Patient Safety and Quality Improvement in Nursing Practice: Associations Among Workload, Occupational Coping Self-Efficacy and Medical Device-Related Pressure Injury Prevention

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This manuscript examines the mediating role of occupational coping self-efficacy (OCSE) in the relationship between nurses’ workload and medical device–related pressure injury (MDRPI) prevention performance. The topic is timely, clinically relevant, and well aligned with patient safety and quality improvement priorities in nursing practice. Grounded in Social Cognitive Theory (SCT), the study provides a theoretically informed explanation of why workload alone may not directly translate into preventive performance. Overall, the manuscript is methodologically sound, clearly written, and makes a meaningful contribution to the MDRPI and nursing workforce literature. However, several conceptual, methodological, and presentation-related issues require clarification and refinement to strengthen the rigor and impact of the work.

Title and Abstract

The title accurately reflects the study variables, population, and analytic approach. It is clear and sufficiently specific. The abstract is well structured and concise, clearly presenting the background, methods, results, and conclusions. However, the authors may consider explicitly stating that full mediation was identified to strengthen the interpretability of the findings for readers scanning the abstract.

Introduction and Theoretical Framework

The introduction provides a strong epidemiological and clinical rationale for focusing on MDRPI prevention. The literature review is comprehensive and current, effectively highlighting gaps in prior research—particularly the lack of mechanism-focused studies. The SCT framework is well articulated, and the rationale for selecting OCSE as a mediator is theoretically sound. Nevertheless, the authors could strengthen this section by more explicitly distinguishing OCSE from general self-efficacy early in the introduction to avoid conceptual overlap and enhance clarity for international readers.

Methods

The descriptive correlational design with mediation analysis is appropriate for the stated aim. The sampling strategy, inclusion criteria, and power analysis are clearly described and justified. Data collection procedures demonstrate attention to ethical rigor and data quality. The justification for modifying the NASA-TLX by excluding the performance subscale is well supported both theoretically and empirically. One concern, however, is the relatively large number of covariates included in the regression models; a clearer rationale for including each covariate in the mediation model (as opposed to descriptive analyses) would improve transparency and reduce concerns about over-adjustment.

Results

The results are logically organized and clearly presented. Tables are detailed and informative, and the mediation findings are reported in accordance with best practices. The statistical interpretation is accurate, and the conclusion of full mediation is appropriately supported by the non-significant direct effect and significant indirect effect. Minor improvements could include reducing redundancy between the text and tables and briefly interpreting the practical magnitude of the effect sizes rather than focusing solely on statistical significance.

Discussion

The discussion is a major strength of the manuscript. The authors effectively interpret the findings within the SCT framework and meaningfully contrast their results with prior studies emphasizing direct workload–performance relationships. The integration of contextual factors, such as role ambiguity between WOCNs and general nurses, adds valuable explanatory depth. The proposed practice implications are realistic and well aligned with the findings. However, the discussion could be further strengthened by explicitly addressing the cross-sectional nature of mediation analysis and clarifying that temporal or causal inferences remain tentative despite theoretical grounding.

Conclusions and Limitations

The conclusions accurately reflect the study findings and appropriately emphasize the importance of psychological resources alongside organizational factors. Limitations are acknowledged, including the single-site design and cross-sectional data. The authors might consider more explicitly discussing potential common method bias due to self-reported measures and how this may influence observed relationships

Author Response

Dear Reviewer 1,

We sincerely appreciate the time and effort you devoted to reviewing our manuscript and for providing thoughtful and constructive comments. Your suggestions were invaluable in improving the clarity, rigor, and interpretability of our study. We have carefully revised the manuscript in accordance with your comments, and our point-by-point responses are provided below. All changes have been incorporated into the revised manuscript.

 

Comment 1

The title accurately reflects the study variables, population, and analytic approach. It is clear and sufficiently specific. The abstract is well structured and concise, clearly presenting the background, methods, results, and conclusions. However, the authors may consider explicitly stating that full mediation was identified to strengthen the interpretability of the findings for readers scanning the abstract.

Response 1:

Thank you for this positive and constructive comment. We agree that explicitly stating the full mediation finding may enhance the clarity and interpretability of the abstract for readers. Accordingly, we revised the Results and Conclusions sections of the abstract to clearly indicate that occupational coping self-efficacy fully mediated the association between workload and MDRPI prevention performance.

