Monitoring Knowledge, Attitudes, and Practices on Restraint Use in Adult and Pediatric Intensive Care Units: The Multicenter Development and Validation of the CON-Ti-IT Questionnaire

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript addresses a relevant topic in intensive care clinical practice and fills an important gap by proposing and validating a specific instrument to assess nurses’ knowledge, attitudes, and practices regarding the use of restraints in both adult and pediatric settings. The introduction provides a solid foundation, appropriately articulating the issue, the ethical implications, and the need for validated tools. The multimethod design is appropriate for the study’s objectives and follows established references for psychometric validation. However, certain methodological aspects could be described more clearly. The Methods section could offer more detail on the criteria used to remove items after factor analysis, as well as clarify the theoretical rationale for retaining subscales with lower alpha coefficients, even if this is expected in complex constructs. It is also recommended to better explain the decision-making process that led to the choice of the final model (29 items), thereby facilitating study replication by other researchers. The results are coherent and well structured, although the presentation of Table 2 could be improved to enhance readability, particularly regarding the grouping of factors. The discussion is consistent, provides pertinent interpretations, and appropriately relates the findings to international studies. The conclusions are proportional and supported by the data presented. Overall, the manuscript demonstrates scientific merit, practical relevance, and a significant contribution to the field of intensive care nursing.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Author(s),
Thank you for submitting your manuscript titled “Monitoring knowledge, attitudes, and practices on restraint use in adult and pediatric intensive care units: The multicenter development and validation of the CON-Ti-IT questionnaire” to Nursing Reports.
This manuscript reports the development and validation process of a new questionnaire to assess ICU nurses’ knowledge, attitudes, and practices (KAP) regarding restraint use in both adult and pediatric settings. This topic is relevant, also considering the increasing global interest on restraint reduction, ethical decision-making, and context-sensitive tools in critical care nursing. I found the manuscript interesting and aligned with COSMIN principles.
However, the manuscript could be reinforced by improving conceptual clarity, enhancing psychometric reporting, refining methodological details, and improving the clarity and conciseness of presentation.
Below, I report my detailed comments organized by section.

ABSTRACT

• Clarify design: Please, explicitly state that this was a multi-method psychometric validation study conducted across both adult and pediatric ICU settings (lines 21-22).
• Strengthen results: The abstract sometimes overstates the validity of the tool. Please, replace phrasing such as “excellent internal consistency” (line 28) with more precise language, particularly considering the low alpha values for subscales (Attitudes and Knowledge).

INTRODUCTION

• Conceptual clarity of KAP framework: The introduction provides strong justification for the need to assess knowledge, attitudes, and practices of ICU nurses, but would benefit from a clearer conceptual explanation of the KAP framework. A brief conceptual description would improve clarity. These references, derived from mental health nursing, may help contextualize the KAP framework in critical care nursing:  https://www.mdpi.com/2039-4403/14/4/301
• Research gap: The gap that the study aims to fill could be refined. For instance, authors could specify that existing tools to assess attitudes of nurses are either not ICU-specific, not validated in the Italian cultural context, or do not incorporate both adult and pediatric care aspects. These references, derived from mental health nursing, may help strengthen the rationale for the development of this instrument:  https://doi.org/10.1111/nicc.12303

MATERIALS AND METHODS

Participants and Procedures

• Please clarify recruitment procedures (e.g., email, paper-based distribution), whether response rates were tracked, and how representation of pediatric vs. adult ICU nurses was managed.
• Please expand inclusion/exclusion criteria. For instance, were agency staff, newly hired nurses, nurse managers, or educators included? Were nurse educators or managers excluded from the psychometric validation stage?
• While IRB approval is reported, please add details regarding confidentiality, data storage, and whether incentives or compensation were provided, especially given the presence of funding (lines 437–438).

Instrument Development

• Panel description: Please clarify the roles (clinical, academic, leadership) and expertise of the nine panelists (line 189), and whether Delphi or structured consensus methods were used.

Psychometric Evaluation

• Test-retest reliability: Please report ICC or Weighted Kappa values in addition to qualitative categories (e.g., “good,” “very good”).
• Construct validity: Please report KMO and Bartlett’s test to support factor analysis suitability.
• Internal consistency: Cronbach’s alpha for the Attitudes and Knowledge scales is below acceptable thresholds. While you acknowledge conceptual variability (lines 335-336), please consider reporting McDonald’s Omega and/or item–total correlations to strengthen reliability assessment.

RESULTS

• Please consider starting the Results section with a brief narrative of participant characteristics, complemented by Table 1, rather than reporting demographic data after.
• Table 2 is really dense, combining EFA loadings and reliability statistics. Please consider splitting into separate tables or adding clearer subheadings for subscales. Also, ensure consistent decimal formatting (commas or period).
• When explaining item removal (lines 299-310), briefly state conceptual reasons (in addition to statistics) to improve transparency and support content validity assessment.

DISCUSSION

• Structure and clarity: Consider reorganizing this section into four subsections (headings optional): Summary of key findings; Comparison to previous research; Clinical implications; Limitations and future research.
• Interpretation of psychometric results: The explanation for low Cronbach's alpha in Attitudes and Knowledge scales is reasonable, but should be better linked to literature on measuring multidimensional constructs (e.g., attitudinal heterogeneity).
• Clinical and educational application: should be more explicitly suggested how this tool can support clinical audits, nursing education, and policy-making on restraint-free care.
• Limitations: Please, include more detail regarding: 1) Convenience sampling and underrepresentation of pediatric nurses; 2) Absence of criterion validity (e.g., comparing KAP scores to observed restraint practices or training outcomes).

CONCLUSION

• Please, use more cautious wording such as “This tool represents an initial validated instrument…” instead of “first tool designed for…”
• Include a brief mention of future research directions, such as CFA, cross-cultural validation, and longitudinal evaluation of the association between KAP scores and restraint-related behaviors.

Language and Formatting

• Writing is generally clear, but sections could benefit from reducing redundancies (e.g., detailed meeting descriptions).
• Ensure consistent terminology when referring to restraints (avoid alternating between “restraint,” “contention,” and “containment”).
• Review reference formatting, DOI, and alignment with journal guidelines.

Overall Evaluation

This manuscript addresses an important gap in ICU nursing research, developing a context-specific, psychometrically evaluated tool for assessing KAP on restraint use. With improved conceptual framing, enhanced methodological transparency, better psychometric reporting, and streamlined presentation, this work has strong potential to make a contribution to the literature.

I hope these comments are constructive and helpful to the Author(s). Best Regards.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for submitting your manuscript. Please refer to the attached file for details. I hope my comments will contribute, even in a small way, to improving your manuscript.

Best regards,

Comments for author File: Comments.pdf

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for revising and adding content based on the reviewer comments within such a short period of time. I have confirmed that the comments have been appropriately addressed and reflected in the manuscript.

Best regards,