Standing Strong: Simulation Training and the Emotional Resilience of Healthcare Providers During COVID-19
Round 1
Reviewer 1 Report
The article addresses a highly relevant topic with a human-centered approach to simulation training in pandemic preparedness. Its integration of technical skills, empathy, and psychological safety gives it the potential to be an interesting contribution to this research field. However, to reach its full potential, the manuscript needs language refinement, clearer structure, and a more critical discussion of limitations and implementation challenges.
I will provide the detailed comments regarding the areas for improvement in a section-by-section fashion.
Introduction: The transition from general pandemic challenges to simulation-based learning (lines 45–47) could be made more fluid: consider introducing simulation earlier and integrating it more gradually into the argument. Also, a more cohesive definition of non-technical skills earlier in the paragraph (e.g., line 38–40) would help orient the reader (this could apply to the distinction between technical and non-techinal skills as well). Finally, watch out the use of generalizations like "current literature emphasizes" (line 38) or "careful attention must be paid" (line 56) and consider being more specific. Regarding section 1.1 of the Introduction: there are multiple spelling and grammar errors to be corrected, but, most importantly, the section would benefit from a reordering that would create a clearer structure; consider, in this order, defining SIT, justifying the use of simulation, identify gaps in the literature and state the contribution of the present study.
Materials and methods: Line 98-99: specify what kind of experiences or themes were expected/explored. Line 103: specify if just conference attendees. Line 107: justify the criterion of "at least six years". Please mention if the demographics of the participants were registered. Line 111: how was saturation assessed? Consider including the semi-structured guide as an appendix of the article. The analysis strategy requires more details: which coding software was used (if any)? Inter-rater reliability assessed? Disagreement in coding? How was it resolved?
Results: The results section is very rich and well-organized in three major themes. Participants from different roles are quoted, adding completeness to the report, but some quotes are very long, and authors could consider to tighten them and focus on the most relevant parts. Numerous typos and grammar errors, and line breaks, need to be corrected.
Discussion and Conclusions: The Discussion links the findings with the main goals of the study and the references are used correctly to support the authors' claims. The Conclusions are well-balanced without over-generalization. What could be improved in these sections is to highlight alternative interpretations or potential challenges represented by simulation-based training. Also, bias from voluntary participation should be mentioned, as well as other possible limitations, e.g. the context-dependency of qualitative data and the challenges of measuring findings like empathy or psycological safety.
Author Response
Point 1: It the research design appropriate and are the methods adequately describe.
Response 1: Thank you for your comment. To ensure clarity regarding our methodological framework, this study employed a descriptive phenomenological approach to explore the lived experiences of healthcare providers mentioned in Line 119. This approach was deemed most appropriate for capturing the essence of their perspectives on emotional resilience and simulation training during the COVID-19 pandemic. For data analysis, we utilized content analysis, following a systematic process to identify, analyze, and report patterns (themes) within the data. The rigor of this analytical process was guided by the principles of qualitative inquiry, drawing upon the foundational concepts of trustworthiness in qualitative research as articulated by Lincoln and Guba (1985), ensuring a credible and dependable interpretation of the findings in Line 154-159.
Point 2: Are the results presented clearly and in sufficient detail, are the conclusions supported by the results and are they put into context within the existing literature?
Response 2: Thank you for your feedback regarding the presentation of our results and the contextualization of our finding results. We have meticulously ensured that the qualitative data presented in the manuscript is both clear and sufficiently, providing rich descriptions and illustrative quotes (after revision of Table 2) to support our thematic analysis of how simulation training enhanced healthcare providers’ emotional resilience during COVID-19. Furthermore, we affirm that all conclusions drawn are directly and robustly supported by the presented results, with a clear logical progression from our empirical findings to the broader implications. As highlighted in both the introduction and discussion sections, these findings are consistently contextualized within the existing literature on emotional resilience, simulation training, and healthcare provider well-being during crises, thereby establishing the study’s contribution to the current body of knowledge.
Point 3: Does this article provide a relevant contribution to the scientific discussion of this topic?