 

Comment ２

The introduction provides a strong epidemiological and clinical rationale for focusing on MDRPI prevention. The literature review is comprehensive and current, effectively highlighting gaps in prior research—particularly the lack of mechanism-focused studies. The SCT framework is well articulated, and the rationale for selecting OCSE as a mediator is theoretically sound. Nevertheless, the authors could strengthen this section by more explicitly distinguishing OCSE from general self-efficacy early in the introduction to avoid conceptual overlap and enhance clarity for international readers.

Response ２:

Thank you for this insightful comment. We agree that clearer conceptual distinction between occupational coping self-efficacy and general self-efficacy may enhance clarity for international readers. In response, we have revised the Introduction to explicitly distinguish OCSE from general self-efficacy early in the theoretical background. Specifically, we clarified that OCSE refers to nurses’ perceived capability to cope with job-specific clinical stressors, rather than a generalized belief in personal competence, thereby reducing potential conceptual overlap and strengthening theoretical precision.

 

Comment ３

The descriptive correlational design with mediation analysis is appropriate for the stated aim. The sampling strategy, inclusion criteria, and power analysis are clearly described and justified. Data collection procedures demonstrate attention to ethical rigor and data quality. The justification for modifying the NASA-TLX by excluding the performance subscale is well supported both theoretically and empirically. One concern, however, is the relatively large number of covariates included in the regression models; a clearer rationale for including each covariate in the mediation model (as opposed to descriptive analyses) would improve transparency and reduce concerns about over-adjustment.

Response ３:

Thank you for this constructive comment. We agree that clearer justification for the inclusion of covariates in the mediation models would enhance transparency and address concerns regarding potential over-adjustment. In response, we have revised the Methods section to more explicitly describe the criteria used for covariate selection. Specifically, covariates were included based on prior empirical evidence and theoretical relevance indicating their associations with workload, occupational coping self-efficacy, or MDRPI prevention performance, rather than for purely descriptive purposes. This approach was intended to control for plausible confounding factors while preserving the interpretability of the mediation model.

 

Comment ４

The results are logically organized and clearly presented. Tables are detailed and informative, and the mediation findings are reported in accordance with best practices. The statistical interpretation is accurate, and the conclusion of full mediation is appropriately supported by the non-significant direct effect and significant indirect effect. Minor improvements could include reducing redundancy between the text and tables and briefly interpreting the practical magnitude of the effect sizes rather than focusing solely on statistical significance.

Response ４:

Thank you for this positive and constructive comment. We agree that the clarity of the Results section could be further improved by minimizing redundancy between the narrative text and the tables. Accordingly, we have revised the Results section to focus on the direction and pattern of key findings relevant to the mediation model, while avoiding repeated reporting of numerical values already presented in the tables.

 

Comment 5

The discussion is a major strength of the manuscript. The authors effectively interpret the findings within the SCT framework and meaningfully contrast their results with prior studies emphasizing direct workload–performance relationships. The integration of contextual factors, such as role ambiguity between WOCNs and general nurses, adds valuable explanatory depth. The proposed practice implications are realistic and well aligned with the findings. However, the discussion could be further strengthened by explicitly addressing the cross-sectional nature of mediation analysis and clarifying that temporal or causal inferences remain tentative despite theoretical grounding.

Response 5:

Thank you for this insightful and encouraging comment. We agree that, despite the strong theoretical grounding of the mediation model in Social Cognitive Theory, the cross-sectional nature of the data limits temporal ordering and causal interpretation. In response, we have further revised the Discussion to explicitly emphasize that the mediation analysis represents a statistical pattern of associations rather than evidence of a causal or temporal mechanism.

 

Comment 6

The conclusions accurately reflect the study findings and appropriately emphasize the importance of psychological resources alongside organizational factors. Limitations are acknowledged, including the single-site design and cross-sectional data. The authors might consider more explicitly discussing potential common method bias due to self-reported measures and how this may influence observed relationships.

Response 6:

Thank you for this thoughtful comment. We agree that the exclusive use of self-reported measures may introduce the possibility of common method bias, which could inflate observed associations among study variables. In response, we have revised the Limitations section to explicitly acknowledge this potential bias and to discuss how reliance on self-reported data may have influenced the strength of the observed relationships. We also note that future studies incorporating multi-source data or objective measures would help mitigate this concern and further strengthen causal inference.

