Review Reports - Educational Needs for Pressure Injury and Diabetic Foot Care Among Community-Based Nurses in Korea: A Borich and Locus for Focus Analysis

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Educational Needs for Pressure Injury Management and Dia- betic Foot Care among Community-Based Nurses: A Borich Needs Assessment and Locus for Focus Analysis

Introduction

The study aims to assess the perceived importance and self-reported performance of community-based nurses in pressure injury management and diabetic foot care interventions, and to identify educational priorities using the Borich needs assessment and Locus for Focus model. The authors have established the importance of the topic through the literature and identified the gap in the field.

Methods

More information about the participating nurses and the institutions where the study was conducted would help readers understand the study setting. The nurses’ working arrangements and the characteristics of the patients they care for should also be described.

In Korea, are nurses required to pass an examination or obtain a certificate to work in community-based care? Table 1 classifies their workplaces as home healthcare-based, long-term care-based, and public health institution. How do these three systems differ? What qualifications or competencies are required of nurses working in each setting? What is the average number of patients cared for by each nurse? Is information available on the total number of nurses working in these settings? Clarifying these points would make the study context easier to understand.

Sample size calculation

The numerical sample size calculation appears consistent with the stated assumptions for a paired-samples t-test. The authors should specify which paired comparison the calculation was based on—for example, the difference between perceived importance and self-reported performance—and explain the source or rationale for the assumed effect size of 0.25. For this cross-sectional survey, “anticipated nonresponse or incomplete questionnaires” would be more appropriate than “dropout rate.”

In addition, the target sample size was not reached. I recommend that the authors also conduct a post-hoc power analysis to support a more accurate interpretation of the findings.

Data collection

Explaining the possible reasons for the low participation rate among nurses would help readers understand why the target sample size was not reached. The authors should also clarify whether the 49 duplicate responses may have been related to the online data collection method. The literature emphasizes that online and face-to-face data collection are different methods and that the mode of data collection may affect participation rates.

The authors should describe how the nurses were contacted, which official communication channels were used, and whether the nurses completed the survey during working hours. These details would make the data collection process clearer.

Ethical considerations

Was permission obtained from the institutions where the participating nurses worked? If institutional permission was not required, this should be stated explicitly.

Results

The methods applied and the resulting findings have been reported appropriately.

Discussion

The findings have been discussed adequately in relation to the literature and the current context. The authors have also clearly presented the study’s limitations.

Conclusion

The conclusion is limited. Taking the findings and acknowledged limitations into account, the authors should state their recommendations for future research more clearly. They should also provide recommendations for the delivery of nursing services in community-based care institutions.

References

The authors have included current references that are directly relevant to the topic.

Author Response

1-1 More information about the participating nurses and the institutions where the study was conducted would help readers understand the study setting. The nurses’ working arrangements and the characteristics of the patients they care for should also be described.

Response: Thank you for this helpful suggestion. We provide detailed participant characteristics, including employment status, institution type, clinical experience, chronic wound patient volume, previous wound-care education, and interprofessional collaboration, in Section 3.1 and Table 1. The study focused on nurses’ characteristics, perceived importance, and self-reported performance; patient-level characteristics were not collected and therefore could not be reported.

Location in Revised Manuscript: Section 3.1. Participant Characteristics | p. 7, lines 291–326,
Table 1 | pp. 7–9 (caption: line 327; table note: lines 328–330)

1-2 In Korea, are nurses required to pass an examination or obtain a certificate to work in community-based care? Table 1 classifies their workplaces as home healthcare-based, long-term care-based, and public health institution. How do these three systems differ? What qualifications or competencies are required of nurses working in each setting? What is the average number of patients cared for by each nurse? Is information available on the total number of nurses working in these settings?

Thank you for this suggestion. We added a description of the three community-based nursing systems in Korea, including their legal basis, target populations, and qualification requirements. Hospital-based home healthcare is provided by home care advanced practice nurses who complete graduate-level training and pass a national certification examination; long-term care visiting nursing may be provided by nurses with at least 2 years of clinical experience; and public health institutions provide visiting health management and chronic disease management services. The study did not collect each nurse’s total caseload across all patient types or a national denominator for the total workforce in these systems. Instead, Table 1 reports the average monthly number of chronic wound patients managed, which was used as the study-relevant indicator of clinical exposure.

Revised text:

Section 2.2. Participants | p. 3, lines 99–111

“Community-based nursing care in Korea is delivered mainly through three systems that differ in legal basis, target populations, and nurse qualification requirements. First, hospital-based home healthcare is provided under the Medical Service Act to patients discharged from or referred by medical institutions. This service must be delivered by home care advanced practice nurses, who are required to complete a graduate-level advanced practice nursing program and pass a national certification examination [12]. Second, long-term care-based services, provided under the Long-Term Care Insurance Act, are delivered to older adults who have been approved for a long-term care grade, either through visiting nursing or within long-term care facilities; visiting nursing may be provided by nurses with at least 2 years of clinical experience [13]. Third, public health institutions, such as public health centers, provide visiting health management and chronic disease management services mainly to socially and economically vulnerable residents [14].”

2. Sample size calculation. The numerical sample size calculation appears consistent with the stated assumptions for a paired-samples t-test. The authors should specify which paired comparison the calculation was based on—for example, the difference between perceived importance and self-reported performance—and explain the source or rationale for the assumed effect size of 0.25. For this cross-sectional survey, “anticipated nonresponse or incomplete questionnaires” would be more appropriate than “dropout rate.”

Thank you for this comment. We clarified that the sample size calculation was based on the paired comparison between perceived importance and self-reported performance, the primary comparison of this study. A prior home visit nursing study using the same Borich needs assessment and Locus for Focus approach assumed dz = 0.30 [15]; we adopted a more conservative value of dz = 0.25. We also replaced “dropout rate” with “anticipated nonresponse or incomplete questionnaires.”

Revised text:

Section 2.2. Participants | p. 3, lines 112–120

“The sample size was calculated using G*Power version 3.1.9.7 for a two-tailed paired-samples t-test comparing perceived importance and self-reported performance, which was the primary comparison of this study. A minimum sample size of 210 was required, assuming an effect size (dz) of 0.25, a significance level of 0.05, and statistical power of 0.95. A prior study applying the Borich needs assessment and Locus for Focus model in home visit nursing assumed an effect size of 0.30 for this paired comparison [15]; a more conservative value of 0.25 was adopted in the present study. Considering an anticipated 15% rate of nonresponse or incomplete questionnaires, the target sample size was 248 participants.”

3. In addition, the target sample size was not reached. I recommend that the authors also conduct a post-hoc power analysis to support a more accurate interpretation of the findings.

Thank you for this recommendation. Using the final sample (n = 128), we conducted a post hoc power analysis and a sensitivity analysis for the minimum detectable effect size with G*Power 3.1.9.7. Achieved power was 0.802 for the a priori effect size (dz = 0.25), 0.976 for the observed pressure injury effect size (dz = 0.35), and 0.999 for the observed diabetic foot effect size (dz = 0.45). The final sample could detect dz = 0.250, 0.289, and 0.321 with 80%, 90%, and 95% power, respectively. These results are now reported in Section 2.6 and interpreted in the Limitations.

Revised text:

Section 2.6. Statistical Analysis | p. 6, lines 270–277

“Because the final analytic sample (n = 128) was smaller than the a priori minimum, a post hoc power analysis and a sensitivity analysis for the minimum detectable effect size were conducted using G*Power version 3.1.9.7, based on the test for the difference between two dependent means (matched pairs) and a two-tailed significance level of 0.05. Achieved power was 0.802 for the a priori effect size (dz = 0.25) and 0.976 and 0.999 for the effect sizes observed for pressure injury management (dz = 0.35) and diabetic foot care (dz = 0.45), respectively. The sensitivity analysis indicated that the final sample could detect effect sizes of dz = 0.250, 0.289, and 0.321 with 80%, 90%, and 95% power, respectively.”

Section 4.5. Limitations | pp. 14–15, lines 537–541

“However, a post hoc power analysis indicated adequate power (≥0.80) for the a priori and observed effect sizes in the primary paired comparisons, and a sensitivity analysis indicated that the final sample could detect effect sizes as small as dz = 0.25–0.32 across 80%–95% power; subgroup analyses with small cell sizes (e.g., public health institutions, n = 10) nonetheless have limited power and precision.”

4. Explaining the possible reasons for the low participation rate among nurses would help readers understand why the target sample size was not reached. The authors should also clarify whether the 49 duplicate responses may have been related to the online data collection method. The literature emphasizes that online and face-to-face data collection are different methods and that the mode of data collection may affect participation rates.

Thank you. We clarified that the 49 excluded responses were online submissions showing clearly careless or inattentive response patterns, including selecting the same single option across the entire questionnaire; no face-to-face responses were excluded for this reason. We also reported that the retained face-to-face and online groups differed in institutional composition and discussed possible reasons for lower-than-targeted participation, including high workload, frequent off-site visits, and the small and geographically dispersed nature of community-based institutions. These mode-related differences are acknowledged in the Limitations.

Revised text:

Section 2.3. Data Collection | p. 3, lines 131–135

“Among the online responses, 49 responses showed clearly careless or inattentive response patterns, including selecting the same single response option across the entire questionnaire, and were excluded as invalid. No face-to-face responses were excluded for this reason. The final analytic sample comprised 128 participants: 64 face-to-face respondents and 64 online respondents.”

