Nursing as a Sustainability Factor of the Health System during the COVID-19 Pandemic: A Qualitative Study

Round 1

Reviewer 1 Report

The wording in some repetitive paragraphs could be improved by avoiding redundancy, for example, the wording of the objectives is repeated in several sections (introduction, methodology and results).

In the results section when the data is dichotomous, it is advisable to only give one of the values, for example:
"with 83.3% women and 16.7% men". This data is redundant as it is a dichotomous parameter.

In the discussion section the argument reflected in lines 202, 203 and 204, the origin of this reflection should be indicated.

In the conclusions section, the argument reflected on lines 253 to 259, the origin of this reflection should be indicated.
The conclusions should be adjusted to give answers to the objectives and the rest of the arguments reflect them as reflections.
The arguments written between lines 270 to 277 should also be reflected as reflections.

Author Response

Dear reviewer,

First of all, we would like to thank you for the time spent reviewing the manuscript. We have modified and eliminate any paragraphs of introduction, methodology and results.

In the discussion section the argument reflected in lines 202, 203 and 204, the origin of this reflection has beeen indicated.

The conclusions have been adjusted to give answers to the objectives and the rest of the arguments reflect them as reflections.

In the results section, we have given one of the values for dichotomous parameter.

We hope that with the contributions made, these sections have been corrected.

Author Response File: Author Response.pdf

Reviewer 2 Report

Author Response

Dear reviewer, thanks you for your time and your contribution to improve and clarify the purpose of this manuscript.

 It is believed that the scope and role of nurses in COVID 19 varies from country to country. we have made  contributions about it, and we hope these sections have been corrected.

Author Response File: Author Response.pdf

Reviewer 3 Report

See attached    

Comments for author File: Comments.pdf

Author Response

First of all, we would like to thank you for the time spent reviewing the manuscript. We have modified the introduction, methodology, results and conclusions. We hope that with the contributions made, these sections have been corrected.

Author Response File: Author Response.pdf

Reviewer 4 Report

I believe that the topic of the manuscript is interesting.

I think that the study doesn´t provide new information.

It is difficult to find differences in the nurse's experience related to COVID-19 presented in this paper result from that of other diseases.

Specific comments:

1. Writing

   The writing, structure and organization of the manuscript is in accordance with the guidelines.

2. Title 

  The title reflects the content and problem studied.

3. Abstract 

  There are no references in the background of research.

4. Background 

   A state of the art is made in relation to the study. I think that The information is a general. The objective of the study is not mentioned at any time.

5. Methods 

 There aren´t a Participant flow (a diagram is strongly recommended). It does not describe the rigor of qualitative research (trust worthiness). These will have to be described in detail.

6. Findings 

  There is no table of general characteristics of the subjects. Please describe the general characteristics of the subject in a table..

7. Discussion 

  Please add a discussion with unique content related to COVID-19

8. Conclusions

  The presentation of nursing practice is insufficient. Please reinforce.

Author Response

We would like to express our gratitude for the time taken to review this manuscript and for the comments made, which we believe to be critical for producing rigorous and quality research.

We have removed the year of publication from the text as you indicated.In addition, our manuscript has been reviewed by a native scientist.

 Regarding the abstract have been introduced those sections that were missing have been completed, as well as the date of the study. In turn, we have included new arguments that describe the conclusions.

There is a table of general characteristics of the subjects. 

We have made modifications in discussion and conclusions and 

We hope that these modifications have been clarifying.

Author Response File: Author Response.pdf

Round 2

Reviewer 3 Report

see attached

Comments for author File: Comments.pdf

Author Response

Review: Sustainability-892196 (Round 2)

Thank you very much for taking the time to address all of my comments. The paper has improved. However, there is still somes problems in the methodology and in the presentation of the results. Some indications were already stated in the first review but have not been addressed. Detailed comments below:

Comment 1:

 - “For the discourse analysis, a preliminary manual categorization was carried out and coded using the Atlas.ti computer program. 8.0. (16)” When add is indicated company and country of the software used is put in the text (not in bibliographic references) as follows: Atlas.ti computer program. 8.0. (Scientific Software Development GmbH, Berlin, Germany).

DONE

Comment 2:

-“provide consent to participate voluntarily in the research”: [written/verbal?] consent. - What is the code of ethical approval and from which institution did you obtain it? this was already stated in the first review.

DONE

Comment 3:

- “data obtained from the various discourses comply with current regulations regarding the protection of personal data”. I suggest adding the reference: Ley Orgánica 3/2018 (Spanish Government)

DONE

Comment 4:

 - “This analysis allowed us to investigate those aspects most relevant to the elaboration of the script used for focus groups” What questions or themes made up the script? Indicate the script of the focus groups. In the same way, the interview had a script or some points that were asked?

Response
Dear reviewer, thank you for your appreciated indications, the interview script, as well as the focus group script, we have attached an annex (annex 1) in which it is specified.

