“We are left with nothing to work with”; challenges of nurses working in the emergency unit at a secondary referral hospital: A descriptive qualitative study

Agani Afaya; Victoria Bam; Thomas Bavo Azongo; Richard Adongo Afaya; Vida Nyagre Yakong; George Kwame Kpodo; Robert Alhassan Kaba; Denis Albanus Nangsire Zinle; Daniel Kofi Tayuu; Stella Asantewaa; Peter Adatara

doi:10.1371/journal.pone.0247062

Peer Review History

Original SubmissionJuly 18, 2020
4 Dec 2020 Decision Letter - Katie MacLure, Editor PONE-D-20-22261 “We are left with nothing to work with”; challenges of nurses working in the emergency unit at a secondary referral hospital: a descriptive qualitative study PLOS ONE Dear Dr. Afaya, 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 pay particular attention to the comments added to your pdf manuscript by Reviewer#1 which will strengthen your paper. Please submit your revised manuscript by Jan 18 2021 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, Katie MacLure, PhD, MSc (dist)., BSc (1st) 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. Please include a copy of the interview guide used in the study, in both the original language and English, as Supporting Information, or include a citation if it has been published previously. 3. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information. 4. Please amend your list of authors on the manuscript to ensure that each author is linked to an affiliation. Authors’ affiliations should reflect the institution where the work was done (if authors moved subsequently, you can also list the new affiliation stating “current affiliation:….” as necessary). [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: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: I Don't Know 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: No 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: No 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: Thank you for submitting this paper which I have read with interest and enjoyment. You and your colleagues have addressed an important area with implications for practice and patient safety. I think you’ve gathered very interesting data which I’m sure will add to an important debate. I have made many comments which I hope will be helpful. Some contextualising information in the introduction section would be helpful for example how patients are triaged in the ED. I am concerned that the hospital may be identifiable and suggest that you anonymise it further – not just a question of removing the name. I found the paragraph on your research philosophy and approach quite confusing and suggest you simplify it for your readers. I don’t agree that research is the key to solving resource-related issues in low to middle income countries. Some important details are missing in the method section including on governance. You describe reaching mutual understanding with your participants but have not addressed reflexivity and considered bias- always inherent in research but more so when you appear to be working with participants? How did you carry our member checking after each interview? Please provide clearer information on your method of analysis. I’ve made comments in the results section. The discussion needs to be re-written completely. Unless PLoS have another structure, I suggest: Key findings, strengths and limitations, discussion in relation to the literature, related areas for research, conclusions I think this is an issue you feel strongly about but your roles are as researchers and you should temper what comes across as almost anger. Some of your recommendations (which shouldn’t be within the main discussion section) are greatly outwith the scope of the research. Several errors in listing of references – please check all against PLoS requirements. I hope you will find these comments helpful and wish you well. Reviewer #2: The manuscript highlighted the challenges experienced by nurses working in an emergence unit in Ghana. This manuscript displays knowledge of the methodical aspects of qualitative research, i.e. research design, sampling and data collection, data analysis and qualitative rigor and ethics. The participants’ voices form the themes which are further discussed in the discussion section. My only comment is when was this study conducted? Was this before or during the pandemic that we are currently experiencing? My opinion is that if the study was conducted at the beginning/during the pandemic then the participants’ responses could be different or have more to add regarding the overcrowding and lack of resources and managerial support. ****** 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: Yes:** Dr Dorien Wentzel [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: PONE-D-20-22261_reviewer TM.pdf Attachment Submitted filename: PLOS ONE review.docx https://doi.org/10.1371/journal.pone.0247062.r001
Revision 1
19 Jan 2021 Author Response Dear Editor We would like to thank you sincerely for the review comments on our manuscript. We find the comments very useful and have responded to them to the best of our knowledge. We acknowledge that the comments have no doubt helped improve the quality of our manuscript. We herein provide further details by showing point-by-point feedback on how each of the comments received was addressed. For easy identification, the reviewers’ comments have been repeated while the Authors’ responses appear in red bold text. We also seek to amend authorship. Dr. Vida Nyagre Yakong was mistakenly removed during the submission process, we, therefore, wish to add her to the authors of the said manuscript. She contributed fully to this study and meets the authorship. Thank you. Reviewer #1: Thank you for submitting this paper which I have read with interest and enjoyment. You and your colleagues have addressed an important area with implications for practice and patient safety. I think you’ve gathered very interesting data which I’m sure will add to an important debate. Dear Reviewer We acknowledge and appreciate