Response 3: Thank you for your comment. This article is applied qualitative research to achieve a profound, contextualized understanding of complex human experiences, such as feelings and perspectives, which are critical data points. This methodology illuminated the human impact of crises, unpacks multifacetedly constructs like emotional resilience, provides vital context-specific knowledge, generated new theoretical insights, informs policy and practice through lived experiences, and give voice to participants. Therefore, by exploring these subjective experiences in depth, the study offers a significant and relevant scientific contribution (according to COREQ checklist), providing nuanced insights that complement quantitative methods and enrich the understanding of the topic.
Point 4: The manuscript needs language refinement, clear structure, and a more critical discussion of limitations and implementation challenges.
Response 4: Thank you for your comment which has provided valuable insights for improving our manuscript. In response to the comments regarding language and clarity, our research team will engage a professional editing service to refine the manuscript’s language, ensuring enhanced readability and precision throughout (editing service recommended from journal). Furthermore, we will thoroughly revise the limitations section to include a more critical and in-depth discussion of the study’s limitations and the practical implementation challenges encountered, thereby strengthening this crucial aspect of our work. We also affirm that the qualitative data presented is clear and sufficiently detailed, with conclusions robustly supported by the results, and that our findings remain consistently contextualized within the existing literature in both the introduction and discussion sections.
Point 5: Introduction: the transition from general pandemic challenges to simulation-based learning (line 45-47) could be made more fluid: consider introducing simulation earlier and integrating it more gradually into the argument. Also, a more cohesive definition of non-technical skills earlier in the paragraph (e.g., line 38-40) would help orient the reader (this could apply to the distinction between technical and non-technical skills as well). Finally, watch out the use of generalizations like “current literature emphasizes” (line 38) or “careful attention must be paid” (line 56) and consider being more specific. Regarding section 1.1 of the Introduction: there are multiple spelling and grammar errors to be corrected, but, most importantly, the section would benefit from a reordering that would create a clearer structure; consider, in this order, defining SIT, justifying the use of simulation, identify gaps in the literature and state the contribution of the present study.
Response 5: Agree. We have carefully reviewed your comments and agree that the Introduction section can be improved. Our team has revised address the concerns raised in Line 38 and line 56 to rephrase the sentences.
“Some literatures emphasize the importance of non-technical skills such as effective communication, in delivering holistic patient care and enhanced pandemic response [7,8,9]. [Line 38-40]
“However, considerable attention should be devoted to its efficacy in ensuring the safety of healthcare providers and, most significantly, patients” [Line 67-69]
Our research team has revised address the concerns raise in Line 45-47 to rephrase the sentences.
“The profound impact of widespread health crises, such as the recent pandemic, has il-luminated the complex array of challenges confronting healthcare professionals. These challenges are not unchanging; they span technical, cognitive, and psychological dimensions, each demanding specific attention and preparedness [10-15]. To effectively equip healthcare providers for such demanding realities, educational strategies must evolve beyond traditional methods. Clinical simulation emerges as a particularly po-tent tool in this context, offering a dynamic and safe environment to explore these multifaceted demands. Through carefully designed scenarios and structured debriefing, simulation allows for deeper engagement with the cognitive processes like decision-making under pressure and situational awareness and the psychological resilience required in high-pressure scenarios. While the acquisition of technical skills for specific tasks and operations remains undeniably essential, it is this holistic approach, ad-dressing the interwoven cognitive and psychological aspects of safety, that is control-ling. Understanding and cultivating these dimensions through practical and introspe-tive methods like clinical simulation is therefore significant [16,17], not only for honing procedural competence but, more critically, for bolstering provider well-being and safeguarding optimal patient care when facing the inevitable stressors of challenging healthcare situations.” [Line 44-60]
We believe these changes significantly to justify the use of simulation, identify gaps in the literature and state the contribution of the present study.
