Influence of Work Environment Characteristics on the Level of Professional Burnout of Healthcare Professionals in Northeastern Bulgaria

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript Healthcare_3803388 entitled ‘Influence of Work Environment 
Characteristics on the Level of Professional Burnout of Healthcare Professionals in 
Northeastern Bulgaria’ analyses the risk factors present in the workplace that 
influence stress among healthcare workers.

The submitted and reviewed manuscript has significant methodological 
shortcomings, which require major revision before it can be reconsidered for 
publication. In addition, it would be advisable to improve the presentation and 
writing ofthe data so thatitis orderly and easy to read.

Specific comments:
Abstract: it needs to be modified in accordance with the suggestions made in each 
of the sections.

Introduction:
Although a brief conceptual introduction is provided, it does not accurately reflect 
the current state of affairs. It also fails to describe or identify any gaps in existing 
knowledge that this study aims to address.
The scope of the study is vaguely defined. It is recommended that the information 
in lines L66–L82 be written more precisely and organised in a clear manner, moving 
from the general to the specific and presenting the risk factors to be analysed more 
precisely.
What does the sentence ‘The work environment is also influenced by macro- and
microeconomic decisions’(L86–L86) mean?
The statement in lines 87–89 requires scientific evidence and the inclusion of 
bibliographical references to supportits validity.
The competencies of the analysed healthcare roles and the characteristics of the 
work environment that 'directly influence work-related stress' (L90) should be 
described in more detail.
The objective is presented adequately.

Materials and Methods
• Study design and participants
The specific design ofthe study is not described.
No reference is made to the size of the population or sample. The study participants 
and their inclusion are described vaguely, without explaining important aspects 
such as the selection or sampling method.
Although it is mentioned that the data collection process was ‘distributed with the 
collaboration of the professional organisations of the participating health 
professionals’ L102-103, it would be advisable to provide more information on this 
process and on the external controls (if any) necessary in the collection of data 
through surveys/questionnaires to support the methodological rigour of the 
procedure.
It is essential to clearly and exhaustively detail the inclusion and exclusion criteria 
used (L103-L107).

• Research methods and tools
The information provided about the instrument used to collect data does not allow 
for an assessment of its validity or reliability.
It is necessary to describe in detail the psychometric validation procedure (validity 
and reliability) carried out in part III of the questionnaire used, so that the data 
collected through this instrument are not classified as data of limited reliability.
It would also be advisable to include the estimated or actual time taken to complete 
the online survey and the total number of items it contained, as well as the scores 
and interpretations of the Maslach Burnout Inventory Human Services Survey test 
that makes up section II of the questionnaire.
The dependent and independent variables are not detailed.
These aspects need to be corrected in an explicit and precise manner.
Results
The number of participants is indicated, but it is necessary to include the response 
rate obtained in this section.
It would be useful to expand the information contained in Table 2, with the results 
broken down by each ofthe working groups and by region (Varna, outside Varna).
The statistics used are adequate for making comparisons between groups, but the 
inferences made go beyond what the statistics used allow.
Determining that there are significant differences in the variable ‘lack of time’ in 
groups with demonstrated emotional exhaustion compared to the group that does 
not show emotional exhaustion does not imply an association between the 
variables: lack of time-emotional exhaustion. This suggested association must be 
established with a correlation analysis. To respond to the stated objective, it would 
be interesting to include these analyses.
It would be advisable to reduce the text in the manuscript on the results shown in 
Table 3, so that duplicate information is eliminated.
Figure 1 requires a more detailed explanation, both of the values reflected and of 
the results presented.
The information contained in L312-L313 should be included in the discussion, not 
in the results section.

Discussion:
In general terms, the discussion is superficial, both in terms of the interpretation of 
the results and their contextualisation, and is presented in a disorderly manner, 
including information that belongs in the results section. It is recommended that the 
discussion be revised to follow the same order as the presentation of results and 
that a more in-depth interpretation be made in the analysis ofthe results.
In this way, the discussion in the manuscript would meet the requirements of this 
section.
The lack of a prior description in the introduction of the functions and 
characteristics of the jobs analysed hinders the discussion. The omission of data on 
the Maslach test categories also does not facilitate the discussion.
The bibliographic reference for the study mentioned in L333-L336 cannot be 
found. It is necessary to include it.
No results have been found to support the discussion of the information contained 
in the discussion in L401-L410, or if it has been included, its relationship is not 
detectable.
The limitations of the study and future lines of research must be included.

Conclusion: in addition to the recommendations offered to reduce the risk factors 
detected, a sentence is required that provides a concise answer to the study's 
objective: ‘to analyse the influence of workplace characteristics on the level of 
professional burnout among healthcare professionals’.

