The Effect of Elderly Patients’ Health Information Literacy, Ageism, and Communication Skills on Clinical Nurses’ Burnout: A Cross-Sectional Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors,

you should add to discıssion new articles thank

Author Response

We have added the updated articles. 

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this article.

This study examined the association between nurses’ perceptions of elderly patients’ health literacy, ageism, communication skills, and burnout. Using validated measures in a cross-sectional survey of 269 Korean nurses, the authors found that higher ageism and lower communication skills were significant predictors of burnout. The topic is timely and the study is well-structured.

Below are several suggestions to further strengthen the manuscript.

First, the rationale for using a single-item assessment for health literacy is understandable, but the validity and limitations of this approach should be discussed more clearly in the methods or limitations section.

Second, the regression model is appropriate, and key assumptions were tested. However, it would be helpful to provide confidence intervals for the regression coefficients to better quantify the precision of the estimates.

Third, the theoretical model and variable relationships are well motivated. Still, a clearer conceptual diagram summarizing hypothesized paths or interrelations among variables (e.g., health literacy → ageism → burnout) could improve interpretability.

Fourth, the finding that ageism was the strongest predictor of burnout is important and well discussed. The discussion may benefit from slightly more elaboration on how this finding aligns or contrasts with international literature on geriatric care burden and age-related biases.

Fifth, while tables are generally well presented, a few formatting adjustments (e.g., consistent decimal places, improved alignment in Tables 2 and 3) would improve clarity.

Sixth, minor typographical errors and inconsistencies (e.g., spacing in variable names, punctuation) should be corrected during proofreading.

Overall, this is a valuable contribution to understanding age-related factors in nurse well-being. I hope the authors find these suggestions helpful.

Author Response

Please refer to the attached file "Response to reviewers".

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The introduction manages to give a conceptual and empirical account of the main constructs of the study. This favors the development of their objectives.

It is recommended to add the objectives and hypotheses of the study explicitly.

In the same vein, it is recommended to clarify the justification of the study carried out in terms of the research gap that it would seek to address, indicating what is the contribution of this study with respect to previous research.

In methodology, some conceptual clarifications are suggested to give robustness to the explanation. In design integrate add the correlational character of the design. In the sample, give an account of the type of sampling used.

In instruments, characterization of the participants, it is indicated that various sociodemographic variables were investigated, but also regarding anxiety about aging and the preference for geriatric nursing. It is not clear how these variables, which appear to be more complex, were measured.

Although the methodology begins with an introduction regarding ethical aspects and data analysis, it is recommended to generate a specific section for these two aspects, to order the methodological story.

Results and discussion are presented appropriately.

Considering the high importance it has for the study, it is recommended to address in the discussion how the measurement of health literacy in a single item may or may not be a methodological limitation.

Only 10% of the literature used corresponds to publications from the last five years. It is suggested to complement the introduction and, with it, the discussion, with updated literature.

Author Response

Please refer to the attached file "Response to reviewers".

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

Dear Author,

First of all, I found the topic addressed extremely interesting and relevant to the field in which we operate; however, it needs improvement in certain aspects: Editing: the tables provided lack a legend for acronyms. Title: the type of study conducted and the reference setting are missing (the same suggestion applies to the keywords). Abstract I suggest framing the conclusions of this section in terms that are more oriented toward “Clinical and Assistive Practice” (see the introduction and possible “Perspectives for Clinical and Assistive Practice”). Introduction Often redundant and at times not very incisive in terms of clinical and assistive perspectives (especially the section devoted to burnout). Regarding redundancy, I suggest reducing the text by at least 30% while retaining the content (burnout aside), which overall is fairly well addressed. As for the section on burnout (lines 95–113, supported by overly dated references), I suggest completely restructuring it and making it more incisive from a clinical practice perspective, focusing on the possible domains of burnout in different care settings that are highly prone to stress and burnout. In this regard, with appropriate reference literature, I suggest discussing topics such as recent issues including burnout syndrome among nurses in prisons; understanding burnout in nurses; burnout syndrome and its associations with coping and job satisfaction in critical care nurses; and the impact of social support in preventing burnout syndrome in nurses. This would certainly broaden the audience of potential readers/researchers interested in the collected data, which moreover have a strong impact on the main topic of the study. For the objectives (lines 114–120), I suggest the classic approach of clearly stating the primary objectives first and then the secondary ones using the standard formula: “the primary objectives of the study were…, whereas the secondary objectives were…”. For the type of study conducted, this is an extremely relevant element. Methods This is certainly the most critical element of the manuscript and deserves greater attention. I suggest being guided by the international reference tool (Equator Network: https://www.equator-network.org/ ) and the related checklist (currently absent and to be added among the supplementary files) for an international-level scientific dissertation. In its current version, the manuscript appears “immature,” especially in this key section given the type of study conducted. Results Overall, these are the strength of the manuscript and will certainly benefit from the previous and subsequent suggestions. Attention is needed only for the necessary editorial improvements. I also suggest creating a summary flowchart of the study. Discussion It needs to be completely restructured because it lacks real scientific value (also in this case, a reduction of at least 30% of the content is suggested). As with the introduction, I also suggest expanding it toward clinical and assistive practice and, building on the introduction’s suggestion, possibly adding a specific section such as “Perspectives for Clinical and Assistive Practice,” which could better support the results obtained and a broader discussion in terms of academic validity. Limitations These are little more than presented in a school-style format and require a specific dedicated section; in my opinion, they should be considered mainly from the perspective of generalizability of the data with respect to the study population. Conclusions I recommend developing critical reflection in line with the points raised above and, again, dedicating a specific section to this. References To be expanded according to the indications given. I also suggest updating those older than 10 years unless they are methodological in nature or have a strong impact as evidence of effectiveness. In summary, the manuscript presents scientific results of interest and, with the proposed improvements, could increase its overall quality. My recommendation is to proceed with the in-depth revision proposed, especially in terms of methods and “Perspectives for Clinical and Assistive Practice,” which, if not adequately addressed, will not allow for a truly international interpretation of the manuscript. A native-language review is recommended.

