Validation of ELPO-PT: A Risk Assessment Scale for Surgical Positioning Injuries in the Portuguese Context

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Congrats on your study and your prepared manuscript. The manuscript presents a well-structured study focusing on the cultural adaptation and validation of the ELPO-PT scale for the Portuguese population. The methodology is rigorous, and the results are significant for the field of perioperative nursing. However, I do have several suggestions for quality improvement:

The Title is descriptive but could be more concise - consider rephrasing to reflect the core findings of the study.

The Introduction provides a strong rationale for the study. There is a lack of mention of any limitations or challenges in previous adaptations of the ELPO scale.

The Methods Section

Provide more details on the back-translation process. How were discrepancies handled between the original and back-translated versions? (Page 4, Lines 146-150).

Figure 1 is not clear, letters are blurred and I can't read anything.

The process of expert selection for the content validity panel is not entirely clear. Specify the criteria used to select these experts and how their expertise aligns with the study's objectives (Page 6, Lines 250-260).

The Results Section

Explain why specific outcomes, such as the low use of advanced support surfaces, are relevant in the context of the study (Page 10, Lines 363-364).

The reported Kappa coefficient values for intra- and inter-observer reliability are excellent. Please discuss the implications of these findings more thoroughly in terms of clinical practice - how will these high levels of agreement influence the implementation of ELPO-PT in Portuguese hospitals? (Page 15, Lines 507-525).

Discussion Section

The discussion effectively compares the current findings with those from the original ELPO study.

The Limitations Section acknowledges the small sample size but does not address potential biases introduced by the non-probabilistic sampling method. Please discuss how this might affect the generalizability of the findings (Page 19, Lines 670-674).

The Conclusion is well-aligned with the study's objectives.

Good luck and lots of regards

Author Response

Comments to Reviewer

Reviewer #1:

Thank you for taking the time to review again our manuscript and for your valuable feedback.

We appreciate the recognition regarding the improved version.

We have carefully considered your input and the alterations are in yellow. 

 

1. Comment

"The Title is descriptive but could be more concise - consider rephrasing to reflect the core findings of the study”

Answer: We have revised the title to be more concise while reflecting the core findings of the study. The new proposed title is: "Validation of ELPO-PT: A Risk Assessment Scale for Surgical Positioning Injuries in the Portuguese Context.". Please, see Title.

 

 

 

2. Comment
   There is a lack of mention of any limitations or challenges in previous adaptations of the ELPO scale..

Answer: We have added a brief discussion about the limitations and challenges encountered in previous adaptations of the ELPO scale. These challenges primarily included differences in surgical practice environments, such as variations in the use of support surfaces and positioning techniques, and differences in patient populations, particularly in terms of comorbidities and demographic factors. These variations underscored the need for careful cultural adaptation to ensure the scale's applicability and effectiveness in the Portuguese context." Please, see page 3, row 123-133.

 

 

3. Comment
   "Provide more details on the back-translation process and handling of discrepancies.

Answer: We have expanded the section detailing the back-translation process. Discrepancies between the original and back-translated versions were resolved through a consensus meeting with the two independent translators and members of the research team, ensuring semantic and conceptual equivalence.

“During the back-translation process, two bilingual translators proficient in both Brazilian and European Portuguese independently conducted the back-translation. The most notable discrepancies were related to the terminology used for "support surfaces" and "position of the limbs," where differences in regional healthcare terminology became apparent. These discrepancies were resolved through a consensus meeting between the translators and the research team, where we ensured that the terms were semantically and conceptually aligned with the original version while being culturally appropriate for the Portuguese healthcare context. After resolving these issues, the back-translated version was sent to the original author of the ELPO scale for verification of semantic equivalence, confirming that the integrity of the scale was maintained. Please, see page 3, Table 1. -

 

 

4. Comment

Figure 1 is not clear, letters are blurred and I can't read anything.
We apologize for the clarity issue. We have replaced Figure 1 with a higher resolution version to ensure the text and images are legible.
.           Answer:  We used a figure with more quality in the texto. . Please, see page 6.

 

 

5.Comment

The process of expert selection for the content validity panel is not entirely clear. Specify the criteria used to select these experts and how their expertise aligns with the study's objectives

Answer: We included this text “ To evaluate the content validity of the Portuguese version of the ELPO scale, we selected a panel of 15 experts. We chose these experts based on their clinical expertise, professional experience, and relevance to the study objectives. The panel included 5 nurses specializing in Medical-Surgical Nursing with a focus on Perioperative Nursing, 5 nurses specializing in Medical-Surgical Nursing and Tissue Viability/Wound Care, 4 surgeons (Orthopedic, General, Oncological, and Plastic), and 1 Chief Manager of an Operating Room. All experts needed to have more than 10 years of experience and specialized training in pressure ulcer prevention and perioperative care.

