Next of kin participation in the care of older persons in nursing homes: A pre–post non-randomised educational evaluation, using within-group and individual person-level comparisons

Albert Westergren; Gerd Ahlström; Magnus Persson; Lina Behm

doi:10.1371/journal.pone.0244600

Peer Review History

Original SubmissionJune 2, 2020
22 Oct 2020 Decision Letter - Lucy Ellen Selman, Editor PONE-D-20-16638 Evaluating participation of next of kin after an educational intervention in nursing homes using methods for individual person-level comparison PLOS ONE Dear Dr. Westergren, Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. ============================== Please review the recommendations and suggestions from the reviewers. In particular please attend to the title and abstract to ensure they adequately reflect the main messages and methods of the paper, and revise the Methods, Results and Discussion sections to ensure consistency. ============================== Please submit your revised manuscript by Dec 06 2020 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols We look forward to receiving your revised manuscript. Kind regards, Lucy Ellen Selman, BA, MPhil, PhD Academic Editor PLOS ONE Journal Requirements: When submitting your revision, we need you to address these additional requirements. 1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 2. We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. In your revised cover letter, please address the following prompts: a) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent. b) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see http://www.bmj.com/content/340/bmj.c181.long for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. We will update your Data Availability statement on your behalf to reflect the information you provide. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ****** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Overall, the manuscript was concise and comprehensive. The author uses two statistical analyses on the data, group, and individual, arriving at different conclusions. This was a unique method to demonstrate significance in alternative results. Also, the author provides explanations as to why results may not have been significant (e.g., next of kin not wanting to take on additional care). However, it may have been beneficial if the author focused on the individual changes instead of comparing group to individual results. It was challenging to determine which overall findings the reader should accept. If this was a psychometric study, it needs to be clearly stated at the beginning of the manuscript. Reviewer #2: Thank for you inviting me to review this manuscript, which makes the case for individual person-level methods for analysis in the context of an educational intervention in nursing homes. Generally, I found this manuscript to be well written and interesting. There are, however, a couple of exceptions in respect of the clarity of the manuscript. 1) Upon first reading the title and abstract, I didn’t feel that they adequately describe the paper. For example, it is not clear from the abstract (see objective) what the three methods are, and I think they may be better described as analytical approaches. In my view, a method refers to a means of data collection (e.g. interview or survey), whereas I think the authors are talking about analytical approaches. 2) The three analytical approaches should be described before the Results section, given this is the key focus of the paper. This only becomes clear in the results and conclusion, and even then not introducing it earlier makes the key focus of the paper unclear in the abstract. 3) I think the authors should consider naming the three analytical approaches in the title, and then briefly mention and describe in the background and objective sections. This will then mean the manuscript has an obvious and clear focus. 4) Under Trial registration it says that the manuscript is a psychometric study – but this is the first time it is mentioned. Something perhaps also to consider adding to the title and abstract. As an active researcher in this field I found the rest of the paper to be of significant interest, particularly the development of the new scales/outcome measures (which I may even use myself at some point). One additional point to consider including in the discussion is whether this manuscript can feed into the relatively emerging field of realist methodology and methods. Because the researchers highlight that individual person-level methods of analysis can unpick the nuances behind aggregate/sample level data, my interpretation of this is that this analytical approach is capable of going beyond finding out whether an intervention is effective (as denoted by sample level reporting) and could highlight how it might, for whom and in what circumstances – based on being able to begin to explore why interventions worked for certain people, and not others. This is what realist evaluation and realist research attempts to do (by exploring the contextual circumstances in which mechanisms fire and lead to outcomes). Interestingly though, many realist evaluations tend to be small scale mixed method or qualitative case studies, and one criticism is that they lack generalisability beyond the case study/unit of analysis (though this is a point for debate as realism, for many, is not necessarily congruent with generalisability. There are many strands of realist philosophy!). When reading lines 346-364 I am left wondering whether this manuscript may be capable of adding some interesting discussion to the emerging debates on realist research, particularly in identifying an analytical approach that may support larger scale realist evaluations (as part of a mixed methods study design). ****** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. If you choose “no”, your identity will remain anonymous but your review may still be made public. Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: No Reviewer #2: No [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0244600.r001
Revision 1
26 Nov 2020 Author Response Reply to reviewers We wish to thank the academic editor and reviewers for your positive feedback and relevant suggestions for revisions. Below we respond to each point raised. Academic Editor Please review the recommendations and suggestions from the reviewers. In particular please attend to the title and abstract to ensure they adequately reflect the main messages and methods of the paper, and revise the Methods, Results and Discussion sections to ensure consistency. Response: Thank you for this advice. We have now made changes according to the reviewers’ recommendations, regarding the title, Abstract, Methods, Results and Discussion. Reviewer #1 R1: Overall, the manuscript was concise and comprehensive. The author uses two statistical analyses on the data, group, and individual, arriving at different conclusions. This was a unique method to demonstrate significance in alternative results. Also, the author provides explanations as to why results may not have been significant (e.g., next of kin not wanting to take on additional care). Response: Thank you for these positive remarks. R1:Q1: However, it may have been beneficial if the author focused on the individual changes instead of comparing group to individual