure 1 Proposed theoretical model.

Theoretical Background and Hypotheses

Whistleblowing in an Organizational Context

From the perspective of the organization, whistleblowing is a proactive, prosocial, and organizational citizenship behavior because employees act on the basis of a sense of morality and take steps to end misconduct, often regardless of a fear of retaliation. Because of the economic and human costs resulting from organizational misconduct, such as bribe-taking, nepotism, and fraud, companies depend on responsible employees when most others are reactive.21 Accordingly, whistleblowing perhaps is “more important than ever before”.31 Whistleblowers display self-starting, forward-looking, and active initiatives to bring about changes in matters that may not be known to the company. In the long run, whistleblowing may influence organizational performance, as it warns of potential traps, prevents the loss of public standing and reputation, and avoids serious financial problems.21 Near & Miceli7 distinguished between internal whistleblowing and external whistleblowing. We pay attention to internal whistleblowing.

Narcissism and Whistleblowing

Although whistleblowing may have potential positive consequences for organizations, many organization members, at least those whose roles do not require them to act, seem to remain passive when confronted with organizational malpractice.21 Narcissism is one of the reasons some employees are more likely than others to engage in whistleblowing. We rely on trait activation theory (TAT) to explain why narcissism is associated with whistleblowing and the mechanisms underlying this relationship. The core idea of TAT is that certain situational cues or job demands can activate or trigger the expression of a person’s traits. In other words, traits are not always consistently displayed but are instead brought to the fore by specific environmental stimuli. When a trait is activated by the relevant situational cues, it leads to trait-expressive behavior. For example, a person with a high level of extraversion is more likely to exhibit talkative and sociable behavior in a social gathering than when they are alone. According to this theory lens, we hypothesize that more narcissists who have grandiose self-image and search for social praise engage in more whistleblowing as a means to enhance their moral feelings of superiority and to gain praise.

Employees often need courage to blow the whistle. Alford11 described the whistleblower's motives as “narcissism moralized”, which requires one’s ideals to be moral. Whistleblowers fear association with a corrupted self rather than isolation from others. As such, narcissism may be the strongest predictor of unselfish behavior like whistleblowing, because narcissistic individuals often seek to reinforce their positive self-image.32 Whistleblowing is a challenging form of extra-role behavior that attempts to prevent or prohibit organizational wrongdoing.33 Narcissism may be a prerequisite to effect change, as whistleblowing appears to promote social goods and take a moral high ground.32

Additionally, narcissists take more risks in their actions. Whistleblowing involves risk. Employees who are risk averse find it difficult to overcome the fear of retaliation and therefore remain silent when they witness wrongdoing. However, for narcissistic individuals, inflated self-view drives them to take risky behaviors and do not worry too much about retaliation. Howard et al14 found a positive relationship between narcissism and prosocial behaviors characterized by personal risks. Finally, grandiose narcissists are commonly described as “disagreeable extraverts” in terms of broader trait models.34 In other words, grandiose narcissism relates positively to extraversion and negatively to agreeableness. Previous studies have shown that high extraversion, dominance, and low agreeableness predict whistleblowing.21,35 Given the proactive aspect of narcissism, we expect a positive relationship between narcissism and whistleblowing.

Hypothesis 1 Narcissism is positively related to whistleblowing.

Mediating Role of Felt Accountability

Although the link between personality and whistleblowing has been raised, few studies have empirically investigated the mechanism underlying this relationship. We propose that the relationship between narcissism and whistleblowing is mediated by felt accountability.

Felt accountability is a subjective concept described as the

perceived expectation that one’s decisions or actions will be evaluated by a salient audience and that rewards or sanctions are believed to be contingent on this expected evaluation.36

Employees who experience higher feelings of accountability believe that their action will be closely watched and scrutinized by a salient audience.27,37,38 Researchers have suggested that there exist individual differences in how felt accountability influences cognitions and behaviors in the workplace.37,39 We argue that several elements of narcissism potentially trigger feelings of accountability when organizational wrongdoing is discovered.

