Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for your effort in studying such an important issue: Impact of resident doctors’ strike on psychological outcomes among Paramedics in teaching-hospital emergency depart ments: A Nationwide multicenter survey

 

 

 Kindly find the following feedback:

 

Please make the introduction clearer and shorter and specify whether the duties of paramedics overlap with those of resident physicians.

Please specify which activities previously performed by residents were taken over by paramedics during the strike, the number of residents who were on strike, the duration of the strike and the number of paramedics who took over the residents' activities.Please specify what is the difference in competence between senior paramedics and junior paramedics?There are previous studies evaluating job stress, self-efficacy, job satisfaction, and confidence in job performance—among paramedics working in teaching-hospital emergency departments? Please explain why you are not comparing the variables during the strike with those before the strike? Why are you comparing the variables after the strike? After the strike, were there changes in the activities and skills of paramedics compared to the period before the strike? 

Materials and Methods:

Please explain why the study is prospective? (Line 137)Please specify the period of the strike, the number of emergency departments involved, the number of residents who went on strike, and the number of paramedics who replaced the residents' work.Please specify what were the inclusion criteria and what were the exclusion criteria in the study?Please specify which scales you used to assess the variables (job stress, self-efficacy, job satisfaction, and confidence in job performance)?  Are the scales validated and accredited? For each scale and variable, please specify the normal, high, and low values.Please present the questionnaire sent with the 41 items.Please specify how the variables were evaluated before the strike. 

Results

Please rearrange the results compared to normal high or low values ​​of the variables (job stress, self-efficacy, job satisfaction, and confidence in job performance) before, during and after the strike.

Discussion

Please organize the discussions on the comparative evaluation of variables (job stress, self-efficacy, job satisfaction, and confidence in job performance) before, during and after the strike in correlation with the legal competencies and activities that the paramedics carried out before, during and after the strike.Please use more references from the specialized literature, including references to the work and skills of paramedics and residents in other countries, and specify whether such a situation has been described before.

Comments for author File: Comments.pdf

Author Response

Comment 1: Please specify which activities previously performed by residents were taken over by paramedics during the strike, the number of residents who were on strike, the duration of the strike and the number of paramedics who took over the residents' activities.

Response 1:
Thank you for this important comment. We revised the Introduction to specify examples of clinical-assistance activities that paramedics reported increasing during the resident staffing disruption, including invasive bedside procedures and high-stakes workflow coordination such as airway-related procedures, assisting with arterial line insertion, wound suturing, and coordinating diagnostic workups and consent processes. Revised text: Lines 72–78.
Regarding the number of residents participating in the walkout, we added a verifiable national context statement based on contemporaneous reporting (Reuters reported that almost 8,000 trainee doctors walked off the job as of 21 February 2024, and participation increased thereafter). Revised text: Lines 72–74.
With respect to the duration of the strike and ED-specific counts (number of EDs affected, number of residents absent per ED), we note that these values fluctuated over time and are not consistently available as stable ED-level aggregates across institutions. We therefore anchored the timeline to the onset of the walkout and the survey administration period. The survey was administered from April 17 to May 2, 2024, which corresponds to approximately 8 to 10 weeks after the onset of the trainee doctors’ walkout in February 2024. Revised text: Lines 166–169.
Finally, the number of paramedics who “took over” residents’ activities is not directly observable nationwide in an auditable manner from our dataset. We therefore reported the study’s institutional coverage and analytic sample: 100 institutions, two paramedics recruited per institution (target N=200), with N=161 included in final analysis. Revised text: Lines 140–146.

Comment 2: Please specify what is the difference in competence between senior paramedics and junior paramedics.

Response 2:
We clarified that career stage was operationalized using years of professional experience, which serves as a practical proxy for clinical competence in ED operations. Junior paramedics were defined as those with fewer than five years of experience, and senior paramedics as those with five years or more, reflecting early-career versus more established clinical practice and typical escalation of responsibility and supervisory expectations. Revised text: Lines 152–155.
We also interpret senior–junior differences in the Discussion by linking experience to practice demands and performance under pressure. Revised text: Lines 470–473.

Comment 3: There are previous studies evaluating job stress, self-efficacy, job satisfaction, and confidence in job performance among paramedics working in teaching-hospital EDs. Please explain. Also, why are you not comparing the variables during the strike with those before the strike? Why are you comparing the variables after the strike?

Response 3:
We clarified in the Introduction that comprehensive quantitative evidence addressing these psychological variables in the context of large-scale resident workforce disruption remains limited, which motivated the present study. Revised text: Lines 93–98.
Regarding the timing of comparisons, the survey was administered once in the post-onset period, and participants retrospectively rated a standardized before-strike reference period defined in the questionnaire. This enabled within-participant comparison between before-strike and post-strike periods using a consistent reference framework, but did not include standardized real-time repeated measurements during the peak disruption (“during-strike”) period. Revised text: Lines 120–122 and Lines 482–485.
We compared post-strike rather than “during-strike” because the study aimed to capture the period when ED workflows were being reorganized under resident shortage conditions, and because real-time “during-strike” measurement was not feasible within this survey design. We explicitly acknowledge this limitation and recommend future studies incorporate repeated measurements across all phases. Revised text: Lines 482–485.

Materials and Methods

Comment 4: Please explain why the study is prospective? (Line 137)

Response 4:
We revised the wording to avoid confusion. The study is now described as a questionnaire-based observational study with a single survey administration and retrospective pre-strike ratings using a standardized reference period, enabling within-participant pre–post comparisons. We removed the emphasis on “prospective” as a design label and clarified the actual data structure and timing. Revised text: Lines 113–122.

Comment 5: Please specify the period of the strike, the number of EDs involved, the number of residents who went on strike, and the number of paramedics who replaced the residents' work.

Response 5:
We anchored the timeline to verifiable milestones and the survey period. We stated that the collective action began in February 2024 and that the survey was administered from April 17 to May 2, 2024 (approximately 8–10 weeks after onset). Revised text: Lines 69–74 and Lines 166–169.
We also added a national context estimate for trainee doctors who walked off the job (Reuters: almost 8,000 as of 21 February 2024). Revised text: Lines 72–74.
ED-specific counts (number of EDs affected and resident absences per ED) and the nationwide number of paramedics substituting residents’ duties were not available as stable, audited aggregates across institutions, and therefore were not presented as definitive counts. Instead, we report the study’s institutional coverage and sample size (100 institutions; N=161 analyzed). Revised text: Lines 140–146.

Comment 6: Please specify what were the inclusion criteria and what were the exclusion criteria in the study?

Response 6:
We clearly stated the inclusion criteria as licensed EMT paramedics currently assigned to and working in the ED of a participating emergency medical center, with at least six months of ED employment, and able to complete the questionnaire in Korean and provide consent. Revised text: Lines 147–151.
Exclusion criteria include not currently working in an ED, unlicensed personnel or non-paramedic healthcare professionals, insufficient ED employment duration, prolonged absence during the study period, and incomplete/invalid questionnaires including missing key outcome responses. Revised text: Lines 157–161.

Comment 7: Please specify which scales you used to assess the variables. Are the scales validated and accredited? For each scale and variable, please specify the normal, high, and low values.

Response 7:
We provided scale descriptions for each construct (job stress, self-efficacy, job satisfaction, performance confidence), including the development/adaptation process, expert content validity review, CVI reporting, pilot testing where applicable, and internal consistency reliability using Cronbach’s alpha. Revised text: Lines 180–297 (scale descriptions and psychometrics).
For score interpretation, we clarified that total scores range from 1 to 5, with 3 indicating a mid-level response, and that higher scores reflect higher levels of each construct. Revised text: Lines 235, 244, and 297.
For job stress specifically, we additionally reported Low/Normal/High interpretive bands to support clearer interpretation. Revised text: Lines 349–350.
For the other scales, we did not impose external “normative” cutoffs because validated population norms for the specific ED-strike context are not established; instead, we provide the full range and mid-point interpretation and report pre–post means and changes.

Comment 8: Please present the questionnaire sent with the 41 items.

Response 8:
We indicated that the full 41-item questionnaire is provided as Supplementary Appendix S1. Revised text: Line 179.
(If the journal requires the questionnaire to be embedded rather than supplementary, we can relocate Supplementary Appendix S1 content into an appendix section in the main manuscript.)

Comment 9: Please specify how the variables were evaluated before the strike.

