Identifying Barriers to the Acquisition of Knowledge about Skin Integrity Impairment in Nursing Students: An Educational Intervention

Round 1

Reviewer 1 Report

Thank you for the opportunity to review this manuscript.

Education about wound care is essential for the nurse's profession.

Below are my comments concerning the article.

In the introduction section, please add information about primary education about wounds in your country (bachelor's or master's), the main learning effects, and the year in which the students start learning about wound care.

Sample: Has the sample been calculated?

Inclusion/exclusion criteria: please describe for both group

Please describe in detail the intervention

Please specify the statistical tests used depending on the normality distribution: ANOVA or Wilcoxon. Please present the data pre I post in the table and discuss the results.

Author Response

We sincerely appreciate the invaluable feedback and guidance provided by the reviewers regarding our manuscript titled " Identifying Barriers to the Acquisition of Knowledge about Skin Integrity Impairment in Nursing Students: An Educational Intervention".  Committed to the ongoing enhancement of our article's quality and relevance, we believe the suggested revisions have significantly contributed to this endeavor.

The current version of the article, including the recommended corrections, new tables and an annex, is attached for your review. Additionally, we have thoroughly addressed specific queries raised during the review process. We are grateful for the opportunity to collaborate with the Nursing Reports Journal, and we trust that the revised version meets the publication's high standards. We remain available for any further revisions or clarifications that may be required.

We also extend our gratitude to the reviewers for their valuable insights and assistance in improving the article's contribution to the field of undergraduate nursing education. We value their thoughtful feedback, and the suggested modifications have been incorporated into the original manuscript. This document serves as our response to their helpful comments.

In the introduction section, please add information about primary education about wounds in your country (bachelor's or master's), the main learning effects, and the year in which the students start learning about wound care.

            We have reviewed and modified the manuscript according to your suggestions.

Sample: Has the sample been calculated?

The total population of 4th year university students was 384. A size of 193 questionnaires made it possible to estimate the parameters of interest on an infinite population of students with a confidence of 95% and a precision of 3.4%.

Inclusion/exclusion criteria: please describe for both group

            Revised and modified in the Materials and Methods section of the manuscript.

Please describe in detail the intervention

Revised and modified in the Materials and Methods section of the manuscript.

Please specify the statistical tests used depending on the normality distribution: ANOVA or Wilcoxon. Please present the data pre I post in the table and discuss the results.

Differences within the pre-test and post-test groups were assessed using the Wilcoxon signed-rank test. We have included two new tables (Table 2 and Table 3) with data pre-post and discussed it in the Results section of the manuscript.

Author Response File: Author Response.pdf

Reviewer 2 Report

Congratulations on the article and your interest in academia.

I attach a document with suggestions for improvement: 

-Update references and correct typos, they refer several times to the country, without ever identifying it and characterize with more information the teaching of nursing of the first cycle, 

-In the method they need to specify more how they came up with the questionnaire and it would be interesting if they shared it (the questions), 

-In the discussion, start with the objectives and add the construction of the questionnaire, 

- In the conclusion - more information is missing regarding the second objective of the study

Comments for author File: Comments.pdf

Author Response

Thanks for giving me the opportunity to review his interesting paper. Please find attached some comments.

The text included in the lines 39 to 42 seems to be a definition. If so, shouldn’t it include a reference?

Thank you, we miss the reference. It’s been revised and added.

Aim: Should include the participants. I.E. Nursing students from a…

Revised.

Desing: I suggest considering it as experimental and define the characteristics. I.E. non-randomized.

Due to the convenience sampling method used to gather responses from final year students to analyze their acquired knowledge throughout the degree, the study would not meet the requirements for classification according to the CONSORT declaration for experimental studies.

Clarify how were participants assigned to intervention and control group.

In the procedure, we explain that the control group was selected by distributing the questionnaire through the internal lists of the Faculty of Nursing only to final year students. The intervention group was formed by offering an elective course to nursing degree students, who voluntarily enrolled in the course. We have included this information in the procedure to clarify the selection process.

Inclusion criteria: if participants signed and informed consent, consider including it as inclusion criteria.

Revised and added.

The dependent variables should be written using a narrative style.

Revised and modified in the Materials and Methods section of the manuscript.

Section 3.1 could be renamed as Demographic or participant characteristics.

            Revised.

I suggest to include a new section (3.2), between descriptive and the educational intervention, named “barriers perception” or similar to present the results that answering the question research related with the principal aim. 

Thank you. The response to the main objective of the study extends beyond the results, hence we have considered addressing it in the discussion section. However, following your suggestion, we have created two tables (Table 2 and Table 3) to outline the thematic areas of greatest weakness observed in the students' responses.

The text located below the tables and figures should be located after them.

Thank you very much. We present the figure legends in paragraph form following the journal's instructions so that during the editorial process they can be modified in terms of size and placement.

Discussion: review the text of the lines 314 to 316.

Thank you very much, it was text from the journal's formatting template. We have proceeded to remove it.

I suggest including a first paragraph in the discussions section according to the principal aim to highlight the principal findings of the research. What was the barriers identified by the students?

Revised and modified in the Discussion section of the manuscript.

Conclusion: “This study demonstrates how the post-test group”, do you mean intervention group?

Indeed, we referred to the intervention group. It has been revised and modified.

Author Response File: Author Response.pdf

Reviewer 3 Report

Thanks for giving me the opportunity to review his interesting paper. Please find attached some comments.

-         -The text included in the lines 39 to 42 seems to be a definition. If so, shouldn’t it include a reference?

-          Aim: Should include the participants. I.E. Nursing students from a…

-          Desing: I suggest considering it as experimental and define the characteristics. I.E. non-randomized.

