Healthcare Workers’ Moral Distress during the COVID-19 Pandemic: A Scoping Review

Round 1

Reviewer 1 Report

• This article is very well structured scoping review covering moral distress in health care workers. All sections of the review have been diligently attended to. 
• It does fit and contribute to literature, appropriate references,  methodology has been reviewed. 
• Line no 141  "The search was carried out from 01.02.2023 till 28.02.2023 in databases..." is incorrect and needs to be corrected. 
• I congratulate authors for their effort and making it "Peer reviewer proof" manuscript if I can say. 

Author Response

Hello dear reviewer!
Thank you for your time and expertise in reviewing this area of activity.
In response to your comment: is in"Line no 141 "The search was carried out from 01.02.2023 till 28.02.2023 in databases..." correct and needs to be corrected" -  I would like to inform you that this is a period in which three of the researchers conducted a selection of studies included in the existing scoping review.

Reviewer 2 Report

The subject addressed is very interesting and the choice of the study design is adequate, allowing for the collection of quantitative and qualitative information.

Despite its interest, the manuscript contains, however, several weaknesses, namely little information regarding the methodology used for data analysis. For example, the number of studies found and rejected differs between what is said in the text and what is presented in the Prism flowchart, some causes of rejection do not appear in the flowchart, it is not stated whether the researchers who selected the articles to be included worked alone or together, it is not clear how they resolved situations of disagreement in the classification. In addition, we are told that two researchers were involved in the initial selection but it is not clear whether these two researchers continued the whole process of analysis and synthesis of results.

Also, the description of the categories/themes found is not clear and there is no section where the frequency data of the themes per study, for example, were exposed. In the description of each theme/category, an initial analysis where a general approach is made to what was found, before listing what was taken from each study, individually is missing. This leads to the fact that, in several situations, the same information is repeated because it was found in more than one study.

The choice of the authors to separate the description of the results from their discussion has led the latter to appear as a continuation of the former and not as a discussion of results, as one would expect. Thus, when reading the discussion, we continue to see a description of what was found in the various selected studies, although, sometimes, there is a cross-reference with the literature on the topic. It would be interesting if the authors could discuss the results without going into so much detail on the contents of the articles studied and, instead, present the main findings and discuss them in relation to the existing literature.

Just a few short comments about the wording and the references: 

Both in the abstract and in the text, the authors use the abbreviation HCW without ever describing, in full, its meaning. The first time they use the term, they should do it in full and only then start using the abbreviation.

Regarding the references, the APA 6 standard was used when, currently, there is APA 7, so there are several references that are not in accordance with the most recent standards. I would advise you to review this as well.

Despite the extensive suggestions, I think the theme is very relevant and the study deserves a reformulation in order to make it more easily understood, thus increasing its quality.

The quality of the English is moderate, with some sentences that are difficult to understand and deserve a rewording.

Author Response

Hello, dear reviewer!
I would like to thank you for the time you have invested in evaluating this scope report.
I have provided answers to your suggestions below.

Point 1: The first detailed explanation of the HCW was provided in the abstract so that the abbreviation form could be used in the text in the future.

Point 2: I wanted to thank you for your attention. Due to technical reasons, you were sent an incomplete PRISMA flowchart, in which data was cut off by mistake. Therefore, your comment is understandable, if there is a data mismatch between the PRISMA flowchart and the description. I'm very sorry for the situation. I have attached a screenshot of what the PRISMA flowchart should look like.

Point 2: As a result of the data synthesis, an explanatory introduction was added to the themes raised.

Point 3: Section 2.3 was supplemented with the identification of researchers' roles according.

Point 4: You are right. APA 7 is used worldwide, but this article uses the Chicago style, referring to the journal's requirements for citation guidelines.

Author Response File: Author Response.pdf

Reviewer 3 Report

The article is interesting but, in the reviewer's opinion, requires some corrections and additions.