Response 9:
We clarified that “before-strike” values were obtained through retrospective self-report using a standardized pre-strike reference period defined in the questionnaire, enabling within-participant comparisons between before-strike and post-strike periods. Revised text: Lines 120–122 and Lines 180–193.
The statistical analysis section further specifies how these pre–post ratings were analyzed using paired tests. Revised text: Lines 302–306.

Results

Comment 10: Please rearrange the results compared to normal/high/low values of variables before, during and after the strike.

Response 10:
We appreciate this suggestion. In the current design, we do not have standardized repeated measurements during the peak “during-strike” period. Therefore, we present before-strike vs post-strike comparisons as the primary analytic contrast. For interpretability, we included Low/Normal/High interpretive bands for job stress. Revised text: Lines 349–350.
We also explicitly acknowledge the limitation of not having standardized “during-strike” repeated measurements and recommend future studies implement repeated assessments across all phases. Revised text: Lines 482–485.

Discussion

Comment 11: Please organize the discussion around comparative evaluation before, during and after the strike in correlation with legal competencies and activities before, during and after.

Response 11:
We strengthened the Discussion by explicitly linking role expansion and task redistribution to legal/institutional constraints and accountability ambiguity, and we integrated governance and task-shifting frameworks to support the policy interpretation. Revised text: Lines 440–448.
We also added concrete policy implications addressing contingency planning, supervision/documentation requirements, legal safeguards, credentialing, and monitoring systems. Revised text: Lines 474–480.
We further acknowledge that “during-strike” was not measured as a standardized repeated phase and therefore interpretive statements about the “during” period are inferential and should be tested in future longitudinal designs. Revised text: Lines 482–485.

Comment 12: Please use more references from specialized literature, including work and skills of paramedics and residents in other countries, and specify whether such a situation has been described before.

Response 12:
We added specialized international literature and policy guidance on task shifting, governance, credentialing, and safety implications of role expansion, to contextualize the Korean experience and clarify that comparable resident-strike–related task substitution by paramedics has been rarely documented in the published literature. Revised text: Lines 445–449 and Lines 475–480.

Reviewer 2 Report

Comments and Suggestions for Authors

Its my pleasure to review the manuscript on Impact of resident doctors’ strike on psychological outcomes among Paramedics in teaching-hospital emergency departments: A Nationwide multicenter survey. The manuscript highlights the significance of assessing the psychological well-being of paramedical staff in the context of the recent resident doctors' strike.

The manuscript is well structured and presented by the authors with clear context, a literature review on the subject in question, and justification of the study and its contributions. Objectives of the study are clearly stated.

However, authors should try to include more recent studies to support their arguments.

Methodology

The authors provided a comprehensive explanation of the study design, sample collection, population, and data collection process.  By providing a specific timeframe, authors have taken steps to reduce recall bias. The data collection tool and its development, measurement of variables has been fully described. However, some areas can be improved:

1. Subheadings under both sub-sections 2.1 and 2.3 are mentioned as the study design. Please mention the study design clealry
2. The authors have not provided the sample design. How was the sample determined and selected? What procedures were followed? What was the total number of paramedics in the country?
3. How were questionnaire validity and reliability tested? Please give details
4. The authors used different career stages, like junior’s vs senior paramedics. How were these categories defined?
5. In statistical analysis, please give details of the specific analysis used to achieve the research objectives

Results and discussion

The results section is presented properly with an adequate number of tables and charts. The discussion gives a comprehensive analysis of the findings with critical reviews relating them to the broader context of emergency care in Korea.

However, the discussion should provide more valuable insights if the authors explored how the expansion of the roles of paramedics affected patient treatment and outcomes.

The discussion should also provide concrete policy recommendations for health policy makers.

Additionally, they should provide the research gaps and how future research can fill these gaps.

 

 

 

 

Author Response

Comment 1: Subheadings under both sub-sections 2.1 and 2.3 are mentioned as the study design. Please mention the study design clearly.

Response 1:
Thank you for the comment. We clarified the study design in Section 2.1 Study design, explicitly describing the predefined protocol, IRB approval prior to recruitment, and the retrospective pre-strike reference period used for within-participant comparison. We also ensured that Section 2.3 is presented as Study materials/protocol and does not redundantly label itself as “study design.”
Revised text: Lines 101–112 (clear study design definition) and Line 151 (2.3 heading and structure).