“This study addresses an identified lack in existing literature by employing a qualitative methodology to delineate the critical factors strengthening the success of simulation-based training programs. These programs are tailored for multidisciplinary healthcare teams responsible for the care of patients with infectious diseases. The investigation specifically explores how effective training programs incorporate strategies to equip healthcare providers with skills for managing stress in unpredictable and demanding environments, such as those precipitated by pandemic crises like the COVID-19 pandemic. Additionally, the research examines how these initiatives foster physical and psychological resilience among these professionals during such public health emergencies.” [Line 89-97]
Point 6: Materials and methods: Line 98-99: specify what kind of experiences of themes were expected/explored. Line 103: specify if just conference attendees. Line 107: justify the criterion of “at least six years”. Please mention if the demographics of the participants were registered. Line 111: how was saturation assessed? Consider including the semi-structured guide as an appendix of the article. The analysis strategy requires more details: which coding software was used (if any)? Inter-rater reliability assessed? Disagreement in coding? How was it resolved?
Response 6: Thank you for your comment. Our research team has revised the concern in Line 107.
“at least one year” [Line 127]
Our research team has revised the concern in Line 137 about the interview guide questions at Supplementary Table 1.
Our research team has revised the concern in Line 111 about the data saturation in data collection section.
“Data saturation was achieved when further data collection yields no new insights, themes, or concepts relevant to this study. This point was reached after the third group session, as the narratives of the final two participants introduced no novel information. With no participants withdrawing, data collection was subsequently concluded.” [Line 139-143]
We revised the analysis strategy for detail explanation.
“After the data collection phase, NVivo software (NVivo Version 12, QSR International, Burlington, MA, USA) was utilized for the timely analysis of interview transcripts.” [Line 147-149]
“The coding process, led by the first author (A.Y.) as primary coder, involved presenting preliminary findings at scheduled team meetings. These sessions facilitated feed-back on coding and categorization, ultimately leading a team consensus and the finalization of the codebook.” [Line 158-161]
To enhance the rigor of the study, we strengthen the content of the rigor.
“Trustworthiness was reinforced through a validation process comprising post-interview member checking, a data analysis audit, research team reflexive discussion on participants’ psychological feelings, and snowball sampling of healthcare providers for wide-ranging perspectives and experiences.” [Line 164-168]
Point 7: Results: The results section is very rich and well-organized in three major themes. Participants from different roles are quotes, adding completeness to the report, but some quotes are very long, and authors could sider to tighten them and focus on the most relevant parts. Numerous typos and grammar errors, and line breaks, need to be corrected.
Response 7: Agree. Our research team revised the sample codes of the results section in Table 2. [Line 184-185]
Point 8: Discussion and Conclusions: The Discussion links the findings with the main goals of the study and the references are used correctly to support the authors’ claims. The Conclusions are well-balanced without over-generalization. What could be improved in these sections is to highlight alternative interpretations or potential challenges represented by simulation-based training. Also, bias from voluntary participant should be mentioned, as well as other possible limitations, e.g. the context-dependency of qualitative data and the challenges of measuring findings like empathy or psychological safety.
Response 8: Thank you for your advice. We have carefully reviewed your comments and agree that the Limitations section can be improved. Our team has revised address the concerns raised in Point 8, providing clearer and more detailed information about our study’s limitations.
“A more exhaustive exploration of alternative interpretations regarding the efficacy of simulation-based training and a deeper analysis of its inherent challenges in fostering resilience during COVID-19 pandemic would enhance the comprehensiveness of this study’s acknowledged limitation. Furthermore, the findings are subject to constraints including potential selection bias from reliance on voluntary participants, the context-dependency of qualitative data which may influence transferability, and the inherent difficulties in objectively measuring complex psychological constructs such as empathy or perceived psychological safety within the simulation environment.” [Line 281-288]
Point 1: It the research design appropriate and are the methods adequately describe.
Response 1: Thank you for your comment. To ensure clarity regarding our methodological framework, this study employed a descriptive phenomenological approach to explore the lived experiences of healthcare providers mentioned in Line 119. This approach was deemed most appropriate for capturing the essence of their perspectives on emotional resilience and simulation training during the COVID-19 pandemic. For data analysis, we utilized content analysis, following a systematic process to identify, analyze, and report patterns (themes) within the data. The rigor of this analytical process was guided by the principles of qualitative inquiry, drawing upon the foundational concepts of trustworthiness in qualitative research as articulated by Lincoln and Guba (1985), ensuring a credible and dependable interpretation of the findings in Line 154-159.
