Interprofessional perceptions of emotional, social, and ethical effects of multidrug-resistant organisms: A qualitative study

Stefan Bushuven; Markus Dettenkofer; Andreas Dietz; Stefanie Bushuven; Petra Dierenbach; Julia Inthorn; Matthias Beiner; Thorsten Langer

doi:10.1371/journal.pone.0246820

Peer Review History

Original SubmissionAugust 18, 2020
7 Nov 2020 Decision Letter - Vijayaprasad Gopichandran, Editor PONE-D-20-25927 Emotional, social and ethical effects of Multidrug-Resistant Organisms: A Qualitative Study Psychological Effects of multidrug resistant organisms PLOS ONE Dear Dr. Bushuven, 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 submit your revised manuscript by Dec 22 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. 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If the need for consent was waived by the ethics committee, please include this information. 5. We noted that you refer to this study as a cross sectional study in the manuscript, but according to your description we would not consider this a cross-sectional study but rather a qualitative study. In order to avoid confusion we would suggest that you change the wording in your manuscript and avoid referring to this study as a cross-sectional study. 6.Thank you for stating the following in the Acknowledgments Section of your manuscript: [We thank all participants for their contribution and the Messmer Foundation, Radolfzell, Gemany for financial support.] We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form. Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows: [The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.] Please include your amended statements within your cover letter; we will change the online submission form on your behalf. 7. Please upload a copy of Figure 5, to which you refer in your text on page 17. If the figure is no longer to be included as part of the submission please remove all reference to it within the text. 8. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. [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: Partly Reviewer #2: Partly Reviewer #3: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know Reviewer #2: I Don't Know Reviewer #3: 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 Reviewer #3: 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 Reviewer #3: No ****** 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: To the authors, I'm particularly susceptible to this topic which is of interest in an era where ID is now a major threat due to covid, and might become the same if we dont fight antibiotic resistance. Better knowning the fear engendered by MDRO is very important to initiate acceptable measures and precautions. Some minor corrections: Introduction there is a gerrman typo "und separation" instead of and "described by Paul Ekman" replace by Ekman et al. Do not number from 1 to 6 if really relevant use i) etc in the text without spaces. Main theme 2 and 3, remove BOLD characters Major suggestions: In the introduction and the discussion you are missing a recent article on the same topic by Hereng et al. that is close to your work and main message "Evaluation in general practice of the patient's feelings about a recent hospitalization and isolation for a multidrug-resistant infection" https://pubmed.ncbi.nlm.nih.gov/31047690/ It should be added. For the coding process, can you add the percentage of the different feelings ? it will be easier to read I don't feel that "experience of medical incompetence" is correct. It is not truly medical incompetence but maybe more the lack of formation and skills in the management of MDRO. Rephrase or clarify. In the discussion of chapter 2 remove this paragraph that brings a conclusion meanwhile discussion should not conclude. "Conclusively, basing on the perception of the participants, not only microbes spread in human societies: emotions also do, contributing to a paralysis of family functioning and exclusion of patient from their social background." Limitations : merge all the paragraph and remove the bold symbols. Also don't say first second etc until seventh, please classify logically and embed in the text the relevant data. Conclusion could be improved. Don't say to our knowledge in a conclusion it's place is in the discussion section. Conclusion is factual. Same goes for study in Germany. It would not change it data where from spain for instance. You must make a generalizable summary. For instance "Our work reports impact of MDRO carriage on emotional, ethical and family-psychological effects experienced by multiprofessional healthcare workers. Then add your major findings. You cannot say that your finding are concordant wth your data ! " Our results could confirm findings in our first study" weird way of making conclusion of new data. Add what is clear in the abstract section instead (Conclusion: MDRO are perceived to have severe impact on emotions and affect bioethical and family psychological issues. Thus, further work should concentrate on these findings to generate a holistic view of MDRO on human life and social systems.) Reviewer #2: In this paper the