Section 3.1. Participant Characteristics | p. 7, lines 299–302

“Among the retained participants, the two data collection modes also differed in the institutional composition of respondents: face-to-face respondents were mostly from long-term care-based institutions (49/64), whereas online respondents were mostly from home healthcare-based (36/64) or public health institutions (10/64).”

Section 4.5. Limitations | p. 15, lines 543–551

“Third, participation lower than targeted may have reflected community-based nurses' high workload and frequent off-site visits, as well as the small, geographically dispersed nature of the participating institutions. All 49 excluded online responses showed clearly careless responding, with participants selecting the same single response option across the entire questionnaire; no face-to-face responses were excluded for this reason. Face-to-face and online respondents also differed in institutional composition, which may partly reflect lower participation among nurses in long-term care-based institutions for the online survey, or other mode-related differences in who chose to participate.”

5. The authors should describe how the nurses were contacted, which official communication channels were used, and whether the nurses completed the survey during working hours. These details would make the data collection process clearer.

Thank you for this suggestion. We revised Section 2.3 to specify the recruitment channels and survey procedures. A professional survey agency posted the online recruitment notice on a community bulletin board for community-based nurses. For face-to-face recruitment, permission was obtained from the heads of visiting nursing centers before paper questionnaires were distributed to eligible nurses. Participants completed the questionnaire at a time of their choosing, regardless of working hours, and a small incentive was provided upon completion.

Revised text:

Section 2.3. Data Collection | p. 3, lines 122–129

6. Was permission obtained from the institutions where the participating nurses worked? If institutional permission was not required, this should be stated explicitly.

Thank you for raising this point. For the face-to-face survey, permission for data collection was obtained from the heads of the participating visiting nursing centers before questionnaires were distributed. Online participants were recruited individually through an online community bulletin board rather than through institutional channels, and participation was based on individual voluntary consent. These procedures are now described in Sections 2.3 and 2.7.

Revised text:

Section 2.3. Data Collection | p. 3, lines 125–128

“For the face-to-face survey, permission for data collection was obtained from the heads of visiting nursing centers, after which paper questionnaires were distributed to eligible nurses at the centers.”

Section 2.7. Ethical Considerations | pp. 6–7, lines 285–288

“For face-to-face participants, permission for data collection was obtained from the heads of the participating visiting nursing centers before the survey was administered. Online participants were recruited individually rather than through institutional channels, and their participation was based on individual voluntary consent.”

7. The conclusion is limited. Taking the findings and acknowledged limitations into account, the authors should state their recommendations for future research more clearly. They should also provide recommendations for the delivery of nursing services in community-based care institutions.

Thank you for this suggestion. We strengthened the practice and future research implications in Sections 4.4 and 5. For community-based care institutions, we recommend that continuing education on these priorities be accompanied by institutional support, such as access to wound-care resources, clear wound-care protocols, and consultation or referral pathways, particularly where nurses have limited exposure to chronic wound care. More broadly, we recommend that educational programs reflect the domain-specific priorities identified in this study and that workload, equipment and resources, communication, and referral pathways be considered when education and chronic wound care are implemented in community settings. For future research, we now recommend including a “not applicable” response option to distinguish limited opportunity from limited competence and conducting psychometric validation of the modified diabetic foot instrument, including factor analysis and cognitive interviewing.

Revised text:

Section 4.4. Implications for Educational Program Development and Implementation | p. 14, lines 521–532

“Educational programs should reflect the different priorities identified for each care domain. Pressure injury education should emphasize treatment principles and clinical judgment for selecting and applying interventions, whereas diabetic foot education should emphasize preventive foot care and patient education. ... Workload, equipment and resources, communication, and referral pathways should also be considered when implementing educational programs in community-based settings [25,38,39].”

Section 5. Conclusions | pp. 15–16, lines 587–594

“For community-based care institutions, continuing education on these priorities could be accompanied by institutional support, such as access to wound-care resources, clear wound-care protocols, and consultation or referral pathways, particularly in settings where nurses have limited exposure to chronic wound care. Future surveys could include a "not applicable" response option to distinguish limited opportunity from limited competence. Future research should also include psychometric validation of the modified diabetic foot instrument among community-based nurses, such as factor analysis and cognitive interviewing.”

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript entitled “Educational Needs for Pressure Injury Management and Diabetic Foot Care among Community-Based Nurses: A Borich Needs Assessment and Locus for Focus Analysis” in its current state addresses a relevant issue in community nursing and has a potentially useful practical contribution by integrating the Borich needs assessment with the Locus for Focus (LfF) model. The distinction between pressure-injury and diabetic-foot educational priorities is potentially valuable. However, several methodological and statistical issues need clarification or correction, particularly the substantially underpowered sample, recalculation of the Borich score after rescaling the response scale, handling of multiple statistical comparisons, the validity of the modified diabetic-foot instrument, and the interpretation of self-reported performance. The manuscript itself appropriately acknowledges several of these limitations, including the final sample of 128 versus the planned 210, self-reported performance, duplicate-response uncertainty, and the modified diabetic-foot instrument.

Major comments

Sample size and statistical power require substantial clarification. The authors calculated a minimum sample size of 210 participants, with a target of 248 after allowing for 15% attrition, but ultimately analyzed only 128 participants. This is an important methodological limitation because the achieved sample represents only approximately 61% of the calculated minimum sample. Although the authors acknowledge this in the limitations, the implications for statistical power should be addressed more explicitly.
The transformation of the diabetic-foot scale from 1–3 to 0–2 has implications for the Borich calculation. This is, in my view, one of the most important methodological issues. The authors state that the original diabetic-foot instrument used a 1–3 scale, which was converted to 0–2 by subtracting 1 from each item score, and then state: “Because this is a constant shift applied equally to importance and performance ratings, it does not affect Cronbach's α or the paired-samples comparisons...” The statement is correct for Cronbach's α and the difference between paired importance and performance scores. However, it is not necessarily correct for the Borich needs score because the Borich calculation weights the importance–performance discrepancy by the mean importance score:

Borich score=∑(I−P)×IˉN\text{Borich score}=\frac{\sum(I-P)\times \bar I}{N}

After subtracting 1 from the importance score, Iˉ\bar I also decreases by 1. Therefore, the Borich scores obtained using the 0–2 scale are not equivalent to those obtained using the original 1–3 scale, and the relative ranking of items could potentially change.

The study assesses self-reported performance, rather than objectively observed nursing performance. The authors appropriately acknowledge this limitation. However, the manuscript occasionally moves close to interpreting importance–performance discrepancies as actual educational or competency gaps. A discrepancy between importance and self-reported performance may reflect: lack of knowledge or competence, limited clinical exposure, and differences in patient case mix, or social-desirability or recall bias.
Table 1 contains a relatively large number of statistical comparisons involving participant characteristics, importance, and performance. The manuscript reports several statistically significant findings but does not indicate whether adjustment for multiple testing was performed. Given the number of comparisons, some nominally significant findings could occur by chance.
The diabetic-foot questionnaire was originally developed for care helpers in long-term-care facilities, not community-based registered nurses. The authors modified the wording and assessed content validity using five experts, obtaining an S-CVI/Ave of 0.98. This is useful, but content validity alone does not establish that the modified instrument validly measures diabetic-foot nursing practice among community nurses.
The manuscript appropriately recognizes that the 2-h repositioning item should not be interpreted as a universal clinical recommendation and cites contemporary guidance emphasizing individualized repositioning. This caution should be extended to other intervention-specific items.
The manuscript's methodological framework identifies items with high importance and high importance–performance discrepancy. However, educational priority is not synonymous with clinical priority or clinical effectiveness. For example, a procedure may have a high Borich score because nurses consider it important but report performing it infrequently. This does not establish that additional education on that intervention will improve patient outcomes. The Discussion partly recognizes this distinction, but it should be made explicit throughout the manuscript.
The manuscript uses the overlap between the highest-ranked Borich items and HH-quadrant LfF items to define first-priority needs. This is reasonable, but the manuscript should explain more clearly: why the number of Borich-selected items was set equal to the number of HH items; why overlap was used as the criterion for “first priority”; whether this approach was prospectively specified; how sensitive the resulting priorities are to the grand-mean cutoffs.

Because both methods are derived from the same underlying importance and performance data, they are not independent methods of validation. The apparent convergence between the two approaches should therefore not be interpreted as independent confirmation.

The final sample was derived from 179 responses, excluding two responses with substantial missing data and 49 online responses with identical response patterns. The authors acknowledge that identical response patterns could not definitively establish duplicate submissions. This is important because removal of 49/179 responses (~27%) is substantial and could introduce selection bias.

Minor comments

The title is informative but somewhat long. I recommend more concise title: “Educational Needs for Pressure Injury and Diabetic Foot Care among Community-Based Nurses: A Borich and Locus for Focus Analysis”
Abstract should explicitly mention the sample-size limitation. Because the achieved sample was substantially below the calculated minimum, this is an important methodological feature and could be briefly acknowledged in the Abstract or Conclusions.
Statistical reporting. Where possible, report: exact p-values rather than only p < 0.001; effect sizes; 95% confidence intervals. This is particularly important for the numerous subgroup analyses.
Cronbach's α. The reported α values are very high for several scales (e.g., 0.937–0.963 for the pressure-injury measure). Although high internal consistency is generally favorable, values approaching or exceeding 0.95 can sometimes indicate item redundancy.
Interpretation of Cohen's dz The reported effect sizes (e.g., dz = 0.35 and 0.45) should be interpreted rather than simply reported. The Discussion could briefly indicate that these represent modest-to-moderate within-participant differences, while avoiding unnecessary categorical labeling.
15. Table 1 contains many variables and four outcomes. It is difficult to interpret visually. Consider: separating participant characteristics from inferential statistics; reporting only clinically relevant variables in the main table; moving some subgroup analyses to supplementary material.
16. The Discussion is generally well structured, but several paragraphs repeat the distinction between self-reported performance and actual competence. This point is important but could be consolidated to improve readability.

