Areas for Improvement and Barriers Identified in Measuring the Quality of Nursing Care: Perceptions of Patients and Professionals

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this article. This study contributes to understanding the dimensions of nursing care by emphasizing both its emotional and technical aspects. The interpretive qualitative approach, along with the use of focus groups and semi-structured interviews, is appropriate for capturing diverse perspectives. Additionally, the study identifies critical barriers, such as workload and inefficiencies in record-keeping.

However, my evaluation reveals some concerns that require attention specifically:

1.     The title does not reflect the study's findings. The study discusses areas for improvement rather than identifying new indicators, which would add more value to the research. The only indicator mentioned is patient satisfaction, which is already in use in healthcare organizations. From the article's title, one would expect the results to include the identification of indicators to measure nursing care. It is suggested to either change the title or introduce some indicators.

2.     The study would benefit from a more detailed description of the sampling strategy and participant selection to assess the representativeness of the data. How were the patients selected—through nursing consultations, databases, or patient associations? The same applies to professionals—were they selected based on their curriculum or proximity? It is not clear who participated in the interviews—professionals, patients? What criteria were used in the selection process?

3.     The following phrase needs clarification: "The final number of informants was determined by the criterion of discourse saturation."

4.     Please correct the error in the number of patients: "A total of 28 participants were recruited; 19 participated in the focus groups (10 in the professional group, 10 in the patient group), and 8 participated in the individual interviews

5.     The implications for practice should be expanded, specifically developing a more novel and creative strategy to improve nursing care conditions, in addition to the continuous training.

Author Response

RESPONSE TO REVIEWER 1

Thank you for the opportunity to review this article. This study contributes to understanding the dimensions of nursing care by emphasizing both its emotional and technical aspects. The interpretive qualitative approach, along with the use of focus groups and semi-structured interviews, is appropriate for capturing diverse perspectives. Additionally, the study identifies critical barriers, such as workload and inefficiencies in record-keeping.

However, my evaluation reveals some concerns that require attention specifically:

Comment 1: The title does not reflect the study's findings. The study discusses areas for improvement rather than identifying new indicators, which would add more value to the research. The only indicator mentioned is patient satisfaction, which is already in use in healthcare organizations. From the article's title, one would expect the results to include the identification of indicators to measure nursing care. It is suggested to either change the title or introduce some indicators.

Response 1: Thank you very much for your contribution. Certainly, after this observation, we can see that the title does not match the content. We propose to replace it with: “Areas for improvement and barriers identified in measuring the quality of nursing care: Perceptions of patients and professionals”.

Comment 2: The study would benefit from a more detailed description of the sampling strategy and participant selection to assess the representativeness of the data. How were the patients selected—through nursing consultations, databases, or patient associations? The same applies to professionals—were they selected based on their curriculum or proximity? It is not clear who participated in the interviews—professionals, patients? What criteria were used in the selection process?

Response 2: Thank you for your comment.  The participants were both users and professionals. The professionals were intentionally selected by a gatekeeper (located in the centre) from different care settings (specialised and primary care), and different centres, according to their knowledge, their ability, and their willingness to talk about the subject. They were of different ages and their professional experience varied. Users were also selected intentionally by a medical or nursing professional from the health centre or hospital known to them, who invited them to participate, as well as through patients' associations. Users were also selected in a variety of situations such as age, the processes/diseases for which they required care, or place of residence (both rural and urban areas).

 Comment 3: The following phrase needs clarification: "The final number of informants was determined by the criterion of discourse saturation.

Response 3: Thank you very much for your question. As indicated in the text, and according to Morse (1995), information collection continued up to the point at which the research team assessed that the necessary elements to build up a comprehensive and convincing framework of the topic of interest were identified

Comment 4: Please correct the error in the number of patients: "A total of 28 participants were recruited; 19 participated in the focus groups (10 in the professional group, 10 in the patient group), and 8 participated in the individual interviews.

Response 4: Thank you for your comment. The mistake has been corrected, and the sentence now reads as follows: "A total of 28 participants were recruited; 20 participated in the focus groups (10 in the professional group, 10 in the patient group), and 8 participated in the individual interviews”.

Comment 5: The implications for practice should be expanded, specifically developing a more novel and creative strategy to improve nursing care conditions, in addition to the continuous training.