First, narcissists have inflated self-views and are overconfident in their capabilities. They consider themselves as having more knowledge and experience than other.40 They like to be dominant at work and crave the deference and even adoration of others.41 Thus, narcissistic employees may bear the responsibility for reporting wrongdoing and become the saviors of the organization.

Second, narcissists search for praise and avoid criticism.32 The essence of felt accountability is an expected evaluation. The actors believe that they will be required to give a salient audience explanation.27 Prior research has shown that narcissistic CEOs are more likely to forgo irresponsible behaviors which can easily lead to criticism from stakeholders and therefore engage in more corporate social responsibility.32 Narcissistic individuals prefer to stand out from the crowd and get attention and recognition. Thus, we expect that narcissism is correlated with felt accountability.

Although whistleblowing is not part of employees’ formal job descriptions, it contributes to effective organizational operations.42 Whether wrongdoing observers consider themselves responsible for taking action has been suggested as the motivation of proactive behaviors such as whistleblowing.43 Employees who know that they will be held accountable expect that their behavior may be reviewed and that they need to provide explanations. Employees who are not accountable for their actions and outcomes are unsure of how and when the organization will ask them to justify their actions.37 The resulting ambiguity and insecurity may lead to silence about wrongdoing.

In summary, we assume that narcissism activates felt accountability, which leads to subsequent whistleblowing.

Hypothesis 2 Felt accountability mediates the effect of narcissism on whistleblowing.

Moderating Role of Ethical Environment

However, prior research on the relationships between felt accountability and extra-role behaviors is inconsistent. Mitchell et al44 suggested that accountability would impair creativity and commitment. Some researchers found that accountability positively impacts organizational citizenship behaviors.42,45 Hall & Ferris36 suggested that there is a nonlinear relationship between felt accountability and contextual performance. These contradictory arguments imply that variables that moderate the relationships between felt accountability and extra-role behaviors may exist. We propose that the ethical environment will moderate the relationship between narcissism and whistleblowing mediated by felt accountability.

According to social information theory, employees often look to the social environment for information about ethical guidance when they are uncertain about whether to report unethical behavior.23 Ethical environment depicts the extent to which employees feel that organizations encourage ethical conduct and the extent to which leaders and coworkers are role models of ethical behavior. Existing research has supported the influence of ethical environment on employees’ behaviors, including whistleblowing. For example, Greenberger et al46 proposed a model to elaborate the relationship between social influence and whistle-blowing. Dalton & Radtke47 found that a highly ethical environment weakens the negative effect of Machiavellianism on whistle-blowing intentions. Mayer et al23 suggested that ethical leadership predicts employees’ internal whistleblowing more strongly when coworkers’ ethical behavior is perceived to be high. O’Keefe et al48 suggested that coworker ethicality strengthens the effect of ethical leadership on ethical intentions and organizational citizenship behavior.

Based on the above evidence, we hypothesize that when an organizational environment is highly ethical, the positive effect of narcissism on whistleblowing mediated by felt accountability might be less salient. A highly ethical situation implies a strong environment to encourage reporting wrongdoings and prohibit unethical behaviors. According to the buffering hypothesis, in strong environments, the effects of individual differences on behaviors are minimal.49 Thus, the interaction of felt accountability driven by narcissism and a highly ethical environment on whistleblowing is minimal. However, due to no such buffering effect in weak ethical environments,49 the relationship between narcissism and whistleblowing via felt accountability might be stronger. That is, when an organizational environment is unethical, narcissists who consider themselves as having more ability and responsibility to control the environment32 are more likely to blow the whistle.

Hypothesis 3: The strength of the mediated relationship between narcissism and whistleblowing via felt accountability varies depending on the level of ethical environment, such that the effect of narcissism on whistleblowing via felt accountability is stronger when employees perceive organizational environment to be unethical.

Methods

Participants and Procedures

To determine the appropriate sample size for our study, we employed a combination of statistical power analysis and practical considerations. Our primary objective was to ensure that the study had sufficient power to detect a meaningful effect. To achieve this, we considered the following criteria:

Effect Size Estimation: Based on a review of prior studies on whistleblowing, we estimated an effect size that we considered to be both practically significant and theoretically justifiable. This effect size was used as a benchmark for our power calculations.