Author Response

Sample size and statistical power require substantial clarification. The authors calculated a minimum sample size of 210 participants, with a target of 248 after allowing for 15% attrition, but ultimately analyzed only 128 participants. This is an important methodological limitation because the achieved sample represents only approximately 61% of the calculated minimum sample. Although the authors acknowledge this in the limitations, the implications for statistical power should be addressed more explicitly.

Thank you for highlighting this important issue. We agree that the implications of achieving approximately 61% of the a priori minimum sample warranted more explicit discussion. We clarified the basis and rationale for the a priori sample-size calculation in Section 2.2, conducted a post hoc power analysis and a sensitivity analysis for the minimum detectable effect size in Section 2.6, and expanded the limitation concerning power and precision in Section 4.5.

Revised text / revised content:

Section 2.2. Participants | p. 3, lines 112–120

Section 2.6. Statistical Analysis | p. 6, lines 270–277

Section 4.5. Limitations | pp. 14–15, lines 534–541

“This study has several limitations. First, convenience recruitment and the final analytic sample of 128 participants, which was smaller than the a priori minimum of 210, limit generalizability and may reduce statistical power and precision, particularly for subgroup analyses. However, a post hoc power analysis indicated adequate power (≥0.80) for the a priori and observed effect sizes in the primary paired comparisons, and a sensitivity analysis indicated that the final sample could detect effect sizes as small as dz = 0.25–0.32 across 80%–95% power; subgroup analyses with small cell sizes (e.g., public health institutions, n = 10) nonetheless have limited power and precision.”

2. The transformation of the diabetic-foot scale from 1–3 to 0–2 has implications for the Borich calculation. [...] After subtracting 1 from the importance score, Ī also decreases by 1. Therefore, the Borich scores obtained using the 0–2 scale are not equivalent to those obtained using the original 1–3 scale, and the relative ranking of items could potentially change.

We thank the reviewer for this important observation. We clarified that the diabetic foot items were administered directly on a 0–2 scale using the same three response anchors as the pressure injury instrument; the data were not transformed from a 1–3 scale. Because the Borich score depends on the origin of the importance scale, we recalculated the Borich scores using the original 1–3 scale as a sensitivity analysis. The five highest-ranked items and the first-priority classification were unchanged; only items 5 and 9 exchanged ranks 6 and 7, and neither was classified as first priority under either scaling.

Revised text / revised content:

Section 2.4.3. Diabetic Foot Prevention and Management | p. 5, lines 197–204

“Kim et al. [18] used a 1–3 response scale; in this study, the items were administered on a 0–2 scale with the same three response anchors to be consistent with the pressure injury instrument. This difference in scale origin does not affect Cronbach's α or the paired-samples comparisons of importance and performance (including Cohen's dz). However, because the Borich needs score weights the discrepancy by mean importance, it depends on the origin of the importance scale; Borich scores were therefore also calculated on the original 1–3 scale as a sensitivity analysis (Supplementary Table S3).”

Section 3.3. Priority Educational Needs | p. 10, lines 381–384

“When the Borich scores were recalculated using the original 1–3 scale, the five highest-ranked items and the first-priority classification remained unchanged; a minor exchange of ranks 6 and 7 occurred between items 5 and 9, neither of which was classified as first priority under either scaling (Supplementary Table S3).”

Supplementary Table S3

“Borich needs scores for diabetic foot care items calculated on the administered 0–2 scale and the original 1–3 scale.”

3. The study assesses self-reported performance, rather than objectively observed nursing performance. [...] the manuscript occasionally moves close to interpreting importance–performance discrepancies as actual educational or competency gaps. A discrepancy [...] may reflect: lack of knowledge or competence, limited clinical exposure, and differences in patient case mix, or social-desirability or recall bias.

We agree. We revised the manuscript so that importance–performance discrepancies are interpreted as indicators of potential educational priorities rather than direct evidence of competency gaps. We also explicitly discuss limited clinical exposure, patient case mix, scope of practice, institutional context, recall bias, and social desirability bias as possible explanations for lower self-reported performance. Sensitivity analyses by wound-care exposure were added, and the limitation that self-reported performance does not directly measure observed competence was retained.

Revised text / revised content:

Section 3.4. Sensitivity Analyses | p. 12, lines 395–405

“To examine the robustness of the overall discrepancies and the priority classification, several sensitivity analyses were conducted (Supplementary Table S4). ... Among nurses who managed at least one chronic wound patient per month (n = 107), the overall pressure injury discrepancy was small and not statistically significant (0.048; dz = 0.17; p = 0.080), whereas the diabetic foot discrepancy remained significant (0.124; dz = 0.33; p = 0.001); item-level priority classifications were unchanged under this restriction.”

Section 4.2. Pressure Injury Education | p. 13, lines 444–460

“The importance–performance discrepancies identified in this study should be interpreted as indicators of potential educational priorities rather than direct evidence of deficient clinical competence or inadequate prior education. A low level of self-reported performance may reflect several factors beyond educational exposure, including limited opportunities to encounter specific clinical conditions, differences in patient case mix, scope of practice, institutional protocols, staffing, and access to appropriate wound-care resources. Such discrepancies may also reflect recall or social desirability bias. ... Accordingly, the high-priority items identified through the Borich and Locus for Focus analyses should be viewed as areas that may warrant greater emphasis in continuing education, rather than as evidence that nurses lack the knowledge or competence required to perform these practices.”

Section 4.5. Limitations | p. 15, lines 541–543

“Second, self-reported performance may be influenced by recall, social desirability, clinical exposure, and local practice context and does not directly measure observed clinical competence.”

4. Table 1 contains a relatively large number of statistical comparisons [...] does not indicate whether adjustment for multiple testing was performed. Given the number of comparisons, some nominally significant findings could occur by chance.

We agree. We applied Holm correction across all 44 subgroup comparisons and reorganized the reporting so that participant characteristics are separated from inferential statistics. Table 1 now presents descriptive participant characteristics only, Table 2 summarizes associations remaining significant after Holm correction, and Supplementary Table S5 provides complete results for all 44 comparisons with exact p-values and effect sizes. The Discussion was also revised so that the univariable association between previous chronic wound management education and performance is not overinterpreted.

Revised text / revised content:

Section 2.6. Statistical Analysis | p. 6, lines 264–267

“To address multiplicity, Holm correction was applied to the 44 subgroup comparisons of participant characteristics with perceived importance and self-reported performance, and to the item-level paired comparisons within each scale.”

Section 3.1. Participant Characteristics | p. 7, lines 312–320

“After applying Holm correction for the 44 comparisons, eight associations remained significant (Table 2): APN certification with perceived importance in both domains; type of institution with perceived importance in pressure injury management and with self-reported performance in both domains; the average number of chronic wound patients managed per month with self-reported performance in both domains; and interprofessional collaboration with perceived importance of pressure injury management. The associations with educational level, employment status, current workplace experience, and previous chronic wound management education did not remain significant after correction (Supplementary Table S5).”

Table 2 | p. 9, lines 331–338

“Participant characteristics significantly associated with perceived importance or self-reported performance after Holm correction for multiple testing (N = 128). ... p-values are Holm-adjusted across all 44 comparisons of participant characteristics; values are capped at 1.000. Complete results for all 44 comparisons, including variables not shown in this table, are provided in Supplementary Table S5.”

Section 4.4. Implications for Educational Program Development and Implementation | p. 14, lines 514–520

“Nurses with previous chronic wound management education reported higher self-reported performance in univariable comparisons; however, this association did not remain significant after correction for multiple testing (Supplementary Table S5), and performance also differed according to type of institution and average number of chronic wound patients managed per month. These findings suggest that institutional context and clinical exposure may be more closely associated with performance than prior education alone; because this study was cross-sectional, causal relationships cannot be inferred.”

Supplementary Table S5

“Importance and performance scores by participant characteristic, with test statistics, effect sizes, and Holm-adjusted p-values for all 44 comparisons.”

5. The diabetic-foot questionnaire was originally developed for care helpers in long-term-care facilities, not community-based registered nurses. [...] content validity alone does not establish that the modified instrument validly measures diabetic-foot nursing practice among community nurses.

We thank the reviewer for this point and agree. We now state explicitly that only content validity of the modified diabetic foot instrument was evaluated and that structural validity among community-based nurses was not examined. We clarified the expertise of the expert panel, acknowledged the absence of pilot testing or cognitive interviewing, and added a recommendation for further psychometric validation, including factor analysis and cognitive interviewing.

Revised text / revised content:

Section 2.4.3. Diabetic Foot Prevention and Management | pp. 4–5, lines 184–192

“The content validity of the modified items was evaluated by a panel of five experts, comprising four professors of nursing (three specializing in community health nursing and one in adult health nursing) and one visiting nurse; two panel members had clinical expertise in wound care, all holding a doctoral degree and with a mean of 32 years of clinical or academic experience. Item-level content validity index (I-CVI) values ranged from 0.80 to 1.00, and the scale-level CVI (S-CVI/Ave) was 0.98. Only content validity of the modified instrument was evaluated in this study; structural validity among community-based nurses was not examined.”

