Ethical and psychosocial considerations for hospital personnel in the Covid-19 crisis: Moral injury and resilience

Alexander Kreh; Rachele Brancaleoni; Sabina Chiara Magalini; Daniela Pia Rosaria Chieffo; Barbara Flad; Nils Ellebrecht; Barbara Juen

doi:10.1371/journal.pone.0249609

Peer Review History

Original SubmissionNovember 4, 2020
12 Jan 2021 Decision Letter - Francesco Di Gennaro, Editor PONE-D-20-34707 Ethical and Psychosocial considerations for hospital personnel in the COVID-19 crisis: Moral Injury and Resilience PLOS ONE Dear Dr. Kreh, 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 5 February. 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, Francesco Di Gennaro 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 additional information regarding the interview guide used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed an interview guide as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. In addition, we recommend that authors use the COREQ checklist, or other relevant checklists listed by the Equator Network, such as the SRQR, to ensure complete reporting (http://journals.plos.org/plosone/s/submission-guidelines#loc-qualitative-research). Please attach such a checklist as Supporting Information. 3. In your Data Availability statement, you have not specified where the minimal data set underlying the results described in your manuscript can be found. PLOS defines a study's minimal data set as the underlying data used to reach the conclusions drawn in the manuscript and any additional data required to replicate the reported study findings in their entirety. All PLOS journals require that the minimal data set be made fully available. For more information about our data policy, please see http://journals.plos.org/plosone/s/data-availability. Upon re-submitting your revised manuscript, please upload your study’s minimal underlying data set as either Supporting Information files or to a stable, public repository and include the relevant URLs, DOIs, or accession numbers within your revised cover letter. For a list of acceptable repositories, please see http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories. Any potentially identifying patient information must be fully anonymized. Important: If there are ethical or legal restrictions to sharing your data publicly, please explain these restrictions in detail. Please see our guidelines for more information on what we consider unacceptable restrictions to publicly sharing data: http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions. Note that it is not acceptable for the authors to be the sole named individuals responsible for ensuring data access. We will update your Data Availability statement to reflect the information you provide in your cover letter. Additional Editor Comments: dear authors follow reviewer suggestion to improve your paper [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: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: N/A ****** 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: No ****** 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: the study was a descriptive based on intensive interviews and was writing in clear standard English understandable for scientific community as well as lay person everything was technically sound and I have no comments on it Reviewer #2: 1.Only 13 experts were interviewed in this study. Is it fully representative and statistically significant？Whether there is a bias in the selection of study object？ 2.Please provide the interview outline and questionnaire. ****** 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:** Dengchuan Wang [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.0249609.r001
Revision 1
12 Mar 2021 Author Response Dear Editors, dear Reviewers, Thank you for reviewing our submission entitled Ethical and Psychosocial considerations for hospital personnel in the COVID-19 crisis: Moral Injury and Resilience (PONE-D-20-34707). Attached to this letter we are uploading a marked-up copy of our manuscript that highlights all changes made as well as an unmarked version of the revised paper. In the following, we want to respond to all points raised by the reviewers. 1. Style requirements We updated the manuscript according to PLOS ONE’s style requirements. 2. Additional information We now include our interview guide in the supporting documents section. Given that we conducted our research in the very beginning of the COVID-19 pandemic, an exploratory approach was necessary to gain insights on the health care worker’s perspective in this new environment. We thus followed the principles of openness and induction, as we stated in the methods section of the revised manuscript. Our interview guide contains topics that provide a framework of orientation to ensure comparability and accompany the communication process. However, instead of asking specific, predetermined types of questions the guide relies on the interaction with the interviewee to steer the interview process and helps constructing questions on the topics of interest as the interview progresses – a method that is widely used in qualitative research (see e.g. Witzel, 2000; Edwards & Holland, 2013, p. 55) We also now provide the COREQ checklist to ensure that we addressed all points relevant for complete reporting. 3. Data availability statement We were asked to make all data underlying the findings in our manuscript fully available. However, in our first submission we pointed out concerns as our interview transcripts contain sensible participant information. Publishing the full transcripts is also excluded in the informed consent our interviewees signed. In order to meet transparency needs, excerpts of the transcripts relevant to the study are made available within the paper. We also provided an overview of our conceptualized data as in this form it does not contain sensible participant information. It is available in a public repository: “Full data cannot be shared publicly because they contain potentially identifying or sensible participant information. However, conceptualized data after using grounded theory methodology can be retrieved from doi.org/10.5281/zenodo.4241858” 4. Additional review comments Reviewer #2 pointed out concerns regarding our sample size, whether there is a bias in the selection process and whether it is fully representative and statistically significant. We would like to point out the inherent principles of sampling approaches in qualitative research. We did not use a random sampling approach in order to find a statistically representative sample (as it is indispensable in quantitative research). Instead, we purposefully selected information-rich cases, aiming at in-depth understanding rather than statistically proven generalizations (see e.g. Patton, 2002, p.230). We thus do not view our sample as biased, but consider the selection of highly experienced interviewees directly involved in the response of the pandemic as a quality criterion of our data. We furthermore believe that our approach is in line with trends of narrative-based medicine in recent years (see e.g. Kalitzkus & Matthiessen, 2009). Our aim in this manuscript was to develop some basic hypotheses regarding resilience and stress experience of healthcare workers in the first phase of the COVID-19 pandemic. However, we agree that a statistical survey would add to the value of our findings. We are therefore currently conducting survey studies with health care workers. The construction of the surveys is based on the findings from qualitative research presented in this manuscript. Findings from quantitative follow-up studies will be presented at a later stage. Sources Edwards, R. & Holland, J. (2013). What is qualitative interviewing? Bloomsbury Academic. Kalitzkus, V. & Matthiessen, P. (2009). Narrative-Based Medicine: Potential, Pitfalls, and Practice. The Permanente Journal, 13(1), 80-86. Patton, M. Q. (2002). Qualitative research & evaluation methods. 3rd (ed.). Thousand Oaks, CA: Sage. Witzel, A. (2000). The Problem-Centered Interview. Forum: Qualitative Social Research, 1(1), Art. 22. Available at https://www.qualitative-research.net/index.php/fqs/article/view/1132/2521 Thank you for taking our manuscript under further consideration. Best regards, Alexander Kreh Corresponding author Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0249609.r002
22 Mar 2021 Decision Letter - Francesco Di Gennaro, Editor Ethical and psychosocial considerations for hospital personnel in the COVID-19 crisis: Moral injury and resilience PONE-D-20-34707R1 Dear Dr. Kreh, 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, Francesco Di Gennaro Academic Editor PLOS ONE Additional Editor Comments (optional): dear authors congratulations Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #2: All comments have been addressed ******** 2. 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 #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #2: Yes ****** 4. 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 #2: Yes ****** 5. 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 #2: Yes ****** 6. 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 #2: (No Response) ****** 7. 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 #2: Yes:** Dengchuan Wang https://doi.org/10.1371/journal.pone.0249609.r003
Formally Accepted
26 Mar 2021 Acceptance Letter - Francesco Di Gennaro, Editor PONE-D-20-34707R1 Ethical and psychosocial considerations for hospital personnel in the Covid-19 crisis: Moral injury and resilience Dear Dr. Kreh: 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. Francesco Di Gennaro Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0249609.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 .