Power Analysis: We conducted a power analysis using G*Power software, aiming for a power of 0.80, which is commonly accepted as a standard for social science research. This means that our study is designed to have an 80% probability of detecting an effect, if there is one, given the estimated effect size.

Significance Level: We set our alpha level at 0.05, meaning we accept a 5% chance of committing a Type I error, which is a standard threshold in social sciences.

Based on these criteria, 366 MBA students were given two surveys to fill in at two different times (roughly two weeks apart). Individuals currently work full time. Independent variables and moderators (ie, demographics, narcissism and ethical environment) were collected at Time 1, whereas the mediator and dependent variables (ie, felt accountability and whistleblowing) were collected at Time 2. The respondents provided their telephone numbers on the first page of each survey for matching purposes.

A total of 366 surveys were distributed to MBA students. Two hundred and sixty-one individuals completed both questionnaires (overall response rate of 71.3%). One hundred and five individuals failed to complete the survey or provided incomplete information (ie, main part was missing). The average work experience of respondents was 6.67 years (SD = 4.41), and the sample consisted of 129 females (49.4%).

Measures

Narcissism

We used the narcissism subscale adapted from “short dark triad” to measure narcissism.50 It included 5 items (α = 0.62). The scale used a 5-point response format with “1” (strongly disagree) to “5” (strongly agree) to assess respondents’ level of agreement with the sentences.

Felt Accountability

We used eight items (α = 0.70) to measure employees’ level of felt accountability.51 The scale used a 7-point response format with “1” (strongly disagree) to “7” (strongly agree) to assess respondents’ level of agreement with the sentences.

Ethical Environment

We used 14 items (α = 0.85) to measure ethical environment.52 The scale used a 7-point response format with “1” (strongly disagree) to “7” (strongly agree).

Whistleblowing

We used two items (α = 0.73) to measure respondents’ willingness to blow the whistle.53 The scale used a 7-point response format with “1” (strongly disagree) to “7” (strongly agree).

Control Variables

Sociodemographic variables were controlled for in the regression analyses, including age, gender, work experience, and enterprise type.

Results

To investigate the effect of narcissism on whistleblowing through felt accountability and the moderating role of ethical environment on this relationship, 261 questionnaires were collected. Using G*power, the sample size corresponded to a sample power of 0.99, above the specified minimum power of 0.8 according to Kyriazos.54

Construct Validity

To test the construct validity of the variables, we conducted confirmatory factor analyses (CFA) using Mplus 8.8. The one-factor model indicated a poor fit to the data (χ2 [377] = 2303.14, P < 0.01, CFI = 0.63, IFI = 0.64, NNFI = 0.61, RMSEA = 0.14). The four-factor model showed a better fit to the data (χ2 [371] = 1479.31, P < 0.01, CFI = 0.79, IFI = 0.79, NNFI = 0.77, RMSEA = 0.11).

Hypothesis Testing

Hierarchical linear regression analyses were conducted using SPSS 22.0 to test the effects of narcissism through felt accountability on whistleblowing intention.

The means, standard deviations, and correlations among the study variables are presented in Table 1. The results indicated that older employees were more likely to engage in whistleblowing than younger employees (r = 0.15, P < 0.05), and employees in non-state-owned firms were more likely to engage in whistleblowing (r = −0.15, P < 0.05) than those in state-owned firms. Both narcissism and felt accountability had significant positive correlations with whistleblowing, thus providing preliminary evidence that both factors predict employees’ whistleblowing.

Table 1 The Means, Standard Deviation, and Correlations Among Study Variables

To examine these hypotheses, we performed hierarchical regression analyses. First, we mean centered narcissism, felt accountability and ethical environment. For Hypothesis 1, after entering the control variables (age, gender, work experience, and enterprise type), we entered the main effect variables for narcissism in the initial step and the mediation term in the second step of the linear regression (Models 2a and 2b, respectively). Table 2 presents the results. Consistent with Hypothesis 1, the relationship between narcissism and whistleblowing was positive (B = 0.44, SD = 0.17, P < 0.05).