 

Once again, we sincerely thank you for your insightful comments and constructive feedback. We believe that these revisions have significantly strengthened the manuscript and improved its clarity and scientific rigor.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,

Thank you for the opportunity to revise your manuscript. The topic is current and interesting. However, revisions are necessary to be made:

Firstly, the introduction, while extensive and well-documented, is overly descriptive and could benefit from greater focus. It is suggested to clarify more directly the specific research gap that the study intends to fill and to better explain the original contribution compared to previous studies that have already examined workloads, self-efficacy and preventive practices. The section could be streamlined, reducing conceptual repetitions, and conclude with explicitly formulated research hypotheses. As far as the study design is concerned, the cross-sectional nature severely limits the interpretation of the proposed mediation model. Although the authors acknowledge this limitation in the concluding section, it is also necessary to discuss it more critically in the methods and discussion section, making it clear that the mediation tested is statistical and not causal. It would also be appropriate to justify more thoroughly the choice of a descriptive-correlational design to meet the theoretical objectives of the study.

The Methods section requires a more thorough review. In particular:

1. The description of convenience sampling should be accompanied by a more nuanced discussion of potential selection biases and implications for the generalizability of the results.
2. The management of control variables is not always clear: it is recommended to explain more systematically the criteria used for their selection and inclusion in regression models.
3. The modification of the NASA-TLX instrument (exclusion of the "Performance" dimension) is justified, but it would deserve a more critical discussion on the theoretical and methodological consequences of such a choice, also in relation to comparability with other studies.

As regards the results, although statistical analyses are appropriate, the presentation could be made clearer and more concise. In particular, some parts are redundant between text, tables and figures. It is suggested to emphasize more the key results relevant to the mediation model, avoiding repeating values already reported in the tables extensively.

The discussion is well articulated, but tends in some points to overinterpret the results. The authors should maintain a clearer distinction between what emerges from the data and the proposed theoretical or practical implications, especially considering the limitations of cross-sectional design and the single-center context. In addition, it would be useful to more critically compare the results with studies that found direct effects of the workload on preventive practices, discussing possible alternative explanations.

Author Response

Dear Reviewer2,

We sincerely appreciate the time and effort you devoted to reviewing our manuscript and for providing thoughtful and constructive comments. Your suggestions were invaluable in improving the clarity, rigor, and interpretability of our study. We have carefully revised the manuscript in accordance with your comments, and our point-by-point responses are provided below. All changes have been incorporated into the revised manuscript.

 

Comment 1

The introduction, while extensive and well-documented, is overly descriptive and could benefit from greater focus. The specific research gap and original contribution should be clarified more directly.

Response 1:

Thank you for this important observation. We agree that the Introduction could be more focused. Accordingly, we streamlined the section by reducing conceptual repetition and reorganizing the narrative to more clearly highlight the specific research gap. In particular, we emphasized that although workload, self-efficacy, and preventive practices have been widely studied, empirical research examining the indirect pathway linking workload to MDRPI prevention performance through occupational coping self-efficacy remains limited. We also clarified the original contribution of the present study by highlighting its theory-driven examination of this understudied mechanism in the context of MDRPI prevention.

 

Comment ２

The authors should better explain how this study differs from and adds to existing research on workload, self-efficacy, and preventive practices.

Response ２:

We appreciate this suggestion and have revised the Introduction to more explicitly distinguish the present study from prior research. Specifically, we clarified that previous studies have largely focused on direct associations between workload and preventive performance, whereas this study uniquely applies Social Cognitive Theory to examine occupational coping self-efficacy as a mediating psychological mechanism.

 

Comment ３

The Introduction should conclude with explicitly formulated research hypotheses.

Response ３:

We agree with this recommendation. The final paragraph of the Introduction has been revised to explicitly state the study aims and to present clearly formulated research hypotheses regarding the associations among workload, occupational coping self-efficacy, and MDRPI prevention performance, including the hypothesized mediating role of occupational coping self-efficacy.

 

Comment ４

The cross-sectional design limits causal interpretation of the mediation model. This limitation should be discussed more critically in the Methods and Discussion, and the choice of a descriptive-correlational design should be more thoroughly justified.

