Connecting the Dots: Occupational Stressors and PTSD Symptoms as Serial Mediators of the Relationship between Fear of COVID-19 and Burnout among Portuguese Police Officers

Round 1

Reviewer 1 Report

Can better define the parameters of burnout. Can further include stressor of potential harm from assailants. 

Author Response

Can better define the parameters of burnout. Can further include stressor of potential harm from assailants.

Thank you for the comment. We added a small description on measurement section and highlighted in yellow. “Burnout is a three-dimensional condition that affects professionals with primary responsibilities. Three subscales labeled as physical fatigue, cognitive fatigue and emotional exhaustion characterize this measurement [20]”.

Reviewer 2 Report

General Comments

·         This article covers a much needed area of study given the world’s experience with COVID-19 and its ramifications.

·         Authors are thorough in explaining in the statistical results to narrative format.

·         Since this is an international journal it may serve this article strength by specifying “Portuguese Police Officers” in its title. This will help readers identify quickly and accurately what population is studied.

·         This article is missing the original hypothesis/hypotheses of the researchers. The first mention of a hypothesis is page 6 in the descriptive text. This should be listed early on in article & in abstract (see comment in Abstract below as well).

·         Inconsistent referencing formatting throughout text - Some intext references are numbered (as the journal requires) and other intext references are using the authors name in parenthesis that need to be numbered, and some are numbered in text references that need to be spelled out

o   Examples: Line 58, Line 249

·         This article spent a significant amount of time creating suggestions for mental health care workers of police officers. The current title of the article does not seem to capture this dynamic of the article, which is an under service.

Abstract

·         The researcher’s clear and stated hypothesis/hypotheses is/are missing from the abstract.

·         Line 12 – grammar error – “with significant impact”. Authors are alluding that stressors impact mental health therefor authors mean “that significantly impact”

·         COVID-19 is an acronym and should be spelled out at first use

·         COVID 19 is used in lowercase throughout article – needs to be capitalized since it is an acronym

Article

·         Line 32-36- authors list our PTEs that are vague but oddly specify children. Is there reasoning behind listing “children” for sexual assault/dead bodies vs. in general dead bodies and sexual assault victims?

·         Line 40 – authors mention “a positive relationship between PTSD and burnout”. This sentence appears incomplete as it is not clear what a positive relationship is, are authors alluding to a positive correlation between the two variables?

·         Line 45-48 – this sentence is awkward and need to be re-written to clarify the point.

·         Line 89 – who was the governing body that granted organization clearance?

·         Procedure Section

o   Was anonymity kept for respondents?

o   How were officers’ private health information protected - if it was at all?

o   Were results then shared with the Police Commanders?

o   Were officers’ job protected if they had significant high level of stress/PTSD?

o   Were therapy/treatment resources offered to police officers?

o   This appears to be part of a dissertation of a Ph.D. and the concern is in the protection of human subjects. For example, what was the protocol if a police officer had high PTSD levels and needed treatment?

·         Line 98-100 – what language was the sociodemographic questionnaire forms in?

·         Line 118 – “stress” is lower cased in title

·         Line 134 – authors mention that only fully completed forms were analyzed. Authors also mention N=200 – is that the number of fully completed or respondents.

o   How many were not fully completed/how many were fully completed?

·         Line 153 – ‘criteria A’ needs to be capitalized

·         Line 98 - mentions that “gender” was measured, however in Table 1 only “sex” is reported.

·         Line 213-14 can be combined

·         Line 219- grammar error “this study aimed our study”

·         Line 218-224 – grammar error & run on sentence. It appears authors are trying to explain the purpose of this study and how they completed the study in one sentence. It is confusing and needs to be clarified. It also appears authors are also trying to include a piece about a study hypothesis as well

·         Line 231 – authors mention fear of covid 19 as an aggravating factor – how are researchers able to state “aggravating” versus a “neutral” factor since they state it was “lowest correlation”.

·         Line 236 – the topic of JDC is introduced late in this article. In a discussion section a new topic is confusing to readers. The topic of JDC should be introduced earlier in the article.

o   Perhaps JDC has something to do with author’s hypotheses?

·         Line 272- this is a new sub-section as the topic changes – future research/suggestions from data?

·         Line 324 – this is a new sub-section - limitations section?

There are some minor grammar changes that need to be made. In addition some paragraphs need to be divided into sub-topics for clarification. 

Author Response

• This article covers a much needed area of study given the world’s experience with COVID-19 and its ramifications. Authors are thorough in explaining in the statistical results to narrative format.

Thank you very much for the comment. It is an honor for us to receive the feedback of our work.

• Since this is an international journal it may serve this article strength by specifying “Portuguese Police Officers” in its title. This will help readers identify quickly and accurately what population is studied.

We added Portuguese Police officers in the title.

• This article is missing the original hypothesis/hypotheses of the researchers. The first mention of a hypothesis is page 6 in the descriptive text. This should be listed early on in article & in abstract (see comment in Abstract below as well).