It is recommended that the answer to the objective be included in the corresponding 
section of the abstract

Comments for author File: Comments.pdf

Author Response

Please find  attached the Response letter, containing our detailed answers to the reviewers^, comments.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Introduction: The authors do not explain the novelty or originality of the study. The objective is wrong: "To monitor the influence of work environment characteristics on the level of professional burnout among healthcare professionals." Based on the methodology exposed above, the study cannot show a causal relationship between psychosocial factors and burnout.  

Methods: The information provided is insufficient. The authors did not mention the design of the study. In turn, sample size calculation was not mentioned. On the other hand, variables were not correctly defined, especially "high levels" of exhaustion (what cutoff point was considered?). 

Results: Lines 154-168 repeat unnecessarily what is mentioned in Table 1. 

Results: "High levels of professional burnout are associated with high scores in the emotional exhaustion and depersonalization scales, and impaired work performance". This information is not accurate but redundant: it is evident that burnout is composed of emotional exhaustion, depersonalization and impaired work performance. But, what do they mean by "high levels"? Besides, this section is entitled "Comparative results", but there is no comparison. Furthermore, I would expect to see some comparisons in Table 2, but this is solely descriptive, and the following paragraph is wrongly repetitive of this Table.  

Results: Table 3 is unclear. What does it try to demonstrate? Seriously, this Table is completely unpresentable. 

Line 183: "While only 68 or 57.6% of those who did not recognise this feature of the work process as risky". This percentage does not correspond to the one presented in Table 3. 

Results: Lines 194-288: This is only an unnecessary repetition of the information provided by Table 3. 

Figure 1: It is a repetition of Table 3, and it is also unclear. 

Lines 305-313: It gives wrong "highlights" based on biased interpretations. 

Discussion: This section repeats unnecessarily the data presented in Results. Its reading is unclear because there is no coherence. 

Conclusion: This section is not derived from the Results. 

 

 

Comments on the Quality of English Language

No comments.

Author Response

Please find attached the Response Letter contaning our detalied ansewrs to the rewierwes comments.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The manuscript Title: Influence of Work Environment Characteristics on the Level of Professional Burnout of Healthcare Professionals in Northeastern Bulgaria has been substantially improved. Most of the suggestions, recommendations and requirements have been addressed.

The introduction has been substantially improved, as has the conceptualisation of the subject
matter and the roles of the professionals analysed.

However, a specific description of the state of the art is still pending. Are there other studies that analyse the same subject? In other populations? In other countries? What are the conclusions and results of those studies? What is the main contribution of this study?

Furthermore, the objective is still not clearly and specifically defined, stated with a measurable
verb.

In relation to materials and methods, the current manuscript includes most of the required
aspects, although it is necessary to review the exclusion criteria (other than the negation of the
inclusion criteria) and include whether the completion of the questionnaires has been controlled
in any way.

Therefore, a new minor revision is recommended to include the detailed aspects. 

Comments for author File: Comments.pdf

Author Response

Please find attached the Response letter containing our detailed answers and comments.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

1. There is no objective in the Introduction. It is, indeed, in the abstract, but it must also be present in the Background. 
2. Table 1: It says "Above 25", "Above 11", and "Above 37". It should say:  

   ≥ 25, ≥ 11, and ≥ 37.

3. Table 1: It says "Below 30". It should say "Below 31".
4. Statistical methods: The authors should mention the Chi-square test as the hypothesis test. On the other hand, they say "analysis of variance", but since there is no evidence of its use in the results, it should be removed. 
5. The final right column should be corrected on the subtitle (the word "Inspector" appears to be incomplete (In-spector). 
6. The authors still repeat unnecessarily in text what is written in Tables 3 and 4. 

   The authors ignored my advice to stop repeating the information from the tables in the article's text. This is visually incorrect, unnecessary, and inefficient. They should have summarized the main results of these tables without repeating all the numbers.

7. Table 4: The phrase "Does not apply" is unnecessary and incorrect. 

   Reading the rest of the table, I realize that the authors refer to the "No" option for each environmental risk factor. It's incorrect to say "this does not apply," as this phrase means there is another option not applicable to the study group. It's unnecessary because this is understood to be a bivariate analysis between the risk factor (present) and a high level of burnout (present).

8. Table 4: The table should not have vertical lines. 
9. Table 4: Each subgroup (dimension) of burnout should include the subsample size (for example: "High level of EE, n = 327 (%)", so it can be understood. 

Author Response

Please find attached the Response letter, containing our detailed answers and comments.

Author Response File: Author Response.pdf

Round 3

Reviewer 2 Report

Comments and Suggestions for Authors

There are no more suggestions.