results. It was challenging to determine which overall findings the reader should accept. Response: Instead of deleting the between-group comparisons, which add valuable information when interpreting the findings, we have now clarified that the within-group and individual person-level comparisons are the primary findings. We have also clarified this by adding matching subheadings in the Methods and Results sections. For example (from the Data analysis section): Between-group comparisons based on individual person-level outcomes Although the main focus of this study was on within-group and within-individual (person-level) comparisons, between-group analyses were also conducted for comparisons between the intervention and control groups. R1:Q2: If this was a psychometric study, it needs to be clearly stated at the beginning of the manuscript. Response: Thank you for pointing this out. We have now deleted “psychometric” under the heading “Trial registration”. Reviewer #2 R2: Thank for you inviting me to review this manuscript, which makes the case for individual person-level methods for analysis in the context of an educational intervention in nursing homes. Generally, I found this manuscript to be well written and interesting. There are, however, a couple of exceptions in respect of the clarity of the manuscript. Response: Thank you for your positive feedback. R2:Q1: Upon first reading the title and abstract, I didn’t feel that they adequately describe the paper. For example, it is not clear from the abstract (see objective) what the three methods are, and I think they may be better described as analytical approaches. In my view, a method refers to a means of data collection (e.g. interview or survey), whereas I think the authors are talking about analytical approaches. Response: Thank you for pointing out this terminology issue. We have now used “analytical approach” instead of “methods”. R2:Q2: The three analytical approaches should be described before the Results section, given this is the key focus of the paper. This only becomes clear in the results and conclusion, and even then, not introducing it earlier makes the key focus of the paper unclear in the abstract. Response: We are grateful to you for this observation. We have now clarified the analytical approaches in the Abstract, Introduction, Methods and Results, for instance by using subheadings. R2:Q3: I think the authors should consider naming the three analytical approaches in the title, and then briefly mention and describe in the background and objective sections. This will then mean the manuscript has an obvious and clear focus. Response: Thank you for this suggestion. To clarify the focus, we have now included these approaches in the title and in various places in abstract, introduction, methods and in results (see also R2:Q2). R2:Q4: Under Trial registration it says that the manuscript is a psychometric study – but this is the first time it is mentioned. Something perhaps also to consider adding to the title and abstract. Response: Thank you for pointing this out. We have now deleted “psychometric” under the heading “Trial registration”, since we do not consider this paper to represent a psychometric study. However, the paper preceding this one was a psychometric study. R2: As an active researcher in this field I found the rest of the paper to be of significant interest, particularly the development of the new scales/outcome measures (which I may even use myself at some point). Response: We are delighted that you found the paper relevant and interesting. R2:Q5: One additional point to consider including in the discussion is whether this manuscript can feed into the relatively emerging field of realist methodology and methods /…/. Response: This was an excellent idea! We have added the following paragraph about this in the Discussion: Since individual person-level analytical approaches can unpick the nuances beyond aggregated group-level data, it becomes possible to find out to what extent an intervention is effective, in other words, what works, for whom and in what circumstances. Traditional evaluation efforts that focus on aggregate effectiveness have been criticized for representing an oversimplification [32, 33]. Through individual person-level analytical approaches we can begin to explore why interventions worked for certain persons and not others. This is in line with the recommendation by Pawson and Tilley [34], developers of the realist evaluation approach, to conduct evaluations for subgroups within programmes; they advised researchers to be cautious since there might be more than one mechanism at work within each subgroup, generating mixed results [34], which was also revealed by the findings in this study. Realist evaluation is situated between positivism and realism [35], and it attempts to explore contextual circumstances in which mechanisms are triggered and lead to outcomes [34]. Interestingly though, many realist evaluations, although being neutral on the qualitative-quantitative spectrum, tend to be small-scale, mixed-method or qualitative case studies. One criticism is that they lack generalisability beyond the case study unit of analysis, and sometimes the evaluations are unclear about context, mechanism and/or outcome [32, 36-38]. The area of outcome assessment tends to be especially problematic [32]. Taken together, these issues can make it hard for realist evaluations to gain scientific credibility [39]. However, this is a point for debate as realism, for some, is not necessarily congruent with generalisability, i.e. neither from a positivism nor an interpretivism point of view [40]. It has been stated that “Prevailing statistical models which by their nature are aggregate /…/ may have limited utility in the analysis of complex systems” [33](p 388). We claim that modern individual person-level analytical approaches may support larger scale realist evaluations as part of a mixed-methods study design. Attachments Attachment Submitted filename: Response to reviewers.docx https://doi.org/10.1371/journal.pone.0244600.r002
14 Dec 2020 Decision Letter - Lucy Ellen Selman, Editor Next of kin participation in the care of older persons in nursing homes: a pre–post non-randomised educational evaluation, using within-group and individual person-level comparisons PONE-D-20-16638R1 Dear Dr. Westergren, We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements. Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication. An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org. Kind regards, Lucy Ellen Selman, BA, MPhil, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0244600.r003
Formally Accepted
15 Jan 2021 Acceptance Letter - Lucy Ellen Selman, Editor PONE-D-20-16638R1 Next of kin participation in the care of older persons in nursing homes: a pre–post non-randomised educational evaluation, using within-group and individual person-level comparisons Dear Dr. Westergren: I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org. If we can help with anything else, please email us at plosone@plos.org. Thank you for submitting your work to PLOS ONE and supporting open access. Kind regards, PLOS ONE Editorial Office Staff on behalf of Dr. Lucy Ellen Selman Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0244600.r004

Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .