PONE-D-20-10854

Ethics in healthcare: Knowledge, attitude and practices of nurses in the Cape Coast Metropolis of Ghana

PLOS ONE

Dear Dr. Sambah,

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.

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All three reviewer raise some important points and the nurse reviewers for this paper were particularly interested in the inclusion of nursing ethics, both in terms of theoretical approaches and also within professional guidelines in Ghana. An inclusion of nursing ethical theory  in your paper will really strengthen your work and we look forward to your revised paper.

Please ensure that your decision is justified on PLOS ONE’s publication criteria and not, for example, on novelty or perceived impact.

==============================

Please submit your revised manuscript by Nov 12 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 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.

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We look forward to receiving your revised manuscript.

Kind regards,

Fiona Cuthill, PhD

Academic Editor

PLOS ONE

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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

Reviewer #3: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

Reviewer #3: Yes

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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

Reviewer #3: Yes

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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: Yes

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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: Review report 30th July, 2020

Summary of Review and overall impression

Ethical issues in nursing is an important area on nursing given that Nurses interact with patients at very delicate point in their lives when they are vulnerable to abuse of their rights.

However, there are important issues that need to be included.E.g the specific ethical principles, theories etc. that are of importance to nursing. The authors need to demonstrate how these principles are integrated in the International Council of Nurses guidelines and operationalized in National nurses’ regulatory body and curricular for nurses in Ghana.

There is also need to describe how the ethical guidelines for nurses relate to the specific areas of Ghana constitution

My general view is that assessment of knowledge, attitude and practice of nurses in the area of ethics is an important issue but the manuscript needs to be revised substantially before publication as follows:

Introduction: There is need for major revision to give description in the subject matter of ethics, magnitude of the problem, the negative effects and gaps in Knowledge, attitudes and practice that justify the study.

The literature review does not demonstrate logical arguments that justify the study

Methodology: There are major methodological issues of concern indicated on the specific areas (see comments in the manuscripts for detailed suggestions).

Results and Discussion: Need to be revised as indicated in the comments within the document.

Generally-there is need to revise the manuscript for logical flow.

Declaration of competing interest-I declare that I do not have any conflicting interest

The specific questions and remarks

Items Remarks

1. The study presents the results of original research √

2. Results reported have not been published elsewhere. √

3. Experiments, statistics, and other analyses are performed to a high technical standard and are described in sufficient detail -Needs revision

4. Conclusions are presented in an appropriate fashion and are supported by the data. -Need revision

5. The article is presented in an intelligible fashion and is written in Standard English. -Needs Re organization to reflect logical flow

6. The research meets all applicable standards for the ethics of experimentation and research integrity.

-Ethical issues observed not clearly explained

7. The article adheres to appropriate reporting guidelines and community standards for data availability

-Yes but needs improvement

Reviewer #2: This is an interesting and informative paper on a geographically understudied area of nursing practice. As I am a qualitative researcher, I cannot comment on the regression analysis specifically. Outside of that, the study design and methodology seem sound and the results support the conclusions, with one caveat:

I would encourage the authors to consider and discuss the difference between 1) 'ethics' in a general social sense, 2) professional ethics as specific to nursing, and 3) the particular written national codes of ethics they discuss in the paper. They should make clear that when discussing 'nurse's knowledge of ethics', they mean the third sense, namely formal written codes of conduct. I'm saying this because it could be well possible that rather than having 'no ethics at all', as the authors seem to imply, the nurses in question simply operate on a different (maybe not formal/bureaucratic) understanding of ethics, which then conflicts with professional standards. For example, their treatment of women in antenatal clinics may not be in tune with formal ethical standards at the hospital - but is it possible that it conforms to a 'local' ethics which demands that women attend the clinic and pay for the items needed there? These distinctions might make for an interesting follow-up study, but as it stands, the data does not support the claim that nurses do not have any knowledge of any ethics at all - just that they do not have knowledge of the relevant formal codes applying to their jobs.

I would also recommend to have the article professionally edited if at all possible to eliminate potential misunderstandings due to language use (e.g. p 57 ln 59 - 'couples'?).