Section 4.5. Limitations | p. 15, lines 555–562

“Sixth, the diabetic foot items were derived from a measure originally used with care helpers in long-term care facilities; although item wording was modified for the nursing context and content validity was evaluated by an expert panel, further psychometric evaluation of construct validity in community-based nurses is warranted. ... Pilot testing or cognitive interviewing with nurses was not conducted when the items were modified.”

Section 5. Conclusions | pp. 15–16, lines 590–594

“Future surveys could include a "not applicable" response option to distinguish limited opportunity from limited competence. Future research should also include psychometric validation of the modified diabetic foot instrument among community-based nurses, such as factor analysis and cognitive interviewing.”

6. The manuscript appropriately recognizes that the 2-h repositioning item should not be interpreted as a universal clinical recommendation [...] This caution should be extended to other intervention-specific items.

We agree and extended this caution to other intervention-specific items. The revised Discussion clarifies that debridement, dead-space packing, and antiseptic or antimicrobial use depend on wound assessment, physician orders, institutional protocols, and the nurse’s scope of practice; therefore, their high priority should be interpreted as a need for education on assessment and decision-making rather than a recommendation for routine or universal use.

Revised text / revised content:

Section 4.2. Pressure Injury Education | p. 13, lines 464–475

“The identified priorities should not be interpreted as recommending routine use of these interventions for all patients. ... Similar caution applies to other intervention-specific items. Debridement, dead-space packing, and antiseptic or antimicrobial use depend on wound assessment, physician orders, institutional protocols, and the nurse's scope of practice. Their high priority therefore indicates a need for education on assessment and decision-making about when these interventions are appropriate, rather than a recommendation for their routine or universal use.”

7. [...] educational priority is not synonymous with clinical priority or clinical effectiveness. [...] This does not establish that additional education on that intervention will improve patient outcomes. [...] it should be made explicit throughout the manuscript.

We agree. We added an explicit definition of “educational priority” in Section 2.5 and reinforced the same distinction in the Conclusions, clarifying that educational priority does not indicate clinical priority or clinical effectiveness and that improvement in patient outcomes would require separate evaluation.

Revised text / revised content:

Section 2.5. Educational Needs Assessment | pp. 5–6, lines 234–238

“In this study, an educational priority refers to the relative emphasis that content may warrant in continuing education, based on nurses' perceived importance and self-reported performance. It does not indicate clinical priority or clinical effectiveness, and whether education on a given intervention improves nursing practice or patient outcomes requires separate evaluation.”

Section 5. Conclusions | p. 15, lines 583–590

“The identified priorities indicate where continuing education content may be relatively emphasized, based on perceived importance and self-reported performance; they do not represent clinical priorities or evidence that education on these items will improve patient outcomes, which would require separate evaluation. For community-based care institutions, continuing education on these priorities could be accompanied by institutional support, such as access to wound-care resources, clear wound-care protocols, and consultation or referral pathways, particularly in settings where nurses have limited exposure to chronic wound care.”

8. [...] the manuscript should explain more clearly: why the number of Borich-selected items was set equal to the number of HH items; why overlap was used as the criterion for “first priority”; whether this approach was prospectively specified; how sensitive the resulting priorities are to the grand-mean cutoffs.

Thank you for this comment. We clarified the prioritization procedure in Section 2.5, including that it was adopted prior to data collection. We explained that the number of Borich-selected items was set equal to the number of HH items so that the overlap between the two selected sets, which defines first priority, could be examined directly. We also examined sensitivity to the grand-mean cutoffs using median-based reference lines and reported the results in Section 3.4 and Supplementary Table S4.

Revised text / revised content:

Section 2.5. Educational Needs Assessment | pp. 5–6, lines 224–243

“Final educational priorities were determined according to the prioritization procedure proposed by Cho [21] and applied by Lee and Jung [15]. ... Items identified by both methods were classified as first-priority educational needs, whereas items identified by only one method were classified as second-priority educational needs. ... This procedure was adopted prior to data collection. Setting the number of Borich-selected items equal to the number of HH items allowed the two approaches to select sets of the same size so that their overlap could be examined directly. To examine the sensitivity of this classification to the grand-mean cutoffs, the Locus for Focus classification was repeated using median-based reference lines as a sensitivity analysis (Supplementary Table S4).”

Section 3.4. Sensitivity Analyses | p. 12, lines 410–415

“Using median-based reference lines for the Locus for Focus model instead of grand means left five of six first-priority pressure injury items and all three first-priority diabetic foot items unchanged; one pressure injury item (antiseptic use) moved to second priority, and the second-priority items differed slightly. Excluding the fixed 2-h repositioning item from the pressure injury classification did not change the remaining first- and second-priority items.”

9. Because both methods are derived from the same underlying importance and performance data, they are not independent methods of validation. The apparent convergence between the two approaches should therefore not be interpreted as independent confirmation.

We agree and revised the manuscript to avoid implying that agreement between the Borich needs assessment and the Locus for Focus model constitutes independent validation. The Methods now state explicitly that both approaches are derived from the same importance and performance data, and the Discussion reiterates that their agreement reflects convergence between related summaries rather than independent confirmation.

Revised text / revised content:

Section 2.5. Educational Needs Assessment | p. 6, lines 243–247

“Because both the Borich needs assessment and the Locus for Focus model are derived from the same underlying importance and performance data, they are not independent methods of validation; agreement between the two approaches reflects convergence between two related summaries of the same data rather than independent confirmation.”

Section 4.3. Diabetic Foot Education | p. 14, lines 509–512

“Because importance ratings were high with relatively little variation, the Borich ranking closely followed the discrepancy ranking; consequently, the agreement between the Borich and Locus for Focus approaches does not represent independent confirmation, as both are derived from the same importance and performance data.”

10. The final sample was derived from 179 responses, excluding two responses with substantial missing data and 49 online responses with identical response patterns. [...] removal of 49/179 responses (~27%) is substantial and could introduce selection bias.

We agree that excluding 49 of 179 responses is a potentially important source of selection bias. We clarified the exclusion criterion in Section 2.3, reported the institutional composition of the retained face-to-face and online groups in Section 3.1, examined retained uniform-response cases in the sensitivity analyses, and acknowledged possible mode-related selection differences in the Limitations.

Revised text / revised content:

Section 2.3. Data Collection | pp. 3–4, lines 130–142

“A total of 179 responses were obtained. Two responses with substantial missing data were excluded. Among the online responses, 49 responses showed clearly careless or inattentive response patterns, including selecting the same single response option across the entire questionnaire, and were excluded as invalid. No face-to-face responses were excluded for this reason. The final analytic sample comprised 128 participants: 64 face-to-face respondents and 64 online respondents. ... Because the total number of nurses who viewed the online recruitment notice or were approached for face-to-face participation was not recorded, a conventional response rate or recruitment reach could not be calculated.”

Section 3.1. Participant Characteristics | p. 7, lines 299–302

Section 3.4. Sensitivity Analyses | p. 12, lines 396–410

“Twenty-three participants (18.0%) gave the same rating across every pressure injury and diabetic foot item ... Excluding the 23 participants with uniform responses across all items increased the overall discrepancies (pressure injury 0.215; diabetic foot 0.278) but did not change the priority classification.”

Section 4.5. Limitations | p. 15, lines 543–551

11. The title is informative but somewhat long. I recommend more concise title: “Educational Needs for Pressure Injury and Diabetic Foot Care among Community-Based Nurses: A Borich and Locus for Focus Analysis”

Thank you for this suggestion. We adopted the more concise title and, to make the study setting explicit, added “in Korea.”

Revised text / revised content:

Title | p. 1, lines 2–4

“Educational Needs for Pressure Injury and Diabetic Foot Care among Community-Based Nurses in Korea: A Borich and Locus for Focus Analysis”

12. Abstract should explicitly mention the sample-size limitation.

Thank you for this suggestion. We revised the Methods sentence of the Abstract to state explicitly that the achieved sample was smaller than the a priori minimum.

Revised text / revised content:

Abstract | p. 1, lines 19–20

“Methods: A descriptive survey was conducted with 128 registered nurses, fewer than the a priori minimum of 210.”

13. Statistical reporting. Where possible, report: exact p-values rather than only p < 0.001; effect sizes; 95% confidence intervals. This is particularly important for the numerous subgroup analyses.

We agree. Exact p-values and effect sizes for subgroup comparisons are now provided in Supplementary Table S5, Holm-adjusted results are summarized in Table 2, and Table 3 now reports Cohen’s dz with 95% confidence intervals for the paired importance–performance comparisons (pressure injury total dz = 0.35, 95% CI 0.22–0.48; diabetic foot total dz = 0.45, 95% CI 0.33–0.58). Exact item-level p-values, Holm-adjusted results, and Wilcoxon signed-rank checks are provided in Supplementary Table S6.

Revised text / revised content:

Section 2.6. Statistical Analysis | p. 6, lines 264–267

Table 2 | p. 9, lines 331–337

Table 3 | pp. 9–10, lines 358–361

“Importance, performance, and educational needs for pressure injury management and diabetic foot care (N = 128). ... Discrepancy = importance − performance; M = mean; dz = Cohen’s effect size for paired samples; 95% CI = 95% confidence interval.”

Supplementary Tables S5–S6

“Supplementary Table S5 provides test statistics, effect sizes, and Holm-adjusted p-values for all 44 subgroup comparisons. Supplementary Table S6 provides item-level paired comparisons with Holm adjustment and Wilcoxon signed-rank tests.”

14. Cronbach’s α. The reported α values are very high [...] values approaching or exceeding 0.95 can sometimes indicate item redundancy.