We designed the selection criteria to align with the study’s focus on validating a tool aimed at preventing injuries related to surgical positioning. Nurses specializing in perioperative care were included for their role in patient positioning during surgery, while those with expertise in tissue viability contributed knowledge on the prevention and management of pressure injuries. The surgeons provided essential insights into the risks associated with patient positioning during various types of surgeries, and the OR manager ensured that institutional practices and protocols were considered. This diverse yet targeted expertise ensured that the panel's evaluation aligned with the study’s goal of adapting the ELPO scale to the Portuguese clinical context.”. Please, see page 7, row 259 to 275.

 

6.Comment

Explain why specific outcomes, such as the low use of advanced support surfaces, are relevant in the context of the study (Page 10, Lines 363-364).

Answer We revised the text to clarify the relevance of the low use of advanced support surfaces in the study. It emphasizes how the limited use reflects current clinical practices and highlights the need for validating the ELPO scale in real-world conditions where advanced preventive measures may not always be available. This underscores the importance of accurate risk assessment in preventing pressure injuries under suboptimal conditions. Please, see page 10, row 284 to 400.

 

 

7.Comment

The reported Kappa coefficient values for intra- and inter-observer reliability are excellent. Please discuss the implications of these findings more thoroughly in terms of clinical practice - how will these high levels of agreement influence the implementation of ELPO-PT in Portuguese hospitals? (Page 15, Lines 507-525).

Answer We have expanded the text to provide a more comprehensive analysis of the clinical implications associated with the high Kappa coefficient values for both intra- and inter-observer reliability. The revised content underscores how these exceptional levels of agreement will facilitate the consistent integration of the ELPO-PT scale within Portuguese hospitals, thereby enhancing patient outcomes through standardized risk assessment and preventive strategies.. Please, see page 16, row 552 to 570.

 

 

8.Comment

The Limitations Section acknowledges the small sample size but does not address potential biases introduced by the non-probabilistic sampling method. Please discuss how this might affect the generalizability of the findings (Page 19, Lines 670-674).

Answer: We have revised the Limitations section to address the potential biases introduced by the non-probabilistic sampling method..Please, see page 19, row 715 to 736.

 

Thank you for your thorough review and valuable comments. We have carefully addressed all of your suggestions and made the necessary revisions to the manuscript. We believe these changes have strengthened the overall quality of the study and improved its clarity.

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

The abstract presents research on the validation and cultural adaptation of the Scale for Assessing the Risk of Surgical Positioning Injuries (ELPO) for the Portuguese population, aiming to ensure its applicability and effectiveness. Here are some suggestions to improve the clarity and cohesion of your article

Abstract:

Redundancy: The study objective is mentioned twice in a row (lines 26-30). The repetition can be eliminated to improve flow.

Clarity in terms: Some phrases can be simplified or rewritten for better understanding. For example, "determinación del coeficiente alfa de Cronbach" can be changed to "calculation of Cronbach's alpha coefficient."

Word usage: "Methodological validation study" can be simplified to "validation study."

Statistics structure: The statistics can be presented more clearly to facilitate interpretation.

Suggestion:

The validation results showed a Cronbach's alpha coefficient of 0.782, indicating reasonable internal reliability. Sensitivity analysis revealed an 85% accuracy rate in identifying patients at risk of developing injuries, while specificity analysis showed a 90% accuracy rate in identifying patients not at risk.

 The introduction seems to be well-structured and clearly addresses the problem, background, and objectives of the study. However, there are some areas where clarity and flow can be improved. Here is a review with suggestions:

Clarity: Some long sentences can be broken down into shorter ones to improve readability. For example:

Original: "Managing safety and preventing the risk of complications is a collective responsibility of the perioperative team." Revision: "Ensuring safety and preventing complications is the collective responsibility of the perioperative team."

Flow and redundancy: There are some repetitions that could be eliminated to make the text more concise. For instance, the section on the need for a culturally adapted tool is mentioned several times in a similar manner.

Transitions between paragraphs: Transitions can be improved to maintain logical continuity. In some sections, the text jumps from one topic to another without a clear connection, which may make it difficult to follow.

Minor style correction: The use of phrases like "Considering patients' right to safety and quality of care..." is adequate but could be simplified to be more direct.

Materials and Methods

This study followed rigorous methodological guidelines for the cultural adaptation and validation of the ELPO scale in a central hospital in Portugal. A quantitative, methodological, and cross-sectional approach was used. This summary highlights the main methodological steps and procedures carried out in the study to validate the ELPO scale adapted to the Portuguese context.

 Results: Unify the same style for all tables according to the journal's style guide

 Discussion: The ELPO-PT scale demonstrated strong validity and reliability for assessing positioning-related injury risk, with good diagnostic performance. However, the study's limitations, including sample size and context, suggest that future research should validate the scale in broader and more diverse populations. Incorporating ELPO-PT into clinical practice could enhance risk assessment and patient outcomes. ELPO-PT is an effective tool for evaluating surgical positioning risk, with results supporting its application in the Portuguese context. It is recommended to maintain and expand validation efforts to ensure its generalization across various populations.