The authors state that the original data will be made available upon request, but it appears that PLOS ONE requires data to be deposited in a public depository for the paper to be accepted. Once these points are addressed, I warmly recommend the paper for publication.

Reviewer #3: 1. Page Number - PN (3) Line Number - LN (58): - Is this issue of unethical practice among nurses a global one or just

specific to some places? Or are there other forms in other places?

2. PN (3) LN (75-79): - Where were these studies conducted? Is this a global problem or localized? You need to be specific

here. There might be a need to present existing global studies especially from the western world in relation to the

unethical nursing practices.

LN 79 - Please change to ‘Midwifery’.

3. PN (4), LN (85-86): - This sentence is not clear. How does the attitude and the practice of nurses influence how they act

and conduct their duties? Or that the nurses’ knowledge of the ethics of their profession influenced their attitudes and

practices?

LN (95-97): - Is this referring to the nurses in Ghana?

4. PN (5), LN (116): - Change to ‘bachelor’s degree’

5. PN (6), LN (144-147): - This appears confusing. Can you please elaborate on this sentence especially regarding the

evaluation by the two senior research assistants? Was this part of the analysis?

LN (149-150): This is not clear. Which of the group of nurses did not take part in the main study? Why were they not

involved in the main study? Was there a pilot test?

6. PN (10), LN (273): - Change to ‘…and in Ghana’

LN (294): Please rewrite this.

7. PN (11), LN (305-307): - Yes, this is true. However, do the nurses in Ghana or any of the African countries face lawsuits

for unethical practices? Are the people aware of their rights regarding the unethical practices of the nurses

who take care of them? Have you also considered the issues of quackery in the nursing profession, whereby people

assumed that everyone working in health facilities wearing ‘white uniforms’ are nurses? In essence, what role does

quackery play in the unethical practices observed among the nurses in Ghana?

LN (314 - 320): From your finding, and with the high percentage of ethical practices among nurses in Ghana, what could

be the explanation for these inhibiting factors raised here and the high percentage of ethical practices among the

nurses interviewed in this study?

8. PN (12), LN (332-333): - You need to expatiate more on this issue. Are diplomate nurses found to be more involved in

unethical practices as a result of their low level of education? Or what?

From this study findings, nurses who have diploma in nursing also have high level of knowledge about the ethics of

nursing profession. This appears to contradict earlier studies in relation to this.

LN (349-350): How can the findings from this study be generalized to other health care professionals? Are they also

influenced by the same factors? Are there studies that suggest that they also practice unethically? Which of the health

care professionals do you want to generalize your findings to?

LN (350-353): Further study should be encouraged to identify specific nursing specialties where there are reports of

unethical practices. There is also a need to identify the specific aspects of the nursing ethics where unethical practices

have been identified among nurses. Studies should be done to identify if there are complaints about unethical practices

among other health care professionals.

9. PN (13), LN (357-358): There should be sanctions and penalties for nurses who are reported and confirmed to be

involved in unethical practices.

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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 Steph Grohmann

Reviewer #3: No

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Attachments

Attachment

Submitted filename: REVD PONE-D-20-10854 Reviewed 30th July 2020.pdf

PONE-D-20-10854R1

Ethics in healthcare: Knowledge, attitude and practices of nurses in the Cape Coast Metropolis of Ghana

PLOS ONE

Dear Dr. Sambah,

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 Oct 01 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 'Response to Reviewers' 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. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Prof. Ritesh G. Menezes, M.B.B.S., M.D., Diplomate N.B.

Academic Editor

PLOS ONE

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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 #1: All comments have been addressed

Reviewer #4: (No Response)

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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 #1: (No Response)

Reviewer #4: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: (No Response)

Reviewer #4: No

**********

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 #1: (No Response)

Reviewer #4: 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 #1: (No Response)

Reviewer #4: No

**********

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 #1: (No Response)

Reviewer #4: • line 34: Method – survey design is not appropriate term. it is preferable to use cross-sectional design

• line 38: high ethical knowledge is not appropriate – it is better to state good knowledge

• line 39: 98% were ethical conscious in their practices – it is better to state 98% had good ethical practices

• line 44: nurses’ practice with high ethical standards – needs to be rephrased

• MeSh terms to be used for Keywords.