1.The purpose of the article contained in lines 7 to 8 should be articulated in the conclusion and summarised in one two-sentence summary.
2.In the first part of the introduction we read about moral distress and in the second part from line 62 about ethical dilemmas. It would be good to link the two parts clearly to each other.
3.The paragraph from lines 90 to 99 is important and needs appropriate footnotes.
4.Does the purpose of the article from the abstract coincide with that written in lines 465 and 466.
5.At least one sentence of explanation as to why the text is based on English-language literature, since the article has already written about this in 4.2. 

Author Response

Good afternoon!

I wanted to thank you for your suggestions on improving the scope of the work report.

I have provided answers to your comments/questions below.

Point 1: “The purpose of the article contained in lines 7 to 8 should be articulated in the conclusion and summarised in one two-sentence summary.”

Answer: As per your suggestion, the scope objective has been added to the conclusions.

Point 2:’ In the first part of the introduction we read about moral distress and in the second part from line 62 about ethical dilemmas. It would be good to link the two parts clearly to each other.”

Answer: In the introductory part, information about moral distress and ethical dilemmas was linked to making the text more understandable.

Point 3: “The paragraph from lines 90 to 99 is important and needs appropriate footnotes.”

Answer: In lines 90 to 91, a reference was added to studies confirming that the COVID-19 pandemic caused significant mental and physical health problems for healthcare workers. Lines 94 - 104 are the original text of the authors of this scope statement.

Point 4: “Does the purpose of the article from the abstract coincide with that written in lines 465 and 466”.

Answer: The target in lines 465 - 466 was corrected to match the target in the abstract.

Point 5: “At least one sentence of explanation as to why the text is based on English-language literature, since the article has already written about this in 4.2.”

Answer: The search strategy was limited to the English language filter, as the researchers of the given scoping review were only proficient in English. Research in other languages would be able to expand the quantity and quality of the information obtained.

With best regards, Evija Nagle!

Round 2

Reviewer 2 Report

Thank you to the authors for their revisions. 

Regarding the comment on the citation style, it was my mistake, because I did not check the style requested by the journal and mistakenly assumed it would be APA7. Thank you for the correction made.

I just have a few suggestions about the parts now included in the text:

The phrase "Continuous rotation within a department or employee turnover" (lines 107-108) appears to be incomplete or misplaced. Revision is advised.

In the sentences "On the other hand, the selection of the studies was carried out by two researchers, independently of each other. Initially, a pilot search was conducted to identify keywords in the abstracts and titles of the articles that were considered relevant to the selected topic. The keywords were searched in two database systems: PubMed and ProQuest." (lines 183-190) it is advised that the order be changed in order to maintain chronological coherence.

For example, keep in this section the sentence "Keywords were searched in two data-base systems: PubMed and ProQuest." and change to the section in line 256 the remaining sentences of this paragraph: "The selection of studies was carried out by two researchers, independently of each other. Initially, a pilot search was conducted to identify keywords from abstracts and article titles that were considered relevant to the selected topic. The results obtained by the two researchers were reviewed in an open discussion for consistency. The third researcher performed the analysis, synthesis, and description of the obtained data results. All disagreements and misunderstandings were resolved through discussion, reaching a common vision".

I believe that the changes introduced have, on the whole, improved the quality of the work and I would like to thank the authors once again for their willingness to provide the suggested changes.

Minor editing of English language required

Author Response

Hello, dear reviewer!

Thank you for your time and knowledge.

This really helped improve the quality of the manuscript.
Below are the answers to your suggestions!

Point 1: The phrase "Continuous rotation within a department or employee turnover" (lines 107-108) was removed from the text.

Point 2: Section 2.3. Identification of relevant studies - the first paragraph has only been modified by arranging the data in chronological order:

“Three researchers designed the search strategy for the study. Keywords were searched in two database systems: PubMed and ProQuest. The selection of studies was carried out by two researchers, independently of each other. Initially, a pilot search was conducted to identify keywords from abstracts and article titles that were considered relevant to the selected topic. The results obtained by the two researchers were reviewed in an open discussion for consistency. The third researcher performed the analysis, synthesis, and description of the obtained data results. All disagreements and misunderstandings were resolved through discussion, reaching a common vision.”