Response ４:

Thank you for this insightful comment. We fully acknowledge that the cross-sectional design severely limits causal interpretation of the mediation model. In response, we strengthened both the Methods and Discussion sections to clearly state that the mediation examined in this study represents a statistical mediation rather than a causal mechanism. Furthermore, we expanded the justification for the descriptive-correlational design by explaining that this approach is appropriate for theory-informed, exploratory examination of associative pathways proposed by Social Cognitive Theory, particularly in clinical contexts where longitudinal or experimental designs are not yet feasible.

 

Comment 5

The description of convenience sampling should be accompanied by a more nuanced discussion of potential selection biases and implications for the generalizability of the results.

Response 5:

Thank you for this insightful comment. We agree that convenience sampling may introduce potential selection bias and limit the generalizability of the findings. Accordingly, we revised the Study Population section to more explicitly acknowledge the possibility of selection bias associated with single-site convenience sampling and to clarify that the findings should be interpreted with caution when generalizing to other institutions or clinical contexts.

 

Comment 6

The management of control variables is not always clear: it is recommended to explain more systematically the criteria used for their selection and inclusion in regression models.

Response 6:

Thank you for this helpful suggestion. We revised the Data Analysis section to more clearly and systematically describe the criteria used for selecting control variables. Specifically, covariates were chosen based on their theoretical relevance within the Social Cognitive Theory framework, prior empirical evidence demonstrating associations with preventive nursing performance, and their potential to act as confounding variables. This clarification was added to improve transparency and reproducibility of the analytical approach.

 

Comment 7

The modification of the NASA-TLX instrument (exclusion of the "Performance" dimension) is justified, but it would deserve a more critical discussion on the theoretical and methodological consequences of such a choice, also in relation to comparability with other studies.

Response 7:

Thank you for this valuable comment. We agree that the modification of the NASA-TLX instrument warrants a more critical discussion. In response, we expanded the Measurement Tools section to more thoroughly address the theoretical and methodological implications of excluding the Performance subscale. In addition to the psychometric justification, we clarified how this decision affects the interpretation of perceived workload and explicitly noted the resulting limitations regarding direct comparability with studies using the original six-item NASA-TLX composite.

 

Comment 8

As regards the results, although statistical analyses are appropriate, the presentation could be made clearer and more concise. In particular, some parts are redundant between text, tables and figures. It is suggested to emphasize more the key results relevant to the mediation model, avoiding repeating values already reported in the tables extensively.

Response 8:

Thank you for this helpful comment. We agree that parts of the Results section contained redundancy between the text, tables, and figures. Accordingly, we revised the Results narrative to improve clarity and conciseness by reducing repetitive reporting of numerical values already presented in the tables and figures.

 

Comment 9

The discussion is well articulated, but tends in some points to overinterpret the results. The authors should maintain a clearer distinction between what emerges from the data and the proposed theoretical or practical implications, especially considering the limitations of cross-sectional design and the single-center context. In addition, it would be useful to more critically compare the results with studies that found direct effects of the workload on preventive practices, discussing possible alternative explanations.

Response 9:

Thank you for this thoughtful comment. We agree that careful interpretation is required given the cross-sectional design and single-center context of this study. In response, we revised the Discussion to more clearly distinguish between findings directly supported by the data and the theoretical or practical implications proposed by the authors. Causal or deterministic language was further moderated where appropriate. In addition, we expanded the Discussion to more critically compare our findings with previous studies that reported direct effects of workload on preventive practices.

 

Once again, we sincerely thank you for your insightful comments and constructive feedback. We believe that these revisions have significantly strengthened the manuscript and improved its clarity and scientific rigor.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this article.

This study tested whether occupational coping self-efficacy (OCSE) mediates the relationship between workload and medical device–related pressure injury (MDRPI) prevention performance among Korean nurses. Using validated instruments and bootstrapped mediation analysis, the study found a full mediation effect through OCSE. The topic is timely and relevant for patient safety and workforce resilience.

Below are suggestions to strengthen the manuscript.

First, while the mediation framework is conceptually well grounded in social cognitive theory, the cross-sectional design limits causal interpretation. The authors appropriately acknowledge this, but stronger caution should be used when discussing mediation and pathways in both the abstract and discussion.

Second, although sample size justification is provided, the use of convenience sampling from a single site limits external validity. The generalizability of findings should be more explicitly discussed as a limitation.

Third, the modified NASA-TLX omits the performance subscale, which is justified on psychometric grounds. However, readers would benefit from a brief explanation of how the total workload score compares to the original six-item index in terms of interpretability.