authors focus on the effects that MDRO patient-isolation protocols have on on healthcare workers; in particular, in the healthcare workers’ emotional experience after interacting with these patients and their families and some ethical implications. This is a very important area of research. However, I have some concerns regarding the methodology and conclusions provided in this study, please see below. General Aim It is not clear that the authors are actually reporting on the emotional, psychological and ethical effects on patients, as stated in the Introduction, Abstract and suggested in the title. This study is aimed at the experience of healthcare workers regarding the management of patients who are affected by MDRO and their families. As such, this must be clear from the beginning (rather than just being acknowledge as a limitation at the end of the paper). Conclusion The conclusion regarding “MDRO impairs Family Functioning” is interesting but requires more work with the patient and families themselves (rather than healthcare workers) to be able to claim the conclusions presented. The “ 3. Medical Ethics” section needs work. The two principles used, benevolence and non-maleficence, are important and complex principles and it is not clear how they play a role in this issue. If this is an area of study they would like to include in their project (as indicated in the Introduction), they must attempt to understand the role that these principles play in the isolation protocols analyzed and the experiences of the people affected by those protocols, for example, questions such as: is the creation of these isolation protocols justified/or not by the benevolence principle? More analysis and discussion are needed to understand the role that healthcare workers’ perceptions play in an ethical analysis of this situation. Also, if the authors are not going to use Kant’s first formulation of the categorical imperative or a virtue ethics approach, it is not clear why are they mentioning it in the paper. I would like to see the authors discuss in more detail their results in the context of the previous literature, how to they compare to previous findings (besides their own previous study) Methods I understand that for both deductive approaches, two coders had to agree to assign a code; however, I would like to see more detail, in particular regarding the reliability among coders. This is applicable to the other kinds of coding used in the paper, I would like to see more detail about the coder such as the training that the coders received and reliability achieved. As noted in the limitations, 50% of the same coders as the previous study were used, that suggests that the coders are familiar with the hypothesis and somewhat biased. I am not satisfied with the explanation provided regarding the advantages of using theses coders. Perhaps if included more information on the coders (as stated above) it may somewhat mitigate this issue (although not resolved it entirely). Finally, I agree with all the seven plus limitations mentioned for the authors, I had very similar concerns while reading this study. I am not entirely satisfied with the explanations they provide and would like to suggest that they add some methodological measurements to address these limitations. For example, as they acknowledge, their study focuses on “our evaluation concentrated on the subjective perceptions and experiences of health care providers from intensive care settings”, I would advise that they conduct interviews with the patients and families and correlate with eh data they already have. Small Notes Please proofread the paper for typos, such as the one on page 2 (Introduction) “und” should be replaced by “and”. Additional data is presented in German if intended for an English publication, the authors may consider translating these additional data. Reviewer #3: The study is well-made, but what concerns me is the syntax and incorrect structure of the language. In addition, there is vagueness in regards to the previous study which is not mentioned separately. In addition, the paper is subjective in nature and has a scope of improvement. Objectivity is the key for your study. ****** 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: Yes: Benjamin Davido Reviewer #2: No Reviewer #3: Yes:** NAVELI SHARMA [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. Attachments Attachment Submitted filename: MRDO Manuscript Review.docx https://doi.org/10.1371/journal.pone.0246820.r001
Revision 1