Point 2: Are the results presented clearly and in sufficient detail, are the conclusions supported by the results and are they put into context within the existing literature?
Response 2: Thank you for your feedback regarding the presentation of our results and the contextualization of our finding results. We have meticulously ensured that the qualitative data presented in the manuscript is both clear and sufficiently, providing rich descriptions and illustrative quotes (after revision of Table 2) to support our thematic analysis of how simulation training enhanced healthcare providers’ emotional resilience during COVID-19. Furthermore, we affirm that all conclusions drawn are directly and robustly supported by the presented results, with a clear logical progression from our empirical findings to the broader implications. As highlighted in both the introduction and discussion sections, these findings are consistently contextualized within the existing literature on emotional resilience, simulation training, and healthcare provider well-being during crises, thereby establishing the study’s contribution to the current body of knowledge.
Point 3: Does this article provide a relevant contribution to the scientific discussion of this topic?
Response 3: Thank you for your comment. This article is applied qualitative research to achieve a profound, contextualized understanding of complex human experiences, such as feelings and perspectives, which are critical data points. This methodology illuminated the human impact of crises, unpacks multifacetedly constructs like emotional resilience, provides vital context-specific knowledge, generated new theoretical insights, informs policy and practice through lived experiences, and give voice to participants. Therefore, by exploring these subjective experiences in depth, the study offers a significant and relevant scientific contribution (according to COREQ checklist), providing nuanced insights that complement quantitative methods and enrich the understanding of the topic.
Point 4: The manuscript needs language refinement, clear structure, and a more critical discussion of limitations and implementation challenges.
Response 4: Thank you for your comment which has provided valuable insights for improving our manuscript. In response to the comments regarding language and clarity, our research team will engage a professional editing service to refine the manuscript’s language, ensuring enhanced readability and precision throughout (editing service recommended from journal). Furthermore, we will thoroughly revise the limitations section to include a more critical and in-depth discussion of the study’s limitations and the practical implementation challenges encountered, thereby strengthening this crucial aspect of our work. We also affirm that the qualitative data presented is clear and sufficiently detailed, with conclusions robustly supported by the results, and that our findings remain consistently contextualized within the existing literature in both the introduction and discussion sections.
Point 5: Introduction: the transition from general pandemic challenges to simulation-based learning (line 45-47) could be made more fluid: consider introducing simulation earlier and integrating it more gradually into the argument. Also, a more cohesive definition of non-technical skills earlier in the paragraph (e.g., line 38-40) would help orient the reader (this could apply to the distinction between technical and non-technical skills as well). Finally, watch out the use of generalizations like “current literature emphasizes” (line 38) or “careful attention must be paid” (line 56) and consider being more specific. Regarding section 1.1 of the Introduction: there are multiple spelling and grammar errors to be corrected, but, most importantly, the section would benefit from a reordering that would create a clearer structure; consider, in this order, defining SIT, justifying the use of simulation, identify gaps in the literature and state the contribution of the present study.
Response 5: Agree. We have carefully reviewed your comments and agree that the Introduction section can be improved. Our team has revised address the concerns raised in Line 38 and line 56 to rephrase the sentences.
“Some literatures emphasize the importance of non-technical skills such as effective communication, in delivering holistic patient care and enhanced pandemic response [7,8,9]. [Line 38-40]
“However, considerable attention should be devoted to its efficacy in ensuring the safety of healthcare providers and, most significantly, patients” [Line 67-69]
Our research team has revised address the concerns raise in Line 45-47 to rephrase the sentences.