We thank the reviewer for this comment. We added mean inter-item correlations and the proportion of participants rating all items as very important for both instruments. We also expanded the Limitations to explain that the high Cronbach’s α values, elevated inter-item correlations, and ceiling effects may reflect essential-practice items, possible redundancy, or uniform responding.

Revised text / revised content:

Section 2.4.2. Pressure Injury Prevention and Management | p. 4, lines 176–179

“In this study, Cronbach’s α values for importance and performance were 0.937 and 0.963, respectively, for the full 18-item measure. Mean inter-item correlations were 0.45 for importance and 0.60 for performance; 51% of participants rated all 18 items as very important.”

Section 2.4.3. Diabetic Foot Prevention and Management | p. 5, lines 204–207

“Kim et al. [18] reported a Cronbach’s α of 0.81. In this study, Cronbach’s α was 0.901 for importance and 0.941 for performance. Mean inter-item correlations were 0.48 for importance and 0.62 for performance; 55% of participants rated all 10 items as very important.”

15. Interpretation of Cohen’s dz. The reported effect sizes (e.g., dz = 0.35 and 0.45) should be interpreted rather than simply reported.

Thank you for this suggestion. We added an interpretive statement in Section 4.1, describing the overall discrepancies as small-to-moderate within-participant differences and noting that 24%–34% of nurses rated importance higher than performance for individual priority items.

Revised text / revised content:

Section 4.1. Principal Findings | p. 12, lines 421–426

“The overall discrepancies corresponded to small-to-moderate within-participant differences (dz = 0.35 and 0.45 for pressure injury management and diabetic foot care, respectively). For individual priority items, 24%–34% of nurses rated importance higher than performance, indicating that these discrepancies, while modest on average, were concentrated among a substantial minority of nurses rather than reflecting a uniform pattern across the sample.”

16. Table 1 contains many variables and four outcomes. It is difficult to interpret visually. Consider: separating participant characteristics from inferential statistics; reporting only clinically relevant variables in the main table; moving some subgroup analyses to supplementary material.

We agree. We reorganized the tables to improve readability. Table 1 now contains participant characteristics only, Table 2 presents the participant characteristics with at least one association remaining significant after Holm correction, and the complete results for all 44 subgroup comparisons are provided in Supplementary Table S5.

Revised text / revised content:

Table 1 | pp. 7–9, lines 327–330

“General characteristics of study participants (N = 128). ... Values are presented as n (%) or mean ± SD. Exact p-values, effect sizes, and multiplicity-adjusted results for the associations between these characteristics and perceived importance and self-reported performance are provided in Supplementary Table S5.”

Section 3.1. Participant Characteristics | p. 7, lines 312–320

“After applying Holm correction for the 44 comparisons, eight associations remained significant (Table 2) ... The associations with educational level, employment status, current workplace experience, and previous chronic wound management education did not remain significant after correction (Supplementary Table S5).”

Table 2 | p. 9, lines 331–338

“Participant characteristics significantly associated with perceived importance or self-reported performance after Holm correction for multiple testing (N = 128). ... Complete results for all 44 comparisons, including variables not shown in this table, are provided in Supplementary Table S5.”

Supplementary Table S5

“Importance and performance scores by participant characteristic, with test statistics, effect sizes, and Holm-adjusted p-values for all 44 comparisons.”

17. The Discussion is generally well structured, but several paragraphs repeat the distinction between self-reported performance and actual competence. This point is important but could be consolidated to improve readability.

We agree. We consolidated the detailed discussion of the distinction between self-reported performance and actual clinical competence in Section 4.2, where possible explanations for lower self-reported performance are discussed together. In Section 4.5, we retained only a concise limitation stating that self-reported performance does not directly measure observed clinical competence.

Revised text / revised content:

Section 4.2. Pressure Injury Education | p. 13, lines 444–463

“The importance–performance discrepancies identified in this study should be interpreted as indicators of potential educational priorities rather than direct evidence of deficient clinical competence or inadequate prior education. A low level of self-reported performance may reflect several factors beyond educational exposure, including limited opportunities to encounter specific clinical conditions, differences in patient case mix, scope of practice, institutional protocols, staffing, and access to appropriate wound-care resources. Such discrepancies may also reflect recall or social desirability bias. ... Further studies using objective competency assessments and measures of clinical exposure are needed to determine whether the identified educational priorities correspond to actual competency gaps and to clarify the factors contributing to lower performance.”

Section 4.5. Limitations | p. 15, lines 541–543

“Second, self-reported performance may be influenced by recall, social desirability, clinical exposure, and local practice context and does not directly measure observed clinical competence.”

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for the opportunity to review your manuscript. This is a clearly written and carefully reported study on a practical question: which wound-care topics should be prioritised in continuing education for community-based nurses. I particularly appreciated your openness about the study's limitations and your caution against reading the importance–performance gap as a sign of poor competence. My comments below are meant to help strengthen the work.

Exclusion of 49 online responses (Sections 2.3 and 4.5).

The removal of 49 online responses because of identical response patterns is my main concern. Because importance ratings were close to the ceiling, it is quite possible that different nurses gave identical answers (for example, all "2"). If so, this exclusion may have removed respondents with little or no discrepancy and could have inflated the estimated needs. The rule also appears to have been applied only to online responses. I would kindly suggest:

(a) a sensitivity analysis including all eligible responses, with the main results shown side by side;

(b) more detail on how the survey was distributed online, and whether any incentive was offered;

Exposure and scope of practice.

Eligibility required being a registered nurse with at least 6 months at the institution, but not actual involvement in wound care. A "never perform" rating could therefore mean not trained, not encountered, or not permitted within the nurse's role. This matters most for items such as debridement, dead-space management, and antimicrobial selection, which may be restricted in some settings. The finding that treatment items rank highest may partly reflect scope of practice rather than an educational gap. It would help to add a "not applicable" option in future work, restrict or stratify the analysis by wound-care exposure (for example, monthly patient volume, APN status, or institution type), and discuss this point more explicitly.

Stability of the priority rankings.

Because importance ratings were high with little variation on a 3-point scale, the Borich ranking is likely to follow the discrepancy ranking closely. In that case, agreement between Borich and Locus for Focus is not fully independent confirmation. Items near the reference lines may also change quadrant with small differences. I would suggest reporting confidence intervals or a bootstrap rank-stability analysis, and softening the wording on "first-priority" items. Also, the recoding of the diabetic foot scale from 1–3 to 0–2 does not affect the t-tests, dz, or Cronbach's alpha, but it can affect Borich scores, because the importance weight changes with the shift. Please check this, or show that the ranking is unchanged.

Item interpretability.

(a) The fixed 2-hour repositioning item is a top priority, yet your Discussion rightly notes that current guidance recommends individualised repositioning. A lower performance rating on this item may reflect guideline-concordant practice. I would recommend either excluding it from the priority ranking or clearly flagging it as not interpretable in the Results.

(b) Some diabetic foot items ask about two actions at once (for example, checking foot hygiene practices and providing education). Respondents can only give one rating for two behaviours, which makes these items hard to interpret. Please acknowledge this limitation.

Instrument validity.

The pressure injury practice domain was developed to measure practice, and using it to rate importance is a new application. The Cronbach's alpha values here (0.937 and 0.963) are much higher than those originally reported (0.645–0.735), which may indicate item redundancy or a uniform response style. Please comment on this. The diabetic foot items were adapted from a study of care helpers, with a five-member expert panel and I-CVI values as low as 0.80. Could you clarify whether the panel included wound-care or diabetes specialists, and whether any pilot testing or cognitive interviewing was done? Some form of structural validation (for example, factor analysis) would strengthen the subdomain comparisons made in the Discussion.

Data handling.

Section 4.5 mentions that a research agency imputed missing face-to-face data, but this is not described in the Methods. Please move this information to the Methods and describe the imputation procedure and the amount of missing data.

Statistical approach.

(a) Given the ordinal, ceiling-limited data, please add a non-parametric check (for example, Wilcoxon signed-rank) alongside the paired t-tests.

(b) Please address multiplicity for the item-level tests and the many subgroup comparisons.

(c) The link between prior education and higher performance (Section 4.4) is based on univariable comparisons and may be confounded by institution type and patient volume. A multivariable model would be more convincing, or the wording should be more cautious.

(d) Nurses are nested within institutions. Please report the number of institutions and comment on clustering.

(e) The Discussion compares subdomains (for example, treatment vs. prevention) but I could not find the corresponding method or test. Please describe it or soften the statements.

Conclusions and interpretation.

(a) The statement that priorities "differed by care domain" is difficult to interpret, because different items on different instruments will naturally produce different top items. Since no formal comparison was made, I would suggest rephrasing.

(b) The Conclusions state that the findings account for differences in clinical exposure and practice context, but I could not find an analysis that did this.

(c) Recommendations on simulation-based and digital education go beyond what the data show and would fit better as suggestions for future work.

(d) The absolute discrepancies are small (about 0.18–0.23 on a 0–2 scale), and Borich always yields a ranked list. Please consider adding some judgement on whether these gaps are educationally meaningful in practice.

Please state the setting (Korea) in the Abstract and Title or Keywords, as it affects how the findings can be applied elsewhere.
Please report the response rate or reach, the recruitment channels, the number of institutions, and the dates of IRB approval relative to data collection. A reporting checklist (for example, STROBE and CHERRIES for online surveys) would be helpful.
The inclusion and exclusion criteria overlap and are slightly inconsistent (the phrase "current role" appears only in the exclusions). Please harmonise them.
The final sample (128) is well below the target (248) and the calculated minimum (210). Please state the achieved power or the smallest detectable effect size.
Please explain in the text how the LH-quadrant items should be understood, since "low importance" is relative to the grand mean. Items such as checking shoes for foreign objects are clinically important despite falling in that quadrant.
Some references (for example, [2], [4,5], and [21]) support several different statements. Please check that each one supports the specific claim it is attached to.
Combining pressure injury and diabetic foot care in one paper is reasonable, but since the scores cannot be compared directly, please clarify in the Introduction why they are analysed together.