25 Jan 2021 Author Response Stefan Bushuven MD MME 1. Style requirements We checked the PLOS ONE templates and made appropriate changes: - Vancover formatting style assigned instead of Numbered - Page numbers and Line numbers - Complete re-editing by a native speaking philologic professional with focus on idiomatic translation of the items 2. Ethics statement We included the ethical statement by the ethical board of the LANDESAERZTEKAMMER BADEN-WURTTEMBERG. Due to our anonymous data obtained, further ethical approval was considered unneeded. To ensure autonomy of the participates we consulted the workers’s council of the hospitals for additional validation and approval. We included the two documents in the re-submission. 3. Demographic details of the participants We made major changes in the methods sections. We displayed participant demographic details in the results sections. Regarding the preceding studies with similar approach, we did not obtain further demographic data of our participants (like age or gender). Representability was assumed regarding the fact, that motivation to participate was not participation in a focus group as a science project, but an education lesson. This shows realistic populations of the interprofessional post - graduate formats and professionals working at our patients. However, selection bias and reduced representability cannot be excluded completely. This should be addressed with quantitative methods and analysis in special groups focusing on distinct age or profession. 4. Informed consent We made some correction in the methods sections and included the information letter for participation. Information was provided in written form. Consent was obtained verbally at the beginning and at the end of the lessons. Written consent was not obtained to guarantee anonymity. Minors were not part of our study. They would not have been excluded, but all post-graduate medical specialists were adults. 5. Study design We changed the study type from “cross sectional” to “qualitative” 6. Acknowledgments We made a correction as desired. The Messmer Foundation only covers the publication costs only. The whole study itself was conducted without external financial support. 7. Figure 5 This was a typo. We changed Figure 5 to 4. 8. Captions We corrected the document concerning captions for supporting information Corrections due to Reviewer #1 1. Minor corrections were considered and implemented. 2. The Article by Hereng was implemented into the introduction and discussion section. 3. We clarified the term of medical incompetence weakening it to the experience of fails. 4. We removed the conclusive paragraph from Discussion Chapter 2 as suggested. Corrections due to Reviewer #2 1. Due to the suggestions, we changed the title addressing the perceptions and not per se the effects of MDRO for precision of the article headline. Additionally, we made some amendments to the introduction focusing on the same issue. 2. We added the coders’ instruction process for clarification of the process. 3. We added the number of codes 3 or 4 of the coders agreed on in table one, to address reliability of the code assignment. Indeed, some codes were “very strong”, as they were assigned by all the coders. However, all codes presented were accepted once by at least three of the coders. 4. The bias provoked by two of the coders familiar with the topic was part of the study protocol to enhance validity. To our knowledge most qualitative studies are conducted be single or only two-coder approaches (Lavrakas 2008 and Riffe et al 2005). Thus, we considered our approach to be “above average”. 5. We appreciate the proposal to do more qualitative work on family members and patients. But this was not the objective of the study. We are preparing these approaches to enhance validity and reliability in future projects. 6. We deleted classical philosophically approaches within the paper like the categoric imperative. Indeed, it does not contribute to this kind the study or the study objectives. Further projects succeeding this study may focus on the bioethical, Kantian or utilitarian approaches. Corrections due to Reviewer #3 1. We reread the paper and made corrections according to the suggestions (typography, interpunctation) with assistance of the mentioned native speaker. See preceding comments by reviewer #1 und #2 2. The reviewer addresses the subjectivity rather than objectivity of the paper without going into detail. With further information in the analysis section, we hope to satisfyingly address these concerns. 3. We presented the former study in the introduction section in deeper detail and intensively revised the introduction section especially regarding typography and style. 4. We changed “unempathy” to “lack of empathy” as suggested 5. We added the labelling of the axes in the figures https://doi.org/10.1371/journal.pone.0246820.r002
27 Jan 2021 Decision Letter - Vijayaprasad Gopichandran, Editor Interprofessional Perceptions of emotional, social and ethical effects of Multidrug-Resistant Organisms: A Qualitative Study PONE-D-20-25927R1 Dear Dr. Bushuven, 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, Vijayaprasad Gopichandran Academic Editor PLOS ONE Additional Editor Comments (optional): Reviewers' comments: https://doi.org/10.1371/journal.pone.0246820.r003
Formally Accepted
11 Feb 2021 Acceptance Letter - Vijayaprasad Gopichandran, Editor PONE-D-20-25927R1 Interprofessional Perceptions of emotional, social, and ethical effects of Multidrug-Resistant Organisms: A Qualitative Study Dear Dr. Bushuven: 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. Vijayaprasad Gopichandran Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0246820.r004

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