“The profound impact of widespread health crises, such as the recent pandemic, has il-luminated the complex array of challenges confronting healthcare professionals. These challenges are not unchanging; they span technical, cognitive, and psychological dimensions, each demanding specific attention and preparedness [10-15]. To effectively equip healthcare providers for such demanding realities, educational strategies must evolve beyond traditional methods. Clinical simulation emerges as a particularly po-tent tool in this context, offering a dynamic and safe environment to explore these multifaceted demands. Through carefully designed scenarios and structured debriefing, simulation allows for deeper engagement with the cognitive processes like decision-making under pressure and situational awareness and the psychological resilience required in high-pressure scenarios. While the acquisition of technical skills for specific tasks and operations remains undeniably essential, it is this holistic approach, ad-dressing the interwoven cognitive and psychological aspects of safety, that is control-ling. Understanding and cultivating these dimensions through practical and introspective methods like clinical simulation is therefore significant [16,17], not only for honing procedural competence but, more critically, for bolstering provider well-being and safeguarding optimal patient care when facing the inevitable stressors of challenging healthcare situations.” [Line 44-60]
We believe these changes significantly to justify the use of simulation, identify gaps in the literature and state the contribution of the present study.
“This study addresses an identified lack in existing literature by employing a qualitative methodology to delineate the critical factors strengthening the success of simulation-based training programs. These programs are tailored for multidisciplinary healthcare teams responsible for the care of patients with infectious diseases. The investigation specifically explores how effective training programs incorporate strategies to equip healthcare providers with skills for managing stress in unpredictable and demanding environments, such as those precipitated by pandemic crises like the COVID-19 pandemic. Additionally, the research examines how these initiatives foster physical and psychological resilience among these professionals during such public health emergencies.” [Line 89-97]
Point 6: Materials and methods: Line 98-99: specify what kind of experiences of themes were expected/explored. Line 103: specify if just conference attendees. Line 107: justify the criterion of “at least six years”. Please mention if the demographics of the participants were registered. Line 111: how was saturation assessed? Consider including the semi-structured guide as an appendix of the article. The analysis strategy requires more details: which coding software was used (if any)? Inter-rater reliability assessed? Disagreement in coding? How was it resolved?
Response 6: Thank you for your comment. Our research team has revised the concern in Line 107.
“at least one year” [Line 127]
Our research team has revised the concern in Line 137 about the interview guide questions at Supplementary Table 1.
Our research team has revised the concern in Line 111 about the data saturation in data collection section.
“Data saturation was achieved when further data collection yields no new insights, themes, or concepts relevant to this study. This point was reached after the third group session, as the narratives of the final two participants introduced no novel information. With no participants withdrawing, data collection was subsequently concluded.” [Line 139-143]
We revised the analysis strategy for detail explanation.
“After the data collection phase, NVivo software (NVivo Version 12, QSR International, Burlington, MA, USA) was utilized for the timely analysis of interview transcripts.” [Line 147-149]
“The coding process, led by the first author (A.Y.) as primary coder, involved present-ing preliminary findings at scheduled team meetings. These sessions facilitated feed-back on coding and categorization, ultimately leading a team consensus and the finalization of the codebook.” [Line 158-161]
To enhance the rigor of the study, we strengthen the content of the rigor.
“Trustworthiness was reinforced through a validation process comprising post-interview member checking, a data analysis audit, research team reflexive discussion on participants’ psychological feelings, and snowball sampling of healthcare providers for wide-ranging perspectives and experiences.” [Line 164-168]
Point 7: Results: The results section is very rich and well-organized in three major themes. Participants from different roles are quotes, adding completeness to the report, but some quotes are very long, and authors could sider to tighten them and focus on the most relevant parts. Numerous typos and grammar errors, and line breaks, need to be corrected.
Response 7: Agree. Our research team revised the sample codes of the results section in Table 2. [Line 184-185]
Point 8: Discussion and Conclusions: The Discussion links the findings with the main goals of the study and the references are used correctly to support the authors’ claims. The Conclusions are well-balanced without over-generalization. What could be improved in these sections is to highlight alternative interpretations or potential challenges represented by simulation-based training. Also, bias from voluntary participant should be mentioned, as well as other possible limitations, e.g. the context-dependency of qualitative data and the challenges of measuring findings like empathy or psychological safety.