Comment 2: The authors have not provided the sample design. How was the sample determined and selected? What procedures were followed? What was the total number of paramedics in the country?

Response 2:
We added a detailed description of the sampling design and selection procedures. Specifically, we constructed a stratified sampling frame by region and center type, allocated sample proportionally to stratum size, and recruited from 100 institutions nationwide, selecting two paramedics per institution to ensure broad institutional coverage. We also provided national context for the total workforce by reporting the number of licensed EMT paramedics in Korea (26,992) and the number employed in medical institutions (4,143).
Revised text: Lines 118–127 (national workforce totals and contextualization), Lines 128–134 (stratified sampling design, institution count, and distribution).

Comment 3: How were questionnaire validity and reliability tested? Please give details.

Response 3:
We expanded the Methods to provide explicit procedures and results for content validity and internal consistency reliability across measures. For baseline characteristics, we report expert panel review methods and indices, including mean CVI = 0.92 and Cronbach’s alpha = 0.81. For each main scale (job stress, self-efficacy, job satisfaction, performance confidence), we report expert review procedures, item-level or scale-level CVI, pilot testing where applicable, and Cronbach’s alpha.
Revised text:

• Baseline items validity/reliability: Lines 180–193

• Job stress validity/reliability and pilot testing: Lines 195–216

• Self-efficacy validity/reliability: Lines 217–232

• Job satisfaction validity/reliability and pilot testing: Lines 233–253

• Performance confidence validity/reliability and pilot testing: Lines 254–275

Comment 4: The authors used different career stages, like junior vs senior paramedics. How were these categories defined?

Response 4:
We clarified the operational definition of career stage based on years of professional experience. Junior paramedics were defined as those with fewer than five years of experience, and senior paramedics as those with five years or more, with rationale provided for this cut point.
Revised text: Lines 140–144.

Comment 5: In statistical analysis, please give details of the specific analysis used to achieve the research objectives.

Response 5:
We revised the Statistical Analysis section to clearly map each analysis to the study objectives. We specified use of paired samples t-tests for within-participant pre–post comparisons, independent samples t-tests for senior vs junior comparisons on post levels and change scores where applicable, and Pearson correlations to examine relationships among constructs. We also clarified the statistical software and significance threshold.
Revised text: Lines 276–288.

Comment 6: The discussion should provide more valuable insights if the authors explored how the expansion of the roles of paramedics affected patient treatment and outcomes.

Response 6:
We expanded the Discussion to explicitly address how strike-related role expansion and task redistribution may plausibly influence patient care processes and outcomes, while acknowledging that patient-level outcomes were not directly measured in this study. We also highlighted the importance of linking future evaluations to objective ED quality indicators.
Revised text: Lines 400–408 and Lines 449–451.

Comment 7: The discussion should also provide concrete policy recommendations for health policy makers.

Response 7:
We added concrete policy implications aimed at health policy makers, including recommendations on contingency planning for task shifting, supervision and documentation requirements, legal safeguards, monitoring systems using ED performance indicators, and competency-based credentialing frameworks for high-risk tasks.
Revised text: Lines 439–446.

Comment 8: Additionally, they should provide the research gaps and how future research can fill these gaps.

Response 8:
We explicitly stated key research gaps, including the absence of direct measurement of patient outcomes and the need for objective ED performance metrics to test inferred pathways. We also proposed directions for future research to address these gaps.
Revised text: Lines 449–451.

Reviewer 3 Report

Comments and Suggestions for Authors

Provide further details on sampling:

1. What was the computed minimum sample size?
2. How many institutions were involved in the survey and what was the relative or comparative size of each? State how the sample was distributed across the selected institutions. Was it all institutions in a locale or province (or country)?
3. Methods - explain the scoring system and interpretation for the various measures (e.g. workload, job stress, etc)- what is minimum vs maximum vs mid-level score?
4. Were any validated measures of stress considered for use in the survey? (e.g .perceived stress scale) Explain
5. Provide a time frame for the strike vis a vis he conduct of the survey. How long after the strike was the survey conducted?
6. Is it possible that other lingering stressors at the time of the survey could be contributing to the results obtained?
7. The issues noted in #4-6 above should form part of the revised Discussion - including limitations  

Author Response

Comment 1: What was the computed minimum sample size?