Author Response

1a. Exclusion of 49 online responses (Sections 2.3 and 4.5). [...] it is quite possible that different nurses gave identical answers (for example, all "2"). If so, this exclusion may have removed respondents with little or no discrepancy and could have inflated the estimated needs. The rule also appears to have been applied only to online responses. I would kindly suggest: (a) a sensitivity analysis including all eligible responses, with the main results shown side by side;

Thank you for this comment. We would like to clarify that the 49 excluded online responses were not removed because their response patterns were identical per se, but because participants selected the same single response option across the entire questionnaire, which was judged as careless or inattentive responding. No face-to-face responses were excluded for this reason. We have revised Section 2.3 to describe this criterion precisely.

(a) We also examined whether any respondents retained in the final sample showed a similarly uniform response pattern. Twenty-three participants (18.0%) gave the same rating across every pressure injury and diabetic foot item (22 of whom rated every item at the maximum score and 1 at the middle score); because such responses were plausible given the overall high importance ratings in this sample, they were retained rather than excluded. To verify that retaining them did not distort the findings, we repeated the analysis after removing these 23 participants as a sensitivity check: the overall discrepancies increased (pressure injury 0.215; diabetic foot 0.278), but the item-level priority classification was unchanged (newly added Section 3.4; Supplementary Table S4).

Revised text / revised content:

Section 2.3. Data Collection | p. 3, lines 131–135

Section 3.4. Sensitivity Analyses (newly added) | p. 12, lines 395–415

“To examine the robustness of the overall discrepancies and the priority classification, several sensitivity analyses were conducted (Supplementary Table S4). Twenty-three participants (18.0%) gave the same rating across every pressure injury and diabetic foot item (22 of whom rated every item at the maximum score and 1 at the middle score); because such uniform responses were plausible given the overall high importance ratings observed in this sample, they were retained in the primary analysis rather than excluded, and their influence was examined as part of the sensitivity analyses below. Among nurses who managed at least one chronic wound patient per month (n = 107), the overall pressure injury discrepancy was small and not statistically significant (0.048; dz = 0.17; p = 0.080), whereas the diabetic foot discrepancy remained significant (0.124; dz = 0.33; p = 0.001); item-level priority classifications were unchanged under this restriction. Restricting the analysis to nurses outside public health institutions produced similar results for pressure injury management; for diabetic foot care, items 4 and 5 exchanged first- and second-priority classifications. Excluding the 23 participants with uniform responses across all items increased the overall discrepancies (pressure injury 0.215; diabetic foot 0.278) but did not change the priority classification. Using median-based reference lines for the Locus for Focus model instead of grand means left five of six first-priority pressure injury items and all three first-priority diabetic foot items unchanged; one pressure injury item (antiseptic use) moved to second priority, and the second-priority items differed slightly. Excluding the fixed 2-h repositioning item from the pressure injury classification did not change the remaining first- and second-priority items.”

1b. (b) more detail on how the survey was distributed online, and whether any incentive was offered

We have added these details to Section 2.3: online participants were recruited through a recruitment notice posted by the survey agency on an online community bulletin board for community-based nurses; for the face-to-face survey, paper questionnaires were distributed at visiting nursing centers after permission was obtained from the center heads; and participants completed the questionnaire at a time of their choosing, regardless of working hours, with a small incentive provided upon completion.

Revised text / revised content:

Section 2.3. Data Collection | p. 3, lines 122–129

1c (c) an explanation of the equal 64/64 split between face-to-face and online participants.

The equal 64/64 split was coincidental rather than by design: 66 face-to-face and 113 online responses were received, of which 2 and 49 were excluded, respectively, leaving 64 in each group. We have also clarified in Section 3.1 that the two modes differed in institutional composition: face-to-face respondents were mostly from long-term care-based institutions (49/64), whereas online respondents were mostly from home healthcare-based (36/64) or public health institutions (10/64).

Revised text / revised content:

Section 3.1. Participant Characteristics | p. 7, lines 299–302

2. Exposure and scope of practice. [...] A "never perform" rating could therefore mean not trained, not encountered, or not permitted within the nurse's role. [...] The finding that treatment items rank highest may partly reflect scope of practice rather than an educational gap. It would help to add a "not applicable" option in future work, restrict or stratify the analysis by wound-care exposure [...] and discuss this point more explicitly.

Thank you for this important point, with which we agree. We conducted sensitivity analyses restricted by wound-care exposure: among nurses who managed at least one chronic wound patient per month (n = 107), the overall pressure injury discrepancy was small and not statistically significant (0.048; dz = 0.17; p = 0.080), whereas the diabetic foot discrepancy remained significant (0.124; dz = 0.33; p = 0.001); item-level priority classifications were unchanged under this restriction. Restricting the analysis to nurses outside public health institutions produced similar results for pressure injury management (newly added Section 3.4; Supplementary Table S4). This indicates that limited clinical exposure contributed substantially to the overall pressure injury discrepancy, even though the priority items identified were robust to this restriction.

We have discussed scope of practice explicitly in Section 4.2, noting that items such as debridement, dead-space management, and antiseptic or antimicrobial use depend on wound assessment, physician orders, institutional protocols, and the nurse's scope of practice, and that their high priority therefore indicates a need for education on assessment and decision-making about when these interventions are appropriate, rather than evidence of a knowledge deficit. We agree that a "not applicable" response option would help distinguish lack of opportunity from lack of competence, and we have added this as a recommendation for future research in the Conclusions.

Revised text / revised content:

Section 3.4. Sensitivity Analyses (newly added) | p. 12, lines 401–405

“Among nurses who managed at least one chronic wound patient per month (n = 107), the overall pressure injury discrepancy was small and not statistically significant (0.048; dz = 0.17; p = 0.080), whereas the diabetic foot discrepancy remained significant (0.124; dz = 0.33; p = 0.001); item-level priority classifications were unchanged under this restriction.”

Section 4.2. Pressure Injury Education | p. 13, lines 470–475

“Similar caution applies to other intervention-specific items. Debridement, dead-space packing, and antiseptic or antimicrobial use depend on wound assessment, physician orders, institutional protocols, and the nurse's scope of practice. Their high priority therefore indicates a need for education on assessment and decision-making about when these interventions are appropriate, rather than a recommendation for their routine or universal use.”

Section 5. Conclusions | pp. 15–16, lines 590–592

“Future surveys could include a "not applicable" response option to distinguish limited opportunity from limited competence.”

3. Stability of the priority rankings. [...] I would suggest reporting confidence intervals or a bootstrap rank-stability analysis, and softening the wording on "first-priority" items. Also, the recoding of the diabetic foot scale from 1–3 to 0–2 [...] can affect Borich scores [...] Please check this, or show that the ranking is unchanged.

We agree. We have clarified that agreement between the Borich needs assessment and the Locus for Focus model reflects convergence between two related summaries of the same importance–performance data rather than independent confirmation (Sections 2.5 and 4.3).

To examine the stability of the priority classification, we repeated the Locus for Focus classification using median-based reference lines instead of grand means (newly added Section 3.4; Supplementary Table S4). Five of the six first-priority pressure injury items and all three first-priority diabetic foot items were unchanged; one pressure injury item (antiseptic use), whose mean importance was only 0.010 above the grand mean, moved to second priority. We also examined the effect of excluding the fixed 2-h repositioning item, which did not change the remaining first- and second-priority items.

Regarding the diabetic foot scale, we would like to clarify that the items were administered directly on a 0–2 scale, using the same response anchors as the pressure injury instrument; the data were not recoded from a 1–3 scale as originally stated, and we have corrected this description in Section 2.4.3. Nevertheless, the reviewer is correct that the Borich score depends on the origin of the importance scale. We therefore recalculated the Borich scores on the original 1–3 scale used by Kim et al. [18] as a sensitivity analysis (Supplementary Table S3): the five highest-ranked items and the first-priority classification were unchanged, with only a minor exchange of ranks 6 and 7 among items that were not classified as first priority under either scaling.

Revised text / revised content:

Section 2.5. Educational Needs Assessment | p. 6, lines 243–247

Section 4.3. Diabetic Foot Education | p. 14, lines 509–512

Section 3.4. Sensitivity Analyses (newly added) | p. 12, lines 410–415

Section 2.4.3. Diabetic Foot Prevention and Management | p. 5, lines 197–204

4a. (a) The fixed 2-hour repositioning item is a top priority, yet your Discussion rightly notes that current guidance recommends individualised repositioning. A lower performance rating on this item may reflect guideline-concordant practice. I would recommend either excluding it from the priority ranking or clearly flagging it as not interpretable in the Results.

We agree. Rather than excluding the item, which would reduce transparency about the full set of 18 pressure injury items assessed, we have retained it but explicitly flagged it in the Results as not interpretable as a performance deficit, because lower performance may reflect guideline-concordant individualized repositioning rather than a gap in practice. We confirmed that excluding this item does not change the remaining priority classification (first priority: items 11, 14, 15, 17, 18; second priority: items 9, 10; newly added Section 3.4; Supplementary Table S4).

Revised text / revised content:

Section 3.3. Priority Educational Needs | p. 10, lines 369–372

“Because current guidance recommends individualized repositioning rather than a fixed interval [22], the 2-h repositioning item should not be interpreted as indicating a performance deficit; its priority ranking may instead reflect a need for education on repositioning assessment and decision-making.”

