Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

in my opinion, the introduction and conclusion need to be developed more fully. The meaning of Narrative Medicine and its applications for patients and staff can be developed more fully. I am concerned that readers with limited or no background in NM will be uncertain about what is being discussed. The authors could draw more deeply on Charon and her colleagues relative to the meaning and use of NM. I have published several papers that offer discussion relative to the use of NM in terms of renegotiating identity, engaging sources of strength, coming to terms with a narrative of illness and treatment or another crisis, identifying hope for the future and sources of meaning. The conclusion of the paper I reviewed is only two sentences long. Perhaps it would be possible to have further discussion of the future possibilities for developing NM applications for nursing providers (RNs and NPs).

This paper provides substantial evidence for the benefit of NM practices to encourage nursing provider wellness and avoid professional burnout. However, additional development is needed in both the introduction and conclusion. The description of NM does not take into account the application of NM for patient care and the potential enhancement of provider satisfaction and effectiveness through the application of NM for patient care. Readers with limited or no prior experience with NM will have difficulty understanding how NM is applied in clinical settings and how NM practices can be helpful for patients and providers. A variety of articles are available to describe NM applications for patients and to discuss more fully the history and meaning of NM. The conclusion consists of two sentences and can be developed to discuss more fully the clinical and personal value of NM practices in the context of the study results relative to the goal of enhancing nursing provider wellness and avoiding professional burnout.

Author Response

Please see the attachment and revised manuscript.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The study addresses a highly relevant and timely topic, and the large sample size constitutes a notable strength. The focus on nurse and nurse practitioner well-being, together with the exploration of Narrative Medicine practices, represents a meaningful contribution to current discussions on workforce sustainability and burnout prevention.

From a methodological perspective, several aspects could be further clarified or strengthened to enhance the robustness and interpretability of the findings. First, the use of snowball sampling is understandable given the national scope of the study and the challenges associated with recruiting large samples of practicing nurses. However, as a non-probabilistic sampling strategy, it may introduce selection and affinity bias, which could limit the generalizability of the results. Emphasizing this limitation more explicitly in the discussion would be beneficial.

In addition, the use of a participation incentive (raffle for gift cards) may have contributed to self-selection bias, potentially influencing both participation rates and response patterns. While incentives are common in survey-based research, acknowledging their possible impact as an additional limitation would strengthen the methodological transparency of the study.

A key area for further development relates to the Narrative Medicine practice questionnaire. Although expert review supports content validity, the absence of reported psychometric analyses (e.g., internal consistency, dimensional structure) limits confidence in the measurement of the construct. Given the large sample size, the inclusion of basic reliability indices and exploratory factor analysis would substantially strengthen the methodological rigor and the interpretability of the observed correlations.

Overall, these considerations do not detract from the relevance of the study but rather represent opportunities to further enhance its methodological clarity and scientific contribution. Addressing these points would improve the strength of the conclusions and the potential impact of the work.

Author Response

Please see the attachment and revised manuscript.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

I commend the authors for submitting this manuscript, which addresses the relationship between two constructs of clear relevance to contemporary nursing practice, considering nurses from different educational backgrounds and potentially differing levels of vulnerability. The topic is timely and aligned with current concerns regarding burnout and professional well-being in nursing.
Overall, the manuscript presents an appropriate background that supports the rationale for exploring the association between narrative medicine practices and well-being indicators in nursing professionals. The progression from the identification of the problem (burnout) to the proposed mitigating strategy (narrative medicine) is logical, and the cited literature adequately supports the relevance of the study.

The study design is consistent with the stated objective and follows the methodological steps of a cross-sectional correlational study. As expected with this type of design, certain limitations and potential sources of bias are inherent. However, some of these issues would benefit from a more explicit justification and discussion, particularly regarding their implications for the interpretation of the findings.
Specifically, potential measurement bias related to the use of a questionnaire that has not been previously tested or validated requires further clarification. A more detailed description and justification of the development and use of this instrument should be provided in the Methods section, ensuring methodological transparency.

The manuscript reports results concerning the relationship between the practice of narrative medicine and levels of well-being. However, it is not sufficiently clear which items/questions of the newly developed tool effectively measure the practice of narrative medicine. In addition, greater clarity regarding how these items map the theoretical dimensions of the construct (attention, representation, and affiliation) would strengthen the interpretation of the findings.
This level of detail would not only enhance the rigour of the Results section but also facilitate a more robust and theoretically grounded Discussion. A clearer explanation on Methods section of how the construct is operationalised is important for readers’ understanding of the results.

The results are presented in narrative form and in tables, which is much appreciated. While the tables present the results clearly, some of the statements in the 'Results' section are not fully supported by the displayed data (e.g. lines 108–109 and 110–120). Additionally, the manuscript lacks sufficient information on the variables used to characterise the study sample in both the Methods and Results sections. Including additional details in the existing tables or providing supplementary tables would improve clarity and prevent potential misinterpretation.

The Discussion would benefit from further development, particularly through deeper integration of the study findings across groups of participants with existing literature.

The references cited are current and relevant to the study topic. Nonetheless, some inconsistencies in writing and formatting were identified throughout the manuscript, including in the reference list (pages 7–9). These issues should be addressed to ensure consistency with the journal’s formatting and editorial standards.

In summary, you may consider improving your manuscript following the major and minor revisions presented below:

Major revision 
1. The Methods section should more clearly describe the questionnaire used to assess narrative medicine, specifying which items measure the “practice of” and those that measure “knowledge”. A clearer summary of the sample characteristics assessed would also improve transparency and contextualization of the findings.
2. The Results section should be revised to resolve inconsistencies between the text and the tables. Providing, if possible, clearer results on the relationship between well-being and the theoretical dimensions of narrative medicine would strengthen interpretation.
3. The Discussion should more clearly interpret findings across participant groups within the theoretical framework of narrative medicine and well-being. Better integration with existing literature would enhance the relevance and robustness of the interpretation.

Minor Revisions
1. While limitations related to the cross-sectional correlational design are acknowledged, these could be stated more explicitly, particularly regarding the potential measurement bias associated with the variable “narrative medicine.”
2. Minor issues related to writing clarity and reference formatting should be addressed to ensure full compliance.

Author Response

Please see the attachment and revised manuscript.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors' revisions respond effectively to the concerns raised in my previous review report. I recommend publication of the revised paper.

Author Response

Thank you.

Reviewer 3 Report

Comments and Suggestions for Authors

Most of the comments from the initial review were adequately addressed. This included providing clarifications on the questionnaire, acknowledging the study's limitations, resolving inconsistencies in the results and revising the references.

No changes were made to the discussion section. However, a limited interpretation of the results in relation to the existing literature remains.

Author Response

Please see the attached table with the response.

Author Response File: Author Response.pdf