Table 2 Results of Hierarchical Linear Regression Analyses Predicting Whistleblowing

Hypothesis 2 proposed that felt accountability would mediate the effect of narcissism on whistleblowing. First, we examined whether narcissism had an effect on felt accountability. We entered the control variables and narcissism into the linear regression for felt accountability (Model 1). The results showed that narcissism had a significant positive effect on perceived accountability (B = 0.44, SD = 0.08, P < 0.01). Subsequently, we examined whether felt accountability had a direct effect on whistleblowing. As predicted, felt accountability positively affected whistleblowing (Model 2b: B = 0.44, SD = 0.13, P < 0.01). Meanwhile, after entering felt accountability, narcissism had no significant effect on whistleblowing (Model 2b). This result suggested that felt accountability fully mediated the relationship between narcissism and whistleblowing. To further examine the significance of the mediation effect, we used the 95% bias-corrected bootstrap confidence interval (CI) estimates with 5, 000 samples. The results indicated that the indirect effect of narcissism on whistleblowing via felt accountability was significant because the 95% CI did not include zero (indirect effect = 0.19, SE = 0.07, 95% CI = [0.06, 0.34]). Thus, Hypothesis 2 was supported.

Hypothesis 3 predicted that the indirect effect of narcissism on whistleblowing via felt accountability would depend on ethical environment. To test the moderated mediation hypothesis, we entered the control variables and the main effect variables for narcissism and felt accountability in the first step and ethical environment and the interaction term between felt accountability and ethical environment in the second step (Model 2c). We found that the interaction between felt accountability and ethical environment on whistleblowing was significant (Model 2c, B = 0.29, SD = 0.12, P < 0.05). Figure 2 shows the interaction effect on whistleblowing, which indicates that the positive effect of felt accountability on whistleblowing is weaker when ethical environment is perceived to be high. Simple slope test indicated that felt accountability positively predicted whistleblowing at the low level of ethical environment (slope = 0.59, SE = 0.16, t = 3.78, P < 0.001). However, felt accountability did not predict whistleblowing at the high level of ethical environment (slope = 0.09, SE = 0.16, t = 0.57, ns).

Figure 2 The moderating effect of ethical environment on the relationship between felt accountability and whistleblowing.

Then, we followed Preacher et al’s55 procedure to test the conditional indirect effect of narcissism on whistleblowing via felt accountability at one standard deviation below the mean score of ethical environment and one standard deviation above the mean score of ethical environment. The results suggested that the conditional indirect effect was significantly positive at the low level of ethical environment (indirect effect = 0.26, SE = 0.08, 95% CI = [0.09, 0.42]). However, the conditional indirect effect was not significant at the high level of ethical environment (indirect effect = 0.04, SE = 0.07, 95% CI = [−0.10, 0.18]). Therefore, Hypothesis 3 was supported.

Discussion and Conclusion

Implications for Theory and Research

We proposed and validated a model to explain how and when narcissistic individuals are willing to blow the whistle. A study of MBA students supported our prediction that whistleblowing intentions are stronger when narcissistic individuals feel more accountable We also found that the indirect effect of narcissism on whistleblowing through felt accountability occurs when an organizational environment is perceived to be unethical.

These findings have several important implications. First, our investigation contributes to our understanding of the bright side of narcissism by combining it with research on whistleblowing, two areas that have yet to be integrated. Traditionally, narcissism has been associated with self-serving and potentially destructive behaviors in organizational settings. By demonstrating that narcissistic individuals may engage in whistleblowing, we challenge the monolithic view of narcissism and suggest a multifaceted approach to understanding this personality trait. This aligns with emerging perspectives in personality psychology that advocate for a more nuanced understanding of personality traits, such as the trait activation theory, which posits that traits can lead to different behaviors depending on situational cues.

Second, our model extends whistleblowing theories by identifying felt accountability as a mediating mechanism in the decision to report wrongdoing. This suggests that whistleblowing is not solely an altruistic act but can also be driven by self-concept maintenance. The findings can be incorporated into the whistleblowing process model, including felt accountability as a key psychological state that influences this decision-making process. Research could explore interventions that organizations might implement to foster a sense of accountability among employees, particularly those with narcissistic tendencies.