Response 1:
Thank you for this comment. Because this study used a nationwide stratified sampling design with a fixed recruitment strategy of two paramedics per institution, the sample size was determined primarily by the sampling frame and feasibility constraints rather than a single-effect a priori power calculation. We clarified this in the Study Population section and reported the planned target sample and achieved analytic sample (target N=200, final N=161).
Revised text: Lines 140–147.

Comment 2: How many institutions were involved in the survey and what was the relative or comparative size of each? State how the sample was distributed across the selected institutions. Was it all institutions in a locale or province (or country)?

Response 2:
We clarified that the survey recruited participants from 100 institutions nationwide, with two paramedics selected per participating institution, yielding an initial target of N=200 and a final analytic sample of N=161. We also clarified that sampling used stratification by regional distribution and center type with proportional allocation across strata.
To provide comparative context on institutional size, we reported the distribution of the number of paramedics working in the same institution as part of baseline characteristics (Table 1).
Revised text:

• Sampling frame and distribution across institutions: Lines 140–147.

• Institutional size proxy (number of paramedics per institution categories reported): Lines 322–326 and Table 1 narrative around Lines 320–326.

Comment 3: Methods – explain the scoring system and interpretation for the various measures (e.g., workload, job stress, etc). What is minimum vs maximum vs mid-level score?

Response 3:
We added explicit scoring interpretation across measures, specifying that scores ranged from 1 to 5, with 3 indicating a mid-level response, and that higher values indicate higher levels of each construct. In addition, for job stress we also provided categorical interpretation bands (Low/Normal/High) to improve interpretability in the table note.
Revised text:

• Job stress scoring and interpretation including mid-level: Lines 231–235.

• Job stress categorical interpretation (Low/Normal/High) in table note: Lines 338–342.

• Job satisfaction scoring interpretation including mid-level: Lines 272–273.

• Performance confidence scoring interpretation including mid-level: Lines 294–295.

• Self-efficacy scoring interpretation including mid-level: Lines 242–244.

Comment 4: Were any validated measures of stress considered for use in the survey (e.g., Perceived Stress Scale)? Explain.

Response 4:
Yes. We added a statement indicating that we considered using general validated stress tools such as the Perceived Stress Scale, but selected an ED- and strike-specific job stress measure because our primary aim was to capture strike-related, task-redistribution stressors in the emergency department context.
Revised text: Lines 231–233.

Comment 5: Provide a time frame for the strike vis-à-vis the conduct of the survey. How long after the strike was the survey conducted?

Response 5:
We clarified the timing of the disruption and the survey period. We specified that the resident doctors’ collective action began in March 2024, and we stated the survey administration dates (April 17 to May 2, 2024, 17 days). This places the survey in the early post-disruption operational adjustment phase following the onset of the strike.
Revised text:

• Strike onset timing: Lines 111–113.

• Survey period timing: Lines 165–167.

Comment 6: Is it possible that other lingering stressors at the time of the survey could be contributing to the results obtained?

Response 6:
Yes. We addressed this explicitly as a limitation by noting that the survey was administered during an ongoing period of operational adjustment, and that unmeasured concurrent stressors (e.g., organizational conflict, policy uncertainty, personal stress) may have contributed to the observed outcomes, limiting strict causal attribution solely to the strike.
Revised text: Lines 486–490.

Comment 7: The issues noted in #4–6 above should form part of the revised Discussion, including limitations.

Response 7:
We incorporated these issues into the Discussion and Limitations. Specifically, we expanded the Discussion to address the plausible implications of role expansion and strain on care processes and patient safety (while noting that patient outcomes were not measured), and we added a clear limitation regarding potential concurrent stressors during the survey period.
Revised text:

• Discussion expansion linking role expansion to care processes/patient safety considerations and ED quality indicators: Lines 426–439.

• Limitations including concurrent stressors: Lines 486–490.

• Consideration of validated stress tools (PSS) is included in Methods as noted above: Lines 231–233.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors I appreciate that it has been a difficult period for paramedics and legislative and organizational changes are necessary.