4b. (b) Some diabetic foot items ask about two actions at once (for example, checking foot hygiene practices and providing education). [...] Please acknowledge this limitation.

We agree and have acknowledged this limitation in Section 4.5.

Revised text / revised content:

Section 4.5. Limitations | p. 15, lines 559–561

“Several diabetic foot items also combined two actions within a single statement (e.g., checking foot hygiene practices and providing education), so a single rating cannot indicate which component drove the discrepancy or the educational need.”

5. Instrument validity. [...] The Cronbach's alpha values here (0.937 and 0.963) are much higher than those originally reported (0.645–0.735) [...] Could you clarify whether the panel included wound-care or diabetes specialists, and whether any pilot testing or cognitive interviewing was done? Some form of structural validation (for example, factor analysis) would strengthen the subdomain comparisons made in the Discussion.

We thank the reviewer for these points. Regarding the elevated Cronbach's α values, mean inter-item correlations were 0.45–0.48 for importance and 0.60–0.62 for performance, exceeding the range generally considered optimal for the performance ratings; ceiling effects were also evident, with 51%–55% of participants rating all items as very important. These patterns may reflect that most of the assessed interventions are considered essential nursing practice, as well as possible item redundancy or uniform responding; the present data cannot distinguish between these explanations, and we have noted this in the Limitations.

The expert panel comprised five members—four professors of nursing (three specializing in community health nursing and one in adult health nursing) and one visiting nurse—two of whom were certified wound care specialists.

Pilot testing or cognitive interviewing with nurses was not conducted when the items were modified; we acknowledge this as a limitation and recommend it for future validation work. We agree that structural validation would strengthen the subdomain comparisons. Only content validity was evaluated for the modified diabetic foot instrument in this study; structural (construct) validity among community-based nurses was not examined, and we have stated this explicitly as a limitation, together with a recommendation for factor analysis in future research.

Revised text / revised content:

Section 2.4.2. Pressure Injury Prevention and Management | p. 4, lines 178–179

“Mean inter-item correlations were 0.45 for importance and 0.60 for performance; 51% of participants rated all 18 items as very important.”

Section 2.4.3. Diabetic Foot Prevention and Management | p. 5, lines 205–207

“Mean inter-item correlations were 0.48 for importance and 0.62 for performance; 55% of participants rated all 10 items as very important.”

Section 4.5. Limitations | p. 15, lines 565–569

“The high Cronbach's α values, together with mean inter-item correlations exceeding the range generally considered optimal for performance ratings and the ceiling effects noted above, may reflect that most of the assessed interventions are considered essential nursing practice, as well as possible item redundancy or uniform responding; the present data cannot distinguish between these explanations.”

Section 2.4.3. Diabetic Foot Prevention and Management | pp. 4–5, lines 184–189

Section 2.4.3. Diabetic Foot Prevention and Management | p. 5, lines 190–192

“Only content validity of the modified instrument was evaluated in this study; structural validity among community-based nurses was not examined.”

Section 4.5. Limitations | p. 15, lines 561–562

“Pilot testing or cognitive interviewing with nurses was not conducted when the items were modified.”

Section 5. Conclusions | p. 16, lines 592–594

“Future research should also include psychometric validation of the modified diabetic foot instrument among community-based nurses, such as factor analysis and cognitive interviewing.”

6. Data handling. Section 4.5 mentions that a research agency imputed missing face-to-face data, but this is not described in the Methods. Please move this information to the Methods and describe the imputation procedure and the amount of missing data.

Thank you for this comment. We have moved this information from the Limitations to Section 2.3 (Data Collection). As part of the survey agency's standard data processing procedure, a small number of missing responses in the face-to-face questionnaires were reviewed and imputed before the dataset was provided to the authors; the specific imputation method and the exact number of affected responses were not documented by the agency and could not be retrieved. We have retained a note in the Limitations stating that this prevents sensitivity analysis of the imputation.

Revised text / revised content:

Section 2.3. Data Collection | pp. 3–4, lines 135–139

“As part of the survey agency's standard data processing procedure, a small number of missing responses in the face-to-face questionnaires were reviewed and imputed before the dataset was provided to the authors; the specific imputation method and the exact number of affected responses were not documented.”

Section 4.5. Limitations | p. 15, lines 552–555

“Fifth, a small number of missing responses in the face-to-face surveys were imputed by the research agency before the dataset was provided, but the affected cells were not identified, preventing sensitivity analysis of the imputation.”

7a. (a) Given the ordinal, ceiling-limited data, please add a non-parametric check (for example, Wilcoxon signed-rank) alongside the paired t-tests.

We agree. We added Wilcoxon signed-rank tests at the item level alongside the paired-samples t-tests. All conclusions were unchanged: no item's statistical significance differed between the two tests (Supplementary Table S6).

Revised text / revised content:

Section 2.6. Statistical Analysis | p. 6, lines 261–264

“Given the ordinal and ceiling-limited nature of the 3-point response scale, Wilcoxon signed-rank tests were additionally conducted at the item level as a non-parametric check alongside the paired-samples t-tests (Supplementary Table S6).”

7b. (b) Please address multiplicity for the item-level tests and the many subgroup comparisons.

We agree. For the item-level paired comparisons, Holm correction was applied within each scale (18 pressure injury items; 10 diabetic foot items); all items classified as first priority remained significant after correction, whereas four pressure injury items (3, 5, 8, and 16) no longer reached significance (Supplementary Table S6).

For the subgroup comparisons according to participant characteristics, Holm correction was applied across all 44 comparisons (Supplementary Table S5). Eight associations remained significant after correction: advanced practice nurse certification with perceived importance in both domains; type of institution with perceived importance in pressure injury management and with self-reported performance in both domains; chronic wound patient volume with self-reported performance in both domains; and interprofessional collaboration with perceived importance of pressure injury management. These associations are summarized in Table 2, and the complete results for all 44 comparisons, including non-significant associations, are reported in Supplementary Table S5.

Revised text / revised content:

Section 2.6. Statistical Analysis | p. 6, lines 264–267

Section 3.1. Participant Characteristics | p. 7, lines 312–320

7c . (c) The link between prior education and higher performance (Section 4.4) is based on univariable comparisons and may be confounded by institution type and patient volume. A multivariable model would be more convincing, or the wording should be more cautious.

As presented in Supplementary Table S5, the univariable association between previous chronic wound management education and self-reported performance did not remain statistically significant after Holm adjustment for multiple testing (pressure injury: adjusted p = 0.417; diabetic foot: adjusted p = 0.473). In addition, in multivariable regression analyses controlling for institutional context and clinical exposure (conducted for the reviewer's confirmation but not presented in the manuscript), prior education was not independently associated with performance (pressure injury: B = −0.02, p = 0.80; diabetic foot: B = 0.02, p = 0.88). Accordingly, this interpretation has been reflected in Section 4.4 of the revised manuscript.

Revised text / revised content:

Section 4.4. Implications for Educational Program Development and Implementation | p. 14, lines 514–520

7d. (d) Nurses are nested within institutions. Please report the number of institutions and comment on clustering.

We agree that clustering of nurses within institutions is an important consideration. However, institutional identifiers were not collected as part of the survey, in order to protect participant and institutional anonymity, and the number of participating institutions is therefore not available. Consequently, clustering could not be modeled statistically. We have acknowledged this as a limitation: because standard errors were estimated assuming independent observations, they may be underestimated if nurses within the same institution gave more similar responses, and statistical tests should be interpreted with this in mind.

Revised text / revised content:

Section 2.3. Data Collection | p. 4, lines 142–144

“Institutional identifiers were not collected to protect participant and institutional anonymity; therefore, the exact number of participating institutions could not be determined.”

Section 4.5. Limitations | p. 15, lines 569–573

“Seventh, institutional identifiers were not collected to protect participant anonymity, so the number of participating institutions could not be determined and clustering of nurses within institutions could not be modeled; standard errors may therefore be underestimated to the extent that responses were correlated within institutions.”

7e. (e) The Discussion compares subdomains (for example, treatment vs. prevention) but I could not find the corresponding method or test. Please describe it or soften the statements.

We agree. We added paired-samples t-tests comparing the importance–performance discrepancy between subdomains within each scale. For pressure injury management, the discrepancy was significantly larger for treatment interventions than for preventive interventions (difference = 0.114; t = 4.86; p < 0.001; dz = 0.43). For diabetic foot care, the discrepancy did not differ significantly between prevention/education and assessment/documentation/reporting (difference = 0.022; t = 0.83; p = 0.41); we have revised the corresponding statements in the Results (Section 3.2) and Discussion (Section 4.1) so that no difference is claimed between the diabetic foot subdomains. We have also described this test in Section 2.6.

Revised text / revised content:

Section 2.6. Statistical Analysis | p. 6, lines 267–268

“Paired-samples t-tests were also used to compare the importance–performance discrepancy between subdomains within each scale.”

Section 3.2. Importance, Performance, and Educational Needs by Scale and Item Group | p. 9, lines 344–354

“Treatment interventions showed a significantly larger discrepancy (0.253 vs. 0.139; t = 4.86, p < 0.001) and Borich needs score (0.453 vs. 0.248) than preventive interventions. ... Prevention and education showed a larger discrepancy (0.237 vs. 0.215) and a higher Borich needs score (0.419 vs. 0.376) than assessment, documentation, and reporting, but the difference was not statistically significant (t = 0.83, p = 0.41).”