Thank you for the comment. We stated the hypotheses in a clearer form at the end of the introduction (highlighted in yellow).

“The present study was carried out during the COVID-19 pandemic, which involved changes in the routines of these professionals. Based on previous research it is known that the interaction between operational and organizational stressors is a predictor of poor mental health and PTSD [9]. Besides, research also shows that PTSD is a predictor of burnout [8]. Therefore, for this study considered 3 hypotheses: 1) the interaction between operational and organizational stressors will mediate the relationship between fear of COVID-19 and burnout; 2) the interaction between operational and organizational stressors will mediate the relationship between fear of covid-19; and  3) The relationship between fear of COVID-19 and burnout would be serially mediated by the combination of stressors interaction and PTSD, in this sequence (see Figure 1)”.

• Inconsistent referencing formatting throughout text - Some intext references are numbered (as the journal requires) and other intext references are using the authors name in parenthesis that need to be numbered, and some are numbered in text references that need to be spelled out.
• Examples: Line 58, Line 249

We corrected the references – line 50 and line 254.

• This article spent a significant amount of time creating suggestions for mental health care workers of police officers. The current title of the article does not seem to capture this dynamic of the article, which is an under service.

We welcome your comment. We consider that the suggestions for mental health care workers of police officers are implications for practice, and not the paper’s objective/hypothesis. Therefore, for now, we kept the original title. However, we are open to change it if the reviewer finds it really important.

Abstract

• The researcher’s clear and stated hypothesis/hypotheses is/are missing from the abstract.

We added “This study tested the hypothesis that occupational stressors and PTSD are serial mediators of the relationship between fear of covid-19 and burnout” in abstract.

• Line 12 – grammar error – “with significant impact”. Authors are alluding that stressors impact mental health therefor authors mean “that significantly impact”.

Thank you for identifying this. We now changed it to ““that significantly impact” as suggested.

• COVID-19 is an acronym and should be spelled out at first use.

We added severe acute respiratory syndrome coronavirus 2 (common denominated as COVID-19) – Line 51-52, as suggested.

• COVID 19 is used in lowercase throughout article – needs to be capitalized since it is an acronym.

We replace all “covid-19” to “COVID-19” as suggested.

Article

• Line 32-36- authors list our PTEs that are vague but oddly specify children. Is there reasoning behind listing “children” for sexual assault/dead bodies vs. in general dead bodies and sexual assault victims?

 We corrected a grammatical error, and we replace “seriously injured or dead children” – line 33.

• Line 40 – authors mention “a positive relationship between PTSD and burnout”. This sentence appears incomplete as it is not clear what a positive relationship is, are authors alluding to a positive correlation between the two variables?

We replace “relationship” to “correlation”

• Line 45-48 – this sentence is awkward and need to be re-written to clarify the point.

We replace the sentence and now is: “Additionally, it is also important to note that research has shown that, more the interaction between operational and organizational stressors that has the greatest impact on mental health, particularly at the level of PTSD symptoms [9].”

• Line 89 – who was the governing body that granted organization clearance?

The organization clearance was Portuguese police organizations, namely National Republican Guard (GNR); Public Security Police (PSP) and Judicial Police (PJ) (highlighted in yellow) Line 96-98

Procedure Section

• Was anonymity kept for respondents?

Participation was anonymous and confidential, and this was explained in the informed consent.

• How were officers’ private health information protected - if it was at all?

We have rephrased the end of the procedure (highlighted in yellow).

• Were results then shared with the Police Commanders?

The general and anonymized data were presented to the police commands. In this presentation, only prevalence rates of the assessed variables were shared.

• Were officers’ job protected if they had significant high level of stress/PTSD?

All participants who showed clinical distress were provided with psychological support by the person responsible for the investigation. All police officers were invited to share their email if they want to have access to their own results. Those police officers that presented high levels of PTSD and that shared their email, were contacted by the psychologist to offer psychological support. Individual results were not shared with the Organizations or the Police Commanders in order to protect officers’ job. To the date, as far as we were able to assess, no police officer presented risk so that the patient-psychologist confidentiality needed to be broken.

Were therapy/treatment resources offered to police officers?

The intervention offered to police officers is Trauma-Focused Cognitive Behavior Therapy, as suggested by the APA.

• This appears to be part of a dissertation of a Ph.D. and the concern is in the protection of human subjects. For example, what was the protocol if a police officer had high PTSD levels and needed treatment?

All participants who showed clinical distress were provided with psychological support by the person responsible for the investigation, who is a clinical and health psychologist with more than 5 years of clinical experience.

• Line 98-100 – what language was the sociodemographic questionnaire forms in?

All measurements were written in Portuguese. Line 113.

• Line 118 – “stress” is lower cased in title

We changed to Stress with capitalized in title.