• lines 78-80: what is the reference /basis for these statements?

• lines 95-96: rephrase statement

• lines 90-115: sentences look repetitive. they may be condensed. syntax errors to be corrected. it seems that problems/concerns with nurse patient communication have been interchangeably used with ethical behaviour. This is not appropriate & needs to be corrected.

• line 119: how was sample size calculated?

• line 130: of the 42 items – only details of 30 items have been mentioned in section A & B

• lines 164-168: grammatical corrections needed

• lines 190-192: how were knowledge, attitude & practice scores aggregated as continuous scores? why were the variables not analysed as categorical variables?

• line 193: what is a latent variable?

• line 194: what is mixture of variables? – it is preferable to utilize appropriate statistical terms.

• line 195: p value<0.05

• what software was used for data analysis?

• line 200: high knowledge – to be corrected

• line 208-209: table title needs to be reworded. level of ethical knowledge is incorrect usage

• tables can be reframed to depict key variables rather than reproducing the data output tables

• line 225: CHN/RCN/RMN – the explanation for the abbreviated terms need to be provided as footnotes under the table

• lines 230-232: it is preferable to classify knowledge as good & poor

• line 311: high level of ethical knowledge to be replaced by good knowledge about ethics

• line 325: who could not be a presentation of the all nurses in Ghana. – needs to be rephrased as not representative of all nurses in Ghana

• lines 331-332: sentences to be rephrased

• lines 334-337: please substantiate your claim on attitudes & patient recovery

• lines 357-358: syntax error to be corrected

• lines 368-370: sentences need to be rephrased

• line 379: conclusion- should summarize key findings of the study in 3-4 sentences

• lines 380-383: may be removed from conclusions

• lines 384-388 avoid usage of term – high ethical standards

• lines 395-396: sentences need to be rephrased

• lines 391-393: are limitations of the study & not conclusions

• line 414: syntax error

• the tool/questionnaire used for the study may be enclosed for better clarity on the questions

**********

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 #1: No

Reviewer #4: 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.

PONE-D-20-10854R2

Ethics in healthcare: Knowledge, attitude and practices of nurses in the Cape Coast Metropolis of Ghana

PLOS ONE

Dear Dr. Sambah,

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 December 16, 2021. 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 'Response to Reviewers' 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: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols. Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols.

We look forward to receiving your revised manuscript.

Kind regards,

Prof. Ritesh G. Menezes, M.B.B.S., M.D., Diplomate N.B.

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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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 #4: 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 #4: Yes

********** 

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #4: 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 #4: 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 #4: No

********** 

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 #4: Line 44: Good high ethical standards is not appropriate phrase. Please correct the statement

Line103: improperly carried out ethical practices in their routine care like insulting patient – please rephrase

Lines 125-126: It is preferable to state that all the 326 nurses working in the municipality hospitals were included in the study

Table 2,3,4: titles can be modified to improve understanding

Line 330: The finding again indicates a high positive attitude – avoid usage of phrases like high positive attitude

Line 333: Oceanian – spell check for errors

Lines 369-372: sentences are grammatically incorrect. Kindly rephrase

********** 

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 #4: 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.

Ethics in healthcare: Knowledge, attitude and practices of nurses in the Cape Coast Metropolis of Ghana

PONE-D-20-10854R3

Dear Dr. Sambah,

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 including language corrections.

Within one week, you’ll receive an e-mail detailing the required amendments. You must seek independent editorial help to address language issues. Refer to the 5th criterion for publication listed by PLoS ONE (https://journals.plos.org/plosone/s/criteria-for-publication). 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,

Prof. Ritesh G. Menezes, M.B.B.S., M.D., Diplomate N.B.

Academic Editor

PLOS ONE

Additional Academic Editor Comments:

Not all grammatical mistakes are addressed by the authors despite providing 3 opportunities to revise the manuscript. PLoS ONE does not copy edit accepted manuscripts. Therefore, authors must address language issues preferably while addressing other technical requirements or at least at the time of proof corrections.