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Ethical approval and institutional permissions were obtained from all participating sites prior to data collection. For the German site (Klinikum Chemnitz gGmbH), approval was granted by the hospital\u2019s Works Council (Betriebsrat) on June 6, 2018, following review of the study protocol and questionnaire by the Nursing Director (Pflegedirektor). Written confirmation of this approval was provided on June 26, 2018. For the Iranian site (Imam Hospital, Tehran University of Medical Sciences), ethical approval was granted by the Research Committee of the Nursing Faculty at Tehran University of Medical Sciences (Approval Code: 96\/d\/250\/6220). A letter of support from the University of Applied Sciences Jena, dated July 3, 2017, facilitated the institutional review process. For the Canadian sites (hospitals in Ontario and Quebec), institutional permission was obtained through direct correspondence with nursing leadership. While the participating Canadian hospitals did not issue formal ethical approval codes, written agreements to participate were secured, and the study procedures were reviewed and approved by the responsible nursing directors and hospital administrators. Participation was voluntary and anonymous across all sites. Written informed consent was implied through voluntary completion and return of the questionnaire. An information cover letter accompanied each questionnaire, explaining the study purpose, confidentiality protections, the voluntary nature of participation, and the right to withdraw at any time without consequence. No identifying information was collected, and all data were handled securely and used exclusively for research purposes. 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