your thorough review of our manuscript. We find the comments very useful and have responded to them to the best of our knowledge. We acknowledge that the comments have no doubt helped improve the quality of our manuscript. Reviewer comments I have made many comments which I hope will be helpful. Some contextualising information in the introduction section would be helpful for example how patients are triaged in the ED. Authors response The facility did not have a formal triage system at the ED. Patients were generally assessed without following any triage process. The authors seek to further explore triaging among nurses in the various hospitals in the region which is our current project. Reviewer comments I am concerned that the hospital may be identifiable and suggest that you anonymise it further – not just a question of removing the name. Authors response Thank you. We did also observe that, we have therefore revised the study setting. Reviewer comments I found the paragraph on your research philosophy and approach quite confusing and suggest you simplify it for your readers. I don’t agree that research is the key to solving resource-related issues in low to middle income countries. Authors response Equally, we don’t disagree with you. Indeed, research is not the only form of resolving clinical issues. We, therefore, removed the sentence. Reviewer comments Some important details are missing in the method section including on governance. You describe reaching mutual understanding with your participants but have not addressed reflexivity and considered bias- always inherent in research but more so when you appear to be working with participants? Authors response Research team and reflexivity has been included in the methods column Reviewer comments How did you carry our member checking after each interview? Authors response Member checking was done by returning the interview transcripts to participants to confirm their responses. Each participant was given the transcribed data to confirm responses by their codes. Member checking is a tool that enhances the trustworthiness or validity of a study, so the authors left this portion in the rigor column Reviewer comments Please provide clearer information on your method of analysis. Authors Authors have given more clear information on the analysis of data Reviewer comments I’ve made comments in the results section. Authors response Dear reviewer, we have addressed all the comments and suggestions. Reviewer comments The discussion needs to be re-written completely. Unless PLoS have another structure, I suggest: Key findings, strengths and limitations, discussion in relation to the literature, related areas for research, conclusions Authors response We appreciate your suggestion on our discussion but the discussion and the manuscript structure are in line with the structure provided by PLoS One. We, therefore, wish to maintain the discussion (https://journals.plos.org/plosone/s/submission-guidelines). Reviewer comments I think this is an issue you feel strongly about but your roles are as researchers and you should temper what comes across as almost anger. Some of your recommendations (which shouldn’t be within the main discussion section) are greatly outwith the scope of the research. Authors response Dear reviewer, we appreciate this comment greatly and have therefore removed recommendations that are not within the scope of the study. Reviewer comments Several errors in listing of references – please check all against PLoS requirements. I hope you will find these comments helpful and wish you well. Authors response We appreciate the thorough review of the manuscript and indeed the manuscript is greatly improved and much clearer than before. The references have been checked and changes effected. Reviewer #2: The manuscript highlighted the challenges experienced by nurses working in an emergence unit in Ghana. This manuscript displays knowledge of the methodical aspects of qualitative research, i.e. research design, sampling and data collection, data analysis and qualitative rigor and ethics. The participants’ voices form the themes which are further discussed in the discussion section. Authors response Dear Reviewer, we appreciate your positive comments about our manuscript. My only comment is when was this study conducted? Was this before or during the pandemic that we are currently experiencing? My opinion is that if the study was conducted at the beginning/during the pandemic then the participants’ responses could be different or have more to add regarding the overcrowding and lack of resources and managerial support. Authors response This study was conducted earlier before COVID 19 pandemic https://doi.org/10.1371/journal.pone.0247062.r002
1 Feb 2021 Decision Letter - Katie MacLure, Editor “We are left with nothing to work with”; challenges of nurses working in the emergency unit at a secondary referral hospital: a descriptive qualitative study PONE-D-20-22261R1 Dear Dr. Afaya, 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, Katie MacLure, PhD, MSc (dist)., BSc (1st) Academic Editor PLOS ONE Additional Editor Comments (optional): These points are minor so can be corrected during the proofing process. Please check your reference to Atakro in the Discussion section which I believe should be 23 not 22. Also where you have reference numbers covering a consecutive range present these as [23-30]. Please remove the possessive apostrophe four lines above Data Analysis "participants were not interrupted". Reviewers' comments: https://doi.org/10.1371/journal.pone.0247062.r003
Formally Accepted
5 Feb 2021 Acceptance Letter - Katie MacLure, Editor PONE-D-20-22261R1 “We are left with nothing to work with”; Challenges of nurses working in the emergency unit at a secondary referral hospital: a descriptive qualitative study Dear Dr. Afaya: 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. Katie MacLure Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0247062.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 .