-          Clarify how were participants assigned to intervention and control group.

-          Inclusion criteria: if participants signed and informed consent, consider including it as inclusion criteria.

-          The dependent variables should be written using a narrative style.

-          Section 3.1 could be renamed as Demographic or participant characteristics.

-          I suggest to include a new section (3.2), between descriptive and the educational intervention, named “barriers perception” or similar to present the results that answering the question research related with the principal aim.  

-          The text located below the tables and figures should be located after them.

-          Discussion: review the text of the lines 314 to 316.

-          I suggest including a first paragraph in the discussions section according to the principal aim to highlight the principal findings of the research. What was the barriers identified by the students?

-          Conclusion: “This study demonstrates how the post-test group”, do you mean intervention group?

Author Response

The authors stated participants were those who wished to participate. Did this study have IRB approval? It is surprising how few students did not participate. Found IRB approval line 157.

This topic is of great interest among nursing students, and their response was exceptionally good, for which we are very grateful. The study was approved by the university's Research Ethics Committee.

2. Not enough information is given about the questionnaire. Did they develop it or was it one already tested? What was the reliability of the instrument? What were high/low scores? What wound types were part of the questionnaire?

We have edited and included in the Materials and Methods section a description of the questionnaire used in our study. This questionnaire was ad hoc, developed by our team based on recommendations from clinical practice guidelines. Additionally, the section on wound bed preparation was based on a previously used questionnaire; however, the questions were adjusted to align with the three response options utilized in our study.

The reliability of the questionnaire was not studied, although we would like to review and attempt to validate the instrument in the future.

We consider a low level of knowledge between 1 and 20 correct answers, a medium level between 21 and 40 correct answers, and a high level between 41 and 61, although the main focus of the study is on the "I don't know/I don't answer" responses.

The main types of injuries included in the questionnaire were pressure ulcers, Dependence-related skin lesions, and lower limb vascular ulcers.

3. Lines 122-127 – what references were used? Where did the author get the questions? Credit must be given to the original papers/authors. I have concerns about the instrument because my questionnaire used the 3 categories of scoring, yet it is not referenced. What types of wounds were part of the test?

We have addressed these inquiries in the Procedure section within the Materials and Methods. Additionally, an annex containing the questions has been added as supplementary material. It would be a pleasure to have access to your questionnaire for future research endeavors. The main types of injuries covered in our questionnaire were pressure ulcers, dependence-related skin lesions, and lower limb vascular ulcers.

4. Was the educational program tested? It was a long program for students who should have had some of that content in school. What was in the educational program?

We have added an entirely new section in the Materials and Methods regarding the educational program. It was not tested. The program lasted for a week. It was an online intensive program designed for students who should have received some of that content in school.

5. All data for Figure 1 must be stated as significant or not significant. The two groups should be comparable to start the study.

The data presented in Figure 1 corresponds to the prior knowledge of students regarding wound healing. The questions posed were:

• Have you received university training (theoretical and practical) related to the DIAGNOSIS and PREVENTION of pressure ulcers and other chronic wounds?
• Have you received university training (theoretical and practical) related to the TREATMENT of pressure ulcers and other chronic wounds?
• Have you treated any pressure ulcers or chronic wounds during your training?
• Have you participated in any research, study, or work related to pressure ulcers or other chronic wounds?

We utilized this data as guidance and primarily as demographic information, with no intention of seeking statistical significance from it

6. Limitations need to include the lack of data about the instruments used.

Revised and added.

7. Detail is in the discussion.

Revised.

Author Response File: Author Response.pdf

Reviewer 4 Report

1.      The authors stated participants were those who wished to participate. Did this study have IRB approval? It is surprising how few students did not participate. Found IRB approval line 157.

2.      Not enough information is given about the questionnaire. Did they develop it or was it one already tested? What was the reliability of the instrument? What were high/low scores? What wound types were part of the questionnaire?

3.      Lines 122-127 – what references were used? Where did the author get the questions? Credit must be given to the original papers/authors. I have concerns about the instrument because my questionnaire used the 3 categories of scoring, yet it is not referenced. What types of wounds were part of the test?

4.      Was the educational program tested? It was a long program for students who should have had some of that content in school. What was in the educational program?

5.      All data for Figure 1 must be stated as significant or not significant. The two groups should be comparable to start the study.

6.      Limitations need to include the lack of data about the instruments used.

7.      Detail is in the discussion.

Author Response

Congratulations on the article and your interest in academia.

I attach a document with suggestions for improvement:

Thank you. We have incorporated your suggestions into the new version of the manuscript, which is enclosed.

Update references and correct typos, they refer several times to the country, without ever identifying it and characterize with more information the teaching of nursing of the first cycle,

Revised. The values in the abstract refer to the raw scores of the 61-item test. Additional information about nursing education related to wounds has been included. References on this topic have been updated. Our country is Spain, which is important for understanding the course content.

In the method they need to specify more how they came up with the questionnaire and it would be interesting if they shared it (the questions),

Revised. The questions have been included as supplementary material (ANNEX I). We have added an entirely new section in the Materials and Methods regarding the questionnaire and the intervention.

Also in the Method section:

It was not a longitudinal study, but we could develop it in this way in the future. Thank you for your input.

The Ethics section has been modified and expanded.

In the discussion, start with the objectives and add the construction of the questionnaire,

Thank you for your feedback. We have revised it accordingly. The construction of the questionnaire has been elaborated in the Materials and Methods section. Additionally, limitations have been updated to include the bias associated with the convenience sample.

In the conclusion - more information is missing regarding the second objective of the study.

Revised and added.

Author Response File: Author Response.pdf