Comments on the Quality of English Language

See the comments

Author Response

Please refer to the attached file "Response to reviewers".

Author Response File: Author Response.pdf

Reviewer 5 Report

Comments and Suggestions for Authors

General Comments: The manuscript addresses a topic relevant to contemporary nursing practice and of interest to both clinical and educational professionals.

The study has a good sample size and uses validated instruments. However, some aspects require clarification regarding the measurement of health literacy, the interpretive language used in a cross-sectional study, and the terminological and methodological consistency of the text. Furthermore, greater caution is recommended when interpreting modest associations.

Comment 1: The introduction could benefit from greater theoretical anchoring in burnout (e.g., work-related stress or the Job Demands-Resources (JD-R) Model), to strengthen the rationale of the study (lines 97-113).

Comment 2: Elderly patients' health literacy is not directly measured; instead, it is assessed subjectively by nurses. This represents a significant methodological limitation, as it reflects the nurse's perception rather than the patient's actual competence.

It would be appropriate to explicitly clarify, both in the Methods and in the Discussion, that this is a proxy measure and to scale back the causal conclusions linking older adults' health literacy to nurse burnout (e.g., lines 346-352).

Comment 3: The study employs a cross-sectional design (lines 150-153), but several sections of the manuscript use language suggesting causal relationships (e.g., "low health literacy increases workload," lines 346-348; "communication skills serve as a protective factor," lines 377-379).

I suggest reformulating these statements in associative terms and strengthening the Limitations section (lines 431-438), highlighting the risk of causal inference bias.

Comment 4: The term “agism” is used repeatedly instead of “ageism,” which is reported in the article title (e.g., lines 249-255, 300-303, Tables 2-5).

Comment 5: The discussion is extensive and well-argued, but in several passages it gives excessive weight to modest correlations (e.g., (r = .13(.14) for health literacy, lines 299-300).

I recommend distinguishing between strong outcomes (e.g., ageism, communication skills) and weak outcomes, and focusing the interpretative focus by placing greater emphasis on predictors with higher β values (lines 323-325)

Final Comment: The manuscript addresses an important topic and presents interesting data; however, minor revisions are needed, especially regarding methodological clarity, conceptual precision, and interpretive caution.

 

Comments for author File: Comments.pdf

Comments on the Quality of English Language

The manuscript is generally understandable; however, the quality of the English language requires improvement. The text contains several inaccuracies in its use of terms. I recommend hiring a native English speaker or utilising a professional editing service to enhance clarity and readability.

Author Response

Please refer to the attached file "Response to reviewers".

Author Response File: Author Response.pdf

Round 2

Reviewer 4 Report

Comments and Suggestions for Authors

I regret that the unresolved gaps range from less relevant issues—such as the lack of a legend for the acronyms used in the tables (Table 3 still being extremely non-intuitive for easy reading) and the continued absence of a coherent flow in the proposed study—to more significant ones. These include the type of study conducted not being clearly stated either in the title or among the keywords, where it is instead confused with “clinical nurse,” which is more likely related to the topic of the study. There is also the persistent absence of a reporting tool (mandatory for the relevant scientific community), which would likely have helped the author manage the manuscript in a more scientifically robust and internationally valid manner, particularly in the Methods section, which once again appears very convoluted. Furthermore, the implications for clinical and assistive practice remain weak, and the limitations—lacking a dedicated section—do not allow for a genuine academic discussion on the potential generalizability of the collected data in terms of tools, methods, and/or population. Perhaps the author could have taken this opportunity with greater humility, as presenting such a relevant manuscript single-handedly risks not fully focusing on academic discussion. The references are still often outdated and not sufficiently able to adequately support the conducted study (this too was a suggestion that was not properly followed).

Comments on the Quality of English Language

See the comments

Author Response

Please refer to the attched file.

Author Response File: Author Response.pdf