Response 8: Thank you for your advice. We have carefully reviewed your comments and agree that the Limitations section can be improved. Our team has revised address the concerns raised in Point 8, providing clearer and more detailed information about our study’s limitations.
“A more exhaustive exploration of alternative interpretations regarding the efficacy of simulation-based training and a deeper analysis of its inherent challenges in fostering resilience during COVID-19 pandemic would enhance the comprehensiveness of this study’s acknowledged limitation. Furthermore, the findings are subject to constraints including potential selection bias from reliance on voluntary participants, the context-dependency of qualitative data which may influence transferability, and the inherent difficulties in objectively measuring complex psychological constructs such as empathy or perceived psychological safety within the simulation environment.” [Line 281-288]
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Please, see detailed comments
Best wishes
Overstatement of Findings
Claim: The manuscript concludes that simulation training significantly strengthens resilience and preparedness.
Issue: These conclusions are overstated, given that only three focus groups (n=18) were included, with no longitudinal follow-up or outcome measures.
Correction Needed: Reframe claims to emphasize “perceived” improvements based on participant narratives.
2. Misinterpretation or Overgeneralization of Qualitative Data
The authors infer systemic resilience and organizational impact without triangulated evidence (e.g., institutional data or behavioral change documentation).
Example: The conclusion discusses system-wide improvements, while the study only captures individual-level perspectives.
3. Thematic Redundancy & Inflated Themes
Themes 1–3 overlap significantly. Many codes under “compassion” and “protocol adherence” are interrelated and could be collapsed into fewer, richer themes.
The authors force alignment with the theoretical framework (Stress Inoculation Training), but this is retrospective rather than inductive and not fully substantiated by the data.
4. Lack of Methodological Transparency
Coding framework is not presented (e.g., no examples of how codes were developed).
No explanation of inter-coder reliability statistics, only anecdotal reference to coder agreement.
5. Table Inconsistencies and Errors
Table 1: The total percentages of educational level do not sum clearly to 100% (likely a formatting artifact, but raises concern).
Table 2:
Some quotes are far longer than needed and lack clear connection to sub-codes.
Sample codes listed are unclear or not representative of broader participant agreement.
Inconsistent use of terminology (e.g., “evaluate” vs. “evaluation” checklist).
Suggestion: Reduce quote length, clearly match them to defined codes, and standardize terminology.
6. Theoretical Misalignment
SIT (Stress Inoculation Training) is introduced, but the study does not actually measure stress response or resilience quantitatively or qualitatively in a structured way.
There is no evidence of actual inoculation phases or follow-up, which undercuts the theoretical claim.
Suggestion: Either fully integrate SIT with matching data or revise the theoretical framing.
Author Response
Point 1: Overstatement of Findings.
Claim: The manuscript concludes that simulation training significantly strengthens resilience and preparedness.
Issue: These conclusions are overstated, given that only three focus groups (n=18) were included, with on longitudinal follow-up or outcomes measures.
Correction: Needed: Reframe claims to emphasize “perceived” improvement based on participant narratives.
Response 1: Thank you for your comment. Our research team has revised this concern in the Results section in Table 2 sample codes based on participant narratives. [Line 184-185]
Point 2: Misinterpretation or Overgeneralization of Qualitative Data
The authors infer systemic resilience and organizational impact without triangulated evidence (e.g., institutional data or behavioral change documentation).
Example: The conclusion discusses system-wide improvements, while the study only captures individual-level perspectives.
Response 2: Thank for your comment. We have revised this concern in the conclusion section.
“The experiences of this study findings highlighted are not solely individual; they emphasize a critical need for participants’ working institutions, particularly at the management level, to cultivate a deeper understanding of their staff’s situation and actively seek improvements. Building on this, future research should not only evaluate the im-pact of expanded simulation curricula on care quality, provider well-being, and system-wide responsiveness during both crisis response and recovery phases but also explore these institutional understandings and commitments can optimize the benefits of such training initiatives.” [Line 305-312]
Point 3: Thematic Redundancy & Inflated Themes
Themes 1–3 overlap significantly. Many codes under “compassion” and “protocol adherence” are interrelated and could be collapsed into fewer, richer themes.