Fourth, some terms (e.g., “effect,” “influence”) imply causality and should be softened to reflect the associative nature of the study design.

Fifth, while figures and tables are clear, image resolution—especially for Figure 1—should be improved using vector format (e.g., SVG) for publication.

Sixth, p-values are reported as thresholds throughout. Exact values should be presented where feasible, and confidence intervals provided for all key estimates to improve interpretability and transparency.

Seventh, the title and some sentences in the conclusion suggest direct influence or effects, which overstates the findings given the cross-sectional data. These should be revised to reflect correlational relationships and indirect associations.

Overall, this study offers meaningful insight into the mechanisms linking workload and prevention performance in nursing. I hope the authors find these suggestions helpful.

Author Response

Dear Reviewer 3,

We sincerely appreciate the time and effort you devoted to reviewing our manuscript and for providing thoughtful and constructive comments. Your suggestions were invaluable in improving the clarity, rigor, and interpretability of our study. We have carefully revised the manuscript in accordance with your comments, and our point-by-point responses are provided below. All changes have been incorporated into the revised manuscript.

 

Comment 1

First, while the mediation framework is conceptually well grounded in social cognitive theory, the cross-sectional design limits causal interpretation. The authors appropriately acknowledge this, but stronger caution should be used when discussing mediation and pathways in both the abstract and discussion.

Response 1:

Thank you for this valuable comment. We fully agree that the cross-sectional design of this study limits causal inference. In response, we have revised the abstract and discussion to adopt more cautious and precise language, avoiding causal interpretations of mediation and pathways.

 

Comment 2

Second, although sample size justification is provided, the use of convenience sampling from a single site limits external validity. The generalizability of findings should be more explicitly discussed as a limitation.

Response ２:

Thank you for this comment. We agree that the use of convenience sampling from a single institution may limit the external validity of the findings. Accordingly, we have revised the Limitations section to more explicitly address the restricted generalizability of the results

 

Comment ３

Third, the modified NASA-TLX omits the performance subscale, which is justified on psychometric grounds. However, readers would benefit from a brief explanation of how the total workload score compares to the original six-item index in terms of interpretability.

Response ３:

Thank you for this helpful comment. We agree that readers may benefit from additional clarification regarding the interpretation of the modified NASA-TLX score. Accordingly, we have added a brief explanation in the Measures section to clarify that the total workload score reflects perceived workload across the remaining five subscales and that direct comparisons with studies using the original six-item NASA-TLX composite should be made with caution.

 

Comment ４

Fourth, some terms (e.g., “effect,” “influence”) imply causality and should be softened to reflect the associative nature of the study design.

Response ４:

Thank you for this important comment. We agree that certain terms may imply causality beyond what is supported by the cross-sectional design. Accordingly, we carefully reviewed the entire manuscript and revised causal language to more appropriately reflect associative relationships. Terms such as “effect,” “influence,” and similar expressions were replaced with non-causal wording (e.g., “association,” “relationship,” “was associated with”) throughout the Abstract, Results narrative, Discussion, and Conclusions.

 

Comment ５

Fifth, while figures and tables are clear, image resolution—especially for Figure 1—should be improved using vector format (e.g., SVG) for publication.

Response ５:

Thank you for this helpful suggestion. We have revised Figure 1 to improve image quality and clarity by exporting it in a high-resolution vector format.

 

Comment ６

Sixth, p-values are reported as thresholds throughout. Exact values should be presented where feasible, and confidence intervals provided for all key estimates to improve interpretability and transparency.

Response ６:

Thank you for this constructive comment. We have revised the Results section to report exact p-values where feasible rather than threshold values. In addition, 95% confidence intervals have been provided for all key estimates, including the direct regression coefficients and the indirect effect.

 

Comment ７

Seventh, the title and some sentences in the conclusion suggest direct influence or effects, which overstates the findings given the cross-sectional data. These should be revised to reflect correlational relationships and indirect associations.

Response ７:

Thank you for this valuable comment. We agree that the title and certain statements in the Conclusions could be interpreted as implying direct causal effects. Accordingly, we revised the title and the Conclusions to adopt more cautious language that reflects correlational relationships and indirect associations, consistent with the cross-sectional design of the study.

 

Once again, we sincerely thank you for your insightful comments and constructive feedback. We believe that these revisions have significantly strengthened the manuscript and improved its clarity and scientific rigor.

Author Response File: Author Response.pdf