Response 5: Thank you for your comment. We have modified some of the implications in accordance with your suggestion. “The development and innovation of tools that incorporate holistic measurements and collect qualitative data can reveal the nurse's hidden work and the patient's emotional experience. Encouraging continuous feedback systems on the quality of care received and delivered can facilitate rapid and personalised adjustments to patient care”.

Reviewer 2 Report

Comments and Suggestions for Authors

Please see attached.

Comments for author File: Comments.pdf

Comments on the Quality of English Language

Some statements are not clear.

Author Response

RESPONSE TO REVIEWER 2

Comment 1 (introduction): Line 64-65. There are currently no effective mechanisms available with which to identify results sensitive to nursing practice to ensure reliable indicators [6]. This statement is quite strong, and readers would be interested to know whether it is based on research findings or if it is a statement from a newspaper. Please provided more information about the statement. For example, a systematic review or a study aimed at indicated that no effective mechanisms available with which to identify results sensitive to nursing practice to ensure reliable indicators.

Response 1:Thank you very much for your comment. The text is based on the referenced study, 'Developing metrics for nursing quality of care for low- and middle-income countries: a scoping review linked to stakeholder engagement,' which conducts a scoping review. However, we have modified the sentence to make it less assertive, in line with the recommendations. “There is significant heterogeneity in the definition and interpretation of indicators, with contextual differences further complicating standardization”.

Comment 2 (introduction): Line 83-84. Incorporating patient perspectives into the process of drug development, health education, service delivery, and research is increasingly recognised, providing better outcomes and benefits for all stakeholders. Please acknowledge where you got this statement.

Response 2: Thank you very much for your comment. The appropriate bibliographical reference has been added: “Patient engagement: technical series on safer primary care (WHO, 2016)”.

Comment 3 (introduction): Lines 54-104. The authors should explore the performance indicators identified in previous studies, adding depth and insight to this study. This would help readers clearly understand how this study builds upon and differs from previous research.

Response 3: Thank you very much for your input. We have added clarifications that are intended to respond to your suggestions. “In the literature on nursing indicators, topics such as patient safety, compliance with protocols and clinical practice guidelines, and rates of adverse effects, among others, stand out.  These indicators are essential for assessing the quality of care, but they can be improved by incorporating the perspectives of patients and professionals, helping to identify and prioritise the issues that really matter, and promoting more personalised and effective care”.

Comment 4 (introduction): Lines 102-104. The aims of this study are challenging to understand and need refinement to help readers align them with the results. It is important to effectively articulate the study's aims with clarity to ensure their contextualisation within the broader research findings.

Response 4: We are grateful for the reviewer's suggestion. The wording of the objectives has been modified in order to identify the purpose of the study more clearly. In line with the changes made to the title, we believe it would be appropriate to reword this paragraph as follows: “The main objective of this study is to identify areas for improvement and potential barriers to measuring the quality of nursing care in a regional health service”.

Comment 5 (materials and methods): Lines 122-132. Participants. The description of the participants is ambiguous. It is not clear who the professionals are. Furthermore, the terms used are inconsistent, for example, one part refers to "users" as participants while in another sentence it is referred to as "patient group." It is important to maintain uniformity by referring to them as "user group".

Response 5: Thank you very much for your comment. The description of professionals and users has been refined, improving the definition of the selection criteria. Additionally, the terminology has been standardised by consistently referring to ‘users’.

Comment 6 (limitations): Lines 445-452. The limitations outlined appear to lack clarity and relevance to the current study. It is advisable for the authors to explore additional limitations, such as the absence of input from carers.

Response 6: Thank you very much for your input.  A limitation of the study lies in the restriction of the sample to public sector professionals, which may have biased the results by not including the perspective of private sector professionals. Despite efforts to homogenise the sample in terms of age, gender, and work area, it is likely that there are subgroups of professionals who were not adequately represented. Additionally, the selection of users may have favoured those who were more proactive and had a greater interest in participating, which may not reflect the opinion of the general user population. As for caregivers, we cannot be certain that none were present within the patient group, and therefore, we cannot include this as a limitation.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

After carefully reviewing the authors' responses to the comments and the revisions made to the manuscript, I am pleased to report that the authors have adequately addressed all of the concerns raised during the initial review process. The changes implemented in the manuscript have improved its clarity and scientific rigor.

I find that this revised version of the article meets the necessary standards for publication.