The authors force alignment with the theoretical framework (Stress Inoculation Training), but this is retrospective rather than inductive and not fully substantiated by the data.
Response 3: Thank you for your advice. Our research team revise all related compassion, protocol, adherence in the whole manuscript to avoid overstate these wordings.
Due to force alignment with theoretical framework, we tried to make the sample code from participants’ narratives revised to alignment with the theoretical framework. [Line 184-185]
Point 4: Lack of Methodological Transparency
Coding framework is not presented (e.g., no examples of how codes were developed).
No explanation of inter-coder reliability statistics, only anecdotal reference to coder agreement.
Response 4: Thank you for your comment. We have carefully review as follows, in data collection section:
“Data saturation was achieved when further data collection yields no new insights, themes, or concepts relevant to this study. This point was reached after the third group session, as the narratives of the final two participants introduced no novel information. With no participants withdrawing, data collection was subsequently concluded.” [Line 139-143]
Analysis strategies section:
“After the data collection phase, NVivo software (NVivo Version 12, QSR International, Burlington, MA, USA) was utilized for the timely analysis of interview transcripts.” [147-149]
“The coding process, led by the first author (A.Y.) as primary coder, involved presenting preliminary findings at scheduled team meetings. These sessions facilitated feed-back on coding and categorization, ultimately leading a team consensus and the finalization of the codebook.” [Line 158-161]
Rigor section:
“Trustworthiness was reinforced through a validation process comprising post-interview member checking, a data analysis audit, research team reflexive discussion on participants’ psychological feelings, and snowball sampling of healthcare providers for wide-ranging perspectives and experiences.” [Line 164-168]
Point 5: Table Inconsistencies and Errors
Table 1: The total percentages of educational level do not sum clearly to 100% (likely a formatting artifact but raises concern).
Response 5: Agree. We have carefully reviewed your comments and agree that the Table 1: The total percentage of occupation and education level do not sum clearly to 100%. We have justified the content in Table 1.
Table 1. Characteristics of participants.
|
|
Frequency (n) |
(%) |
|
Occupation |
|
|
|
6 |
33.3 |
|
18 |
66.7 |
|
Highest education qualification |
|
|
|
8 |
44.5 |
|
4 |
22.2 |
|
6 |
33.3 |
|
Clinical experience in acute care hospital settings |
|
|
|
10 8 |
55.6 44.4 |
Point 6: Table 2:
Some quotes are far longer than needed and lack clear connection to sub-codes.
Sample codes listed are unclear or not representative of broader participant agreement.
Inconsistent use of terminology (e.g., “evaluate” vs. “evaluation” checklist).
Suggestion: Reduce quote length, clearly match them to defined codes, and standardize terminology.
Response 6: Thank you for your comment. We have revised all your concerns and change as “evaluation checklist” [Line 184, 204] in the manuscript.
At the same time reduce quote length, clearly match them to defined codes, and standardize terminology in Table 2. [Line 184-185]
Point 7: Theoretical Misalignment
SIT (Stress Inoculation Training) is introduced, but the study does not actually measure stress response or resilience quantitatively or qualitatively in a structured way.
There is no evidence of actual inoculation phases or follow-up, which undercuts the theoretical claim.
Suggestion: Either fully integrate SIT with matching data or revise the theoretical framing
Response 7: Agree. Our qualitative study in Line 101-109, by acting as a reflective mirror, has made visible the raw, human dimension of healthcare providers’ experience during the COVID-19 pandemic. It emphasized the immense pressures they faced and provides a critical lens through we can understand their resilience. This understanding is important for developing more effective support systems and interventions to protect and bolster the well-being of healthcare professionals in the future public health crisis. The narratives shared by our participants are a powerful call for continued investigation and a more holistic approach to supporting this vital workforce.
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
The authors have addressed the comments made in a satisfactory way and improved the overall shape of the manuscript.
The authors have addressed the comments made in a satisfactory way and improved the overall shape of the manuscript.
Reviewer 2 Report
Thank you for addressing the comments
None