Finally, our findings go beyond previous research by demonstrating the moderating effect of ethical environment on the relationship between felt accountability and whistleblowing. We suggested that the relationship between narcissism and whistleblowing via felt accountability was stronger when the environment of an organization was perceived to be unethical. This challenges the conventional view of narcissism as negative within organizational contexts and suggests that under certain conditions, such as perceived unethical environments, narcissistic individuals may act in the interest of the greater good. The study enriches our understanding of the complex interplay between individual personality traits, psychological states, and organizational context in predicting whistleblowing. Future research could examine the specific aspects of an organization’s ethical climate that are most influential in this relationship and how they interact with individual personality traits.

Limitations

We have pointed out some theoretical implications of our study, but it has some shortcomings. First, the data in the study came from a single source, which may lead to common method bias. To mitigate the bias, we collected data in two distinct times. Additionally, since interaction effects are less affected by common method bias, concerns about the bias are less.23 Second, although our findings suggest that narcissism leads to whistleblowing through felt accountability, we cannot completely eliminate other causal relationships than the proposed model. To make causality more robust, future research should attempt to validate our model using experimental designs. Finally, we used an established measure of narcissism. However, the reliability of the measure was somewhat lower than the conventional reliability thresholds in our study. Future research comparing alternative measures of narcissism in different cultures is required.

Future Research Directions

We propose several directions for future research. First, future research should examine the motivations by which narcissism is linked to whistleblowing. Earlier research has described whistleblowing as analogous to organizational citizenship and prosocial behaviors.21 However, recent research has emphasized that individuals may perform OCBs out of self-serving motives (eg, impression management) and even negative forces (eg, counterproductive work behavior),56,57 rather than out of prosocial motives. For example, Bourdage et al58 suggested that when employees have a lower score on humility (similar to a higher score on narcissism), they are more likely to conduct OCBs as an impression management strategy. Thus, while narcissists are more likely to display whistleblowing intentions, they may do so just to meet their own needs.34 To illustrate the circumstances under which narcissism leads to whistleblowing, researchers could further explore the links between narcissism, whistleblowing, and motives to blow the whistle.

Second, we operationalized whistleblowing using self-report measures to depict employees’ tendency toward whistleblowing in their workplace. The measures used are well developed, but the indicators of whistleblowing they capture are more subjective. Research has suggested that narcissism negatively predicted supervisor ratings of OCBs and positively predicted self-ratings of OCBs.59 Future research could further investigate our model by rating the occurrence of whistleblowing by supervisors or coworkers. Moreover, employing longitudinal and experimental research designs could help to establish causal relationships and track changes over time in the whistleblowing behavior of narcissistic individuals. This could also help to discern the long-term consequences of whistleblowing for individuals with different personality profiles.

Finally, it is worthwhile to expand our model to incorporate more antecedents of whistleblowing. For example, research on moral decision-making and behavior has indicated that many emotions, such as moral courage, anger, and envy, can affect moral outcomes.60,61 However, the role of emotions in whistleblowing has rarely been empirically examined.9 Future research could test the impact of moral emotions such as contempt and resentment on felt accountability and whistleblowing.

Conclusion

The constant exposure of corporate scandals put unethical behavior in organizations under high scrutiny. Our findings suggested that felt accountability mediated the positive relationship between narcissism and whistleblowing, and the indirect effect of narcissism on whistleblowing through felt accountability was stronger when individuals perceived organizational environment to be unethical. Therefore, organizations who hope to prevent such scandals should balance accountability mechanism and ethical culture. In this way, they may be sure that unethical conducts are reported to avoid evolving into larger, institution-threatening corruption.

Data Sharing Statement

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Ethics Approval

This study was approved by Science and Technology Ethics Committee of Jimei University (JMU202206033).

Consent for Publication

Informed consent was obtained from all the participants included in the study.

Funding

This study was supported by key commissioned project of Party School of C.P.C, JiangSu Committee (Project Number 2023XZD003).

Disclosure

The authors declare that they have no competing interests.

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