DONE

Comment 5:

- “Data triangulation was carried out, using various techniques (non-participant observation, interviews and discussion groups) in order to grant greater validity and reliability to the obtained data”. Precisely, when one uses a mixed technique, it is done to triangulate and, for this, it is necessary to carry out the analysis and presentation of the results correctly and clearly. It is important to know the method by which the different categories and subcategories have been achieved. By not doing so, the power for discussion, understanding of reality and reliability is lost. “Categories drawn from discourse analysis during the interviews and discussion groups, different categories underlying the professional identity of nurses emerged. Such themes arise following reflection on the way in which the study population thinks, talks about and intervenes on a day-today basis in relation to the well-being and health of individuals and groups. Three categories were used for this analysis” In the same way, as I already pointed out to you in the previous review (In methodology, it was indicated that non-participant observation was made. Where are the results of this observation shown? Who made it? For how long? How was it done during the alarm state?). In addition, the authors do not appear to indicate in results any of the field notes derived from nonparticipant observation that may be very important. This part has to be worked on carefully. For example: “Recognition. Informants were asked in the interviews whether nursing work is recognized by service users independent of whether this work is recognized by the system itself. Outcomes were again seen to be highly positive. According to participating nurses, almost all service users recognize their work and display high levels of gratitude”. Does this mean that this category emerges only from interviews? Review the results section to adequately expose which technique comes from each category and subcategory. What categories are supported by the different techniques, if there are differences, etc.

Response:

Dear reviewer, thanks for the suggestions to improve the article. We have modified Table 2

where the different techniques used and the categories and subcategories that emerge from

the study are described.

In reference to non-participant observation, we must tell you that after the numerous data

obtained, we are writing another article with this information as the protagonist.

DONE

Comment 6:

-“This obviates the need for further study into 4 improvement to the healthcare system”.

This sentence seems to me not very correct, do you really consider that it is not necessary to do studies to improve the health system? maybe it's wrongly expressed.

Response:

Dear reviewer, your consideration is very correct, it has been a writing error. We have proceeded to modify it to give it a correct meaning.

DONE

Comment 7:

- In the discussion line 5 a reference is missing or is the comma an error? “This obviates the need for further study into improvement to the healthcare system. In the same sense, several studies (,18,19,20) have shown that the relationship between professional self-concept and the performance of workers generates job satisfaction and autonomy.”

DONE

Comment 8:

 - “In the same sense, other authors (22,23,24) refer to job dissatisfaction associated with unfavorable organizational and structural conditions, interfering in role performance and professional preparation itself.” I don't quite understand how this statement relates to your results.

Response:

Dear reviewer, your consideration is very correct, it has been a writing error. We have proceeded to modify it.

DONE

Comment 9:

- “In this sense it is important to make workers feel that they are a fundamental cog in the sustainability of the institution. Commitment to this may be increased through financial incentives and individual recognition, making nurses feel supported by the organization and motivated.” I think there can be more discussion, in their results they have observed what said professionals perceive and fundamentally it is linked to their patients, isn't it? The perception of institutional valuation has not been addressed.

Response

Dear reviewer, thank you for your appreciation. We have proceeded to complement the discussion to improve it in the sense that you propose

DONE

Comment 10:

- “This is strongly linked to levels of self-esteem, with the service users themselves also increasing their security and confidence in the nurses themselves and, therefore, in the health system.” Levels??? This has not been measured. It would be more correct to speak of the perception of selfesteem in the subjects of the sample.

Response:

Dear reviewer, your consideration is very correct, it has been a writing error. We have proceeded to modify it.

DONE

Comment 11:

- “According to nurses, the advantages of socio-health coordination determine numerous patient benefits, enabling them to better manage their symptoms and family needs in extreme situations such as the present one. In agreement with other studies (38), this may be due to greater access to resources. Nurses state that their profession is highly important to socio-health care due to the direct and close contact they have with patients (39) express that community nurses play an important role in patient care, especially in-home care. Further, authors such as (40) clarify that nurses are considered to be hugely important for socio-health coordination. A reason for this is that they are the link between resources and needs of the system, coordinating healthcare resources. This was reflected in the present study through the perceptions given by informants. In the study conducted by (41), this was reflected following administration of an intervention which uncovered a decrease in the use of social and health resources targeting nursing performance. This outcome was particularly notable in the case of case managers” At this point, it may be interesting to discuss with the establishments set up to attend to these patients, both through telephone consultations and video consultations. This appears in your results and put references that support the claims you make.

Response:

Dear reviewer, thank you for your appreciation. We have proceeded to complement the discussion to improve it in the sense that you propose. We have added references to support our claims.

DONE

 - References: Reference 14 remove the crossed-out reference.

DONE

- Reference 33 check that there is an underline that should not be.

DONE

Round 3

Reviewer 3 Report

Below are some comments:

As indicated in the previous revision, Atlas ti is not placed in the references section. What was added in brackets in text is sufficient (which was what was indicated in previous revisions). Remove reference 17. But in the text it says that it is 16. There is error in this sense. Review and fix.

The 17 in text is the Helsinki Declaration. Reference 18 is not well written, it is missing to complete the reference according to standards 18. Organic Law 3/2018 (Spanish Government). Complete

Author Response

Estimado revisor,

muchas gracias  por el tiempo dedicado a revisar el artículo y por sus sugerencias de mejora. Se han modificado y revisado las referencias indicadas y esperamos que con los cambios realizados esté todo correcto y listo para su publicación.

De nuevo agradecerle su dedicación,

un cordial saludo