Section 4.1. Principal Findings | p. 12, lines 428–431

“For diabetic foot care, prevention and education showed a numerically larger discrepancy and Borich needs score than assessment, documentation, and reporting, although this difference was not statistically significant.”

8a. (a) The statement that priorities "differed by care domain" is difficult to interpret [...] Since no formal comparison was made, I would suggest rephrasing.

We agree. Because pressure injury management and diabetic foot care were assessed using different instruments and no formal statistical comparison was made between the two domains, we have revised the wording in the Abstract and Section 4.1 to describe the priorities identified separately within each domain, rather than implying a comparison between domains.

Revised text / revised content:

Abstract | p. 1, lines 29–31

“Conclusions: First-priority educational needs were identified separately for pressure injury management and diabetic foot care.”

Section 4.1. Principal Findings | p. 12, lines 434–435

“These findings indicate the educational focus identified within each care domain.”

8b. (b) The Conclusions state that the findings account for differences in clinical exposure and practice context, but I could not find an analysis that did this.

Thank you for this comment. We agree that this statement implied an analysis we did not conduct. We have removed this phrase; the Conclusions now state only what the study's analyses directly support.

Revised text / revised content:

Section 5. Conclusions | p. 15, lines 583–587

8c. (c) Recommendations on simulation-based and digital education go beyond what the data show and would fit better as suggestions for future work.

We agree. We have revised this sentence in Section 4.4 so that it no longer states that these formats are effective, but instead identifies this as a direction for future research.

Revised text / revised content:

Section 4.4. Implications for Educational Program Development and Implementation | p. 14, lines 526–530

“Case-based or practical learning may be useful when opportunities to perform specific interventions are limited. Whether case-based, simulation-based, or digital formats are effective for addressing these priorities among community-based nurses should be examined in future research[34-37].”

8d. (d) The absolute discrepancies are small (about 0.18–0.23 on a 0–2 scale), and Borich always yields a ranked list. Please consider adding some judgement on whether these gaps are educationally meaningful in practice.

We agree and have added an interpretive judgment to Section 4.1. While the overall absolute discrepancies were modest (0.177–0.228 on the 0–2 scale), for individual priority items 24%–34% of nurses rated importance higher than performance, indicating that these gaps may be educationally meaningful for a substantial minority of nurses rather than for the workforce as a whole.

Revised text / revised content:

Section 4.1. Principal Findings | p. 12, lines 421–426

9. Please state the setting (Korea) in the Abstract and Title or Keywords.

Thank you. We have added "in Korea" to the Title and to the Keywords. We have also added a mention of the setting to the Abstract.

Revised text / revised content:

Title | p. 1, lines 2–4

“Educational Needs for Pressure Injury and Diabetic Foot Care among Community-Based Nurses in Korea: A Borich and Locus for Focus Analysis”

Abstract | p. 1, lines 12–14

“Pressure injuries and diabetic foot ulcers are prevalent chronic wounds requiring nurses to provide prevention, assessment, treatment, and education, especially in community settings in Korea.”

Keywords | p. 1, lines 33–34

“Keywords: pressure ulcer; diabetic foot; needs assessment; continuing nursing education; community health nursing; Republic of Korea”

10. Please report the response rate or reach, the recruitment channels, the number of institutions, and the dates of IRB approval relative to data collection. A reporting checklist (for example, STROBE and CHERRIES for online surveys) would be helpful.

Thank you for this helpful comment. We clarified the recruitment channels, the inability to calculate a conventional response rate or recruitment reach, the reason the exact number of participating institutions could not be determined, and the timing of IRB approval relative to data collection. We also reviewed the reporting with reference to the STROBE checklist and the relevant CHERRIES recommendations for the online component of the survey.

Revised text / revised content:

Section 2.3. Data Collection | pp. 3–4, lines 122–144

“Data were collected from 20 June to 27 July 2026 using a structured questionnaire administered either face-to-face or online through a professional survey agency. Online participants were recruited through a recruitment notice posted by the survey agency on an online community bulletin board for community-based nurses. For the face-to-face survey, permission for data collection was obtained from the heads of visiting nursing centers, after which paper questionnaires were distributed to eligible nurses at the centers. Participants completed the questionnaire at a time of their choosing, regardless of working hours, and a small incentive was provided upon completion. ... Because the total number of nurses who viewed the online recruitment notice or were approached for face-to-face participation was not recorded, a conventional response rate or recruitment reach could not be calculated. Institutional identifiers were not collected to protect participant and institutional anonymity; therefore, the exact number of participating institutions could not be determined.”

Section 2.7. Ethical Considerations | p. 6, lines 279–281

“The study was conducted in accordance with the Declaration of Helsinki and approved by the Institutional Review Board of Chungbuk National University on 28 April 2026 (IRB No. CBNU-2026-A-0054), prior to data collection.”

11. The inclusion and exclusion criteria overlap and are slightly inconsistent (the phrase "current role" appears only in the exclusions). Please harmonise them.

Thank you for pointing out this inconsistency. We revised the eligibility criteria to remove the overlap between the inclusion and exclusion criteria and to use consistent terminology. The minimum experience requirements for the current institution, current role, and total clinical experience are now stated as inclusion criteria, while the exclusion criterion is limited to nurses whose primary duties are administrative or managerial rather than direct nursing care.

Revised text / revised content:

Section 2.2. Participants | p. 3, lines 92–98

“Participants were registered nurses working in community-based healthcare settings in Korea. The inclusion criteria were: (1) being a registered nurse; (2) having at least 6 months of total clinical experience; (3) having worked at the current institution for at least 6 months; (4) having worked in the current role for at least 6 months; and (5) understanding the purpose of the study and voluntarily agreeing to participate. Nurses whose primary duties were administrative or managerial rather than direct nursing care were excluded.”

12. The final sample (128) is well below the target (248) and the calculated minimum (210). Please state the achieved power or the smallest detectable effect size.

Thank you for this important comment. Because the final analytic sample (n = 128) was smaller than the a priori minimum, we conducted a post hoc power analysis and a sensitivity analysis using G*Power 3.1.9.7 for a two-tailed paired-samples t-test. The achieved power was 0.802 for the prespecified effect size of dz = 0.25, and 0.976 and 0.999 for the observed effect sizes for pressure injury management (dz = 0.35) and diabetic foot care (dz = 0.45), respectively. The sensitivity analysis indicated that the final sample could detect effect sizes of dz = 0.250, 0.289, and 0.321 with 80%, 90%, and 95% power, respectively. These results have been added to the Statistical Analysis section.

Revised text / revised content:

Section 2.6. Statistical Analysis | p. 6, lines 270–276

13. Please explain in the text how the LH-quadrant items should be understood, since "low importance" is relative to the grand mean. Items such as checking shoes for foreign objects are clinically important despite falling in that quadrant.

Thank you for this clarification. We revised the Methods and Discussion to clarify that “low importance” in the LH quadrant is relative to the grand mean and does not indicate low clinical importance. We also emphasized that checking shoes for foreign objects remains clinically important despite its LH classification.

Revised text / revised content:

Section 2.5. Educational Needs Assessment | p. 5, lines 220–223

“In this classification, “low importance” indicates that an item’s mean importance score is below the overall grand mean and does not imply low clinical importance. Thus, items in the LH quadrant may still represent clinically important aspects of care despite having relatively lower importance scores within the set of items.”

Section 4.3. Diabetic Foot Education | p. 14, lines 501–507

“Importantly, classification in the LH quadrant reflects an importance score below the grand mean within this set of items and should not be interpreted as indicating low clinical importance; checking shoes for foreign objects remains an important preventive component of diabetic foot care. These findings illustrate that the Borich needs assessment and the Locus for Focus model emphasize different aspects of the same importance and performance data when educational priorities are identified.”

14. Some references (for example, [2], [4,5], and [21]) support several different statements. Please check that each one supports the specific claim it is attached to.

Thank you for this important comment. We rechecked References [2], [4,5], and [21] in the original submission against each specific claim and reviewed the citations throughout the manuscript. Where a statement was broader than the direct evidence provided by the cited source, we refined the wording to better match the scope of the reference. Citations that directly supported the corresponding statements were retained. Please note that, following revisions to the reference list, Reference [21] in the original submission is now Reference [22] in the revised manuscript.

Revised text / revised content:

Section 1. Introduction | p. 2, lines 42–44

“Early identification of risk factors and appropriate preventive and management strategies are therefore important for reducing adverse health consequences associated with both conditions [2,3].”

Section 1. Introduction | p. 2, lines 56–58

“gaps in nurses’ knowledge and training related to diabetic foot assessment, preventive care, and patient education have also been reported [4,5]”

15. Combining pressure injury and diabetic foot care in one paper is reasonable, but since the scores cannot be compared directly, please clarify in the Introduction why they are analysed together.

Thank you for this helpful comment. We clarified in the Introduction that pressure injury management and diabetic foot care were examined together because both are common chronic wound-related care domains in community-based nursing and require ongoing assessment, preventive care, patient education, and follow-up.

Revised text / revised content:

Section 1. Introduction | p. 2, lines 75–78

“Pressure injury management and diabetic foot care were examined within the same study because both represent common chronic wound-related care domains in community-based nursing and require ongoing assessment, preventive care, patient education, and follow-up”

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors’ response has been carefully evaluated and is considered satisfactory and convincing. The concerns raised during the review process have been adequately addressed.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for your careful and detailed response to my previous comments. I appreciate the time and effort you have put into revising the manuscript.

All of my earlier comments have been addressed satisfactorily. The revisions have strengthened the manuscript.

Best regards,