• Line 134 – authors mention that only fully completed forms were analyzed. Authors also mention N=200 – is that the number of fully completed or respondents.
• How many were not fully completed/how many were fully completed?

Seventy-five responses were not fully complete, and 200 (72.7%) were fully completed. This information has been added to the article and highlighted in yellow. Line 183

• Line 153 – ‘criteria A’ needs to be capitalized

We change CRITERION A, as suggest.

• Line 98 - mentions that “gender” was measured, however in Table 1 only “sex” is reported.

We changed “gender” to “sex”.

• Line 213-14 can be combined.

As suggest we combined new line 223-224.

• Line 219- grammar error “this study aimed our study”.

We removed “our study” as suggest.

• Line 218-224 – grammar error & run on sentence. It appears authors are trying to explain the purpose of this study and how they completed the study in one sentence. It is confusing and needs to be clarified. It also appears authors are also trying to include a piece about a study hypothesis as well.

Thank you for the comment. We clarify the sentence of the discussion (Page 7 highlighted in yellow).

• Line 231 – authors mention fear of covid 19 as an aggravating factor – how are researchers able to state “aggravating” versus a “neutral” factor since they state it was “lowest correlation”.

We argued that it was “aggravating” in the sense that it was another factor of increased stress which added new demands both personally and professionally.  Despite the direct relationship between fear of COVID-19 and burnout correlation being low.

• Line 236 – the topic of JDC is introduced late in this article. In a discussion section a new topic is confusing to readers. The topic of JDC should be introduced earlier in the article.
• Perhaps JDC has something to do with author’s hypotheses?

 We added a sentence at the end of the introduction to clarify this point. (Page 2 highlighted in yellow).

• Line 272- this is a new sub-section as the topic changes – future research/suggestions from data?

We added a new sub-section – “4.1. future research”

• Line 324 – this is a new sub-section - limitations section?

We added a new sub-section “4.2. limitations”

• Comments on the Quality of English Language
• There are some minor grammar changes that need to be made. In addition some paragraphs need to be divided into sub-topics for clarification. 

Thank you for your comment. We have corrected the grammatical errors noted

Reviewer 3 Report

1. Line 41-42: It is not clear what is a significant predictor of the burnout. (reference # 8). 

2. Line 70-72: It is difficult to follow that what is mediated by the interaction. 

3. Line 72: "Based on evidence..." This statement needs clarification, may be some English editing. Possibly some phrases are used multiple times. 

4. Table 1. Categories of FCV-19S, PSQ-Op, PSQ-Org and Burnout should be further explored. Like PCL-5 which clearly states in the text that score more than or equal to 31 suggests probable diagnosis of PTSD. Similarly, categories of these 3 variables should be explained. 

5. Table 1. For PSQ-Op and PSQ-Org, should categories be <2, 2-3.5, and >= 3.5? I do not understand how the score of these variables will be < 2 because it's a 20-item 7-ppint likert scale. Hence, the range of these scores would be 20-140. 

6. Line 183-184: The author is controllig the model with fear of COVID. However, the model itself was looking at the relationship between fear of COVID and burnout. 

- The last line of abstract reads "...minimize the negative effects the adverse effects of these stressors." No need to include both "negative effects" and "adverse effects". 

Author Response

• Line 41-42: It is not clear what is a significant predictor of the burnout. (reference # 8).

 We clarify the model in figure 1

• Line 70-72: It is difficult to follow that what is mediated by the interaction.

Thank you for the comment. We clarified this information at the end of the introduction (Page 2 highlighted in yellow).

• Line 72: "Based on evidence..." This statement needs clarification, may be some English editing. Possibly some phrases are used multiple times.

We clarify form the end of the introduction (highlighted in yellow). We changed this expression. Page XXX highlighted in yellow.

• Table 1. Categories of FCV-19S, PSQ-Op, PSQ-Org and Burnout should be further explored. Like PCL-5 which clearly states in the text that score more than or equal to 31 suggests probable diagnosis of PTSD. Similarly, categories of these 3 variables should be explained.

Cut-off points have been added to the description of each instrument and highlighted in yellow (Page 3-4).

• Table 1. For PSQ-Op and PSQ-Org, should categories be <2, 2-3.5, and >= 3.5? I do not understand how the score of these variables will be < 2 because it's a 20-item 7-ppint likert scale. Hence, the range of these scores would be 20-140.

Thanks for the comment. The calculation is done through the mean of each subscale and not through the sum.

• Line 183-184: The author is controllig the model with fear of COVID. However, the model itself was looking at the relationship between fear of COVID and burnout.

Thank you for the comment. With this sentence we aimed to show that the assumptions for the serial mediation were met.

• The last line of abstract reads "...minimize the negative effects the adverse effects of these stressors." No need to include both "negative effects" and "adverse effects".

We removed the “negative effects” as suggest.

Round 2

Reviewer 3 Report

I want to congratulate the author and thank for this contribution to the field.