Review the bibliography

Author Response

Reviewer #2:

Thank you for taking the time to review again our manuscript and for your valuable feedback.

We appreciate the recognition regarding the improved version. It was introduced a Theoretical Framework and we have carefully considered your input.

 

1. Comment

" Redundancy: The study objective is mentioned twice in a row (lines 26-30). The repetition can be eliminated to improve flow…””

Answer: Thank you for your helpful suggestions. We have revised the manuscript to address the redundancy in the study objective, improving the flow of the text by eliminating repetition. Additionally, we simplified and clarified certain phrases as suggested, including replacing "determinación del coeficiente alfa de Cronbach" with "calculation of Cronbach's alpha coefficient" and simplifying "methodological validation study" to "validation study." The presentation of the statistics has been restructured for clarity, and the validation results now clearly report the Cronbach's alpha coefficient, as well as sensitivity and specificity rates.

We believe these revisions enhance the clarity and readability of the manuscript and appreciate your valuable feedback.". Please, see page 1, row 31 to 39.

 

 

 

2. Comment

" The introduction seems to be well-structured and clearly addresses the problem, background, and objectives of the study. However, there are some areas where clarity and flow can be improved. Here is a review with suggestions:

Answer: Thank you for your thoughtful feedback. We have revised the Introduction to address your suggestions for improving clarity, flow, and conciseness. Specifically, we simplified some of the longer sentences, removed redundant sections, and improved transitions between paragraphs to enhance logical continuity. We have also reworded some phrases to make the text more direct and easier to understand.". Please, see page 1 and 2, row 50 to 132.

 

 

3. Comment

"  Results: Unify the same style for all tables according to the journal's style guide

Answer:Thank you for your feedback. We have revised all the tables in the Results section to ensure they are formatted consistently and according to the journal's style guide. This includes unifying the layout, font style, and headings for clarity and alignment with the journal's requirements..". Please see tables in yellow

 

The Bibliography was reviewed and adapted

 

 

Thank you for your thorough review and valuable comments. We have carefully addressed all of your suggestions and made the necessary revisions to the manuscript. We believe these changes have strengthened the overall quality of the study and improved its clarity.

 

 

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors,

Thank you very much for the opportunity to review your manuscript. The topic is crucial for improving patient safety.

Below are my comments concerning the article:

In the introduction section, please provide some data about the occurrence of PI related to surgical positioning in your country.

Did you exclude the patients with ulcer pressure, some skin, and skin damage? Please define the pressure ulcer assessment (what kind of scale did you use) and describe the NRS (Braden Scale). This information is necessary for the interpretation of the results

 

Author Response

Reviewer #3:

Thank you for taking the time to review again our manuscript and for your valuable feedback.

We appreciate the recognition regarding the improved version. We have carefully considered your input.

 

1. Comment

" In the introduction section, please provide some data about the occurrence of PI related to surgical positioning in your country

Answer: Thank you for your comment. We have introduced a theoretical framework in the Introduction section that provides worldwide data on the occurrence of pressure ulcers/injuries  related to surgical positioning. This broader perspective helps highlight the global significance of the issue and provides a solid foundation for understanding the relevance of adapting and validating the ELPO scale within the Portuguese context.. Please, see page 1, row 133 to 193.

 

 

 

2. Comment

Did you exclude the patients with ulcer pressure, some skin, and skin damage? Please define the pressure ulcer assessment (what kind of scale did you use) and describe the NRS (Braden Scale). This information is necessary for the interpretation of the results

Answer: Thank you for your insightful comment. We have clarified the exclusion criteria in the manuscript to state that patients with pre-existing pressure ulcers or significant skin damage were excluded from the study. We included this text: “The study focused on examining the development of new injuries related to surgical positioning. To ensure the accuracy of the findings, patients with pre-existing pressure ulcers, significant skin damage, or existing wounds were excluded from the study. Ad-ditionally, patients who underwent emergency procedures or had significant cognitive impairment that prevented them from understanding and responding to the question-naire were also excluded [4, 39]. .. Please, see page 6, row 231 to 236.

 

 

Answer:Additionally, we have updated the Methods section to define the pressure ulcer assessment, specifying that the Braden Scale was used for this purpose. Iwas already in the text - The data collection instrument also included a health characterization questionnaire, a pain analog scale, the Braden scale, and a skin inspection protocol. We included this text: “The Braden Scale, was used in conjunction with the ELPO-PT to provide a comprehensive assessment of the risk of developing pressure ulcers during surgery “This information is now clearly described in the manuscript for better interpretation of the results.. Please, see page 7, row 263 to 264.

 

 

Thank you for your thorough review and valuable comments. We have carefully addressed all of your suggestions and made the necessary revisions to the manuscript. We believe these changes have strengthened the overall quality of the study and improved its clarity.

 

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors, Thank you for consistently implementing my suggestions to improve the quality of this article. Best regards and good luck with your publication.