Development and initial validation of the Japanese healthy work environment assessment tool for critical care settings

Mio Kitayama; Takeshi Unoki; Yui Matsuda; Yujiro Matsuishi; Yusuke Kawai; Yasuo Iida; Mio Teramoto; Junko Tatsuno; Miya Hamamoto

doi:10.1371/journal.pone.0268124

Peer Review History

Original SubmissionDecember 19, 2021
11 Feb 2022 Decision Letter - Fatih Özden, Editor PONE-D-21-39634Development and Initial Validation of the Japanese Healthy Work Environment Assessment Tool for Critical Care SettingsPLOS ONE Dear Dr. Kitayama, 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 Mar 28 2022 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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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: Thank you for asking me to review this article. The results are very interesting, the article is clearly written and organized, and I believe the article will be of interest to the readers. There are some minor fixes to consider. Introduction On page 5, line 89, a few more recent studies examining the impact of the work environment on patient and employee health/outcomes should be included. The Covid-19 pandemic has been an important factor affecting intensive care environments, workforce planning, rapid decision making, communication and collaboration. This is not mentioned at all in the article. Briefly, the effect of the pandemic on the intensive care work environment can be mentioned. Background Page 6, line 99. Does this measurement tool (HWE-AT) have a cutoff score? How is the score obtained from the scale interpreted? It should be explained briefly. Methods/ Content validity What technique was content validation done (Davis?) Page 8, line 141. It is the expert opinion experienced in the hospital setting? Or were those with intensive care experience selected? Participant Selection for Construct Validity Is the delivery of care in intensive care units in Japan cascaded according to the severity of the patient condition? Which level (1st, 2nd or 3rd level) of the nurses participating in the study work in the intensive care unit? Results Pilot testing Were 40 nurses participating in the study included in the sample of the study at this stage? It must be disclosed. Sample size Page 10, line 184. Has the sample size been confirmed by the Kaiser-Meyer-Olkin test as to whether the sample size is sufficient for factor analysis? Before the discussion, the characteristics of the final form should be given briefly. It is as if any item was removed from the Japanese scale and the sub-factor structure was preserved. Clinical Implications/Research Implication Page 17, lines 301-302. “standard” should be explained, whether a unit falls below the standard will be evaluated according to a written/valid procedure or according to the score obtained from the scale! Figure 1 “Testeing” should be fixed Reviewer #2: #1 Since HWE-AT-j is an evaluation method derived from the original HWE-AT, it is necessary to discuss the comparison with the original HWE-AT (distribution of the sample, factor loading for each question, etc.). #2 The author started the analysis with confirmatory factor analysis. Please explain why you did not consider factor structure, factor loading, etc. in the exploratory factor analysis. #3 The reader cannot evaluate the ceiling effect and floor effect from table2. Please make it a general table (mean, SD). #4 In table 5, Cronbach's increases when Q10 is deleted. Please explain this in the discussion. Is it the same trend in the original paper? #5 (line 241) There is no mention of this in table2. Please correct it. #6 Please list χ2 and df in table3. The researcher is free to use any index to some extent, but χ2 is usually necessary. #7 What is the reason why the factor loading in table3 is not standardized?　In other papers, standardized factor loading is used. #8 In Japan, what is the difference between a certified nurse and a specialist?　What kind of license is it?　Please describe. #9 The percentages for staff and administration in table 4 are blank. Please correct it. #10 Why don't you combine the characteristics in table 1 and 4 into the same table? This is a suggestion. #11 Please attach the Japanese version of the questionnaire (HWE) prepared by the author to the supporting information. ****** 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. 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Revision 1
4 Apr 2022 Author Response Response to Editor and Reviewer Journal Requirements: Comment #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 Response Thank you for pointing this out. We have made the corrections as per PLOS ONE’s style requirements. Comment #2 Please provide additional details regarding participant consent. In the Methods section, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal). 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. Response Thank you for your comment. We added these sentences. ------Revised Manuscript------ P12, Line221 For participant consent, an instruction sheet was attached on the web and a check box was provided so that participants could indicate their willingness to participate. The consent form had to be viewed and checked to be able to respond. In addition, contact information was attached so that participants could request verbal explanations or written consent, and this was handled on an individual basis. Comment #3 Thank you for stating the following financial disclosure: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” Response Thank you for your comment. The authors received no specific funding for this work. We apologize for any misleading representations. In addition, we got to advice about English expressions, so we added that part. ------Revised Manuscript------ These sentences were deleted. P28, Line382 The authors thank the Clinical Research Support Office of the Medical Research Institute (institution name blinded for peer review) for their excellent support in this study. These sentences were added. P28, Line384 We would like to thank Dr. James Britton and the University of Miami School of Nursing and Health Studies for the editorial support. Comment #4 Please ensure that you refer to Figure 1 in your text as, if accepted, production will need this reference to link the reader to the figure. Response Thank you for your comment. We added these sentences. ------Revised Manuscript------ P6, Line 106 Reviewer #1 Thank you for asking me to review this article. The results are very interesting, the article is clearly written and organized, and I believe the article will be of interest to the readers. There are some minor fixes to consider. Comment #1 Introduction On page 5, line 89, a few more recent studies examining the impact of the work environment on patient and employee health/outcomes should be included. Response Thank you for your comment. We have added a few more recent studies related to the impacts of work environment on patients and employees. ------Revised Manuscript------ P4, Line 67 In turn, a healthy work environment, such as an environment with higher perceptions of authentic leadership, was associated with lower burnout and higher compassion satisfaction [5]. Effectively promoting a healthy work environment (HWE) has not only prevented burnout among nurses but also decreased medication errors and pressure ulcers [6,7]. Comment #2 Introduction The Covid-19 pandemic has been an important factor affecting intensive care environments, workforce planning, rapid decision making, communication and collaboration. This is not mentioned at all in the article. Briefly, the effect of the pandemic on the intensive care work environment can be mentioned. Response Thank you for your comment. We have added material about the effect of the COVID-19 pandemic on work environment in intensive care units. ------Revised Manuscript------ P4, Line 72 Furthermore, there has been a growing interest in improving the work environment during the COVID-19 pandemic; however, the lack of human and personal protective equipment during the pandemic makes it difficult to maintain a safe work environment, such by as reducing the risk of infection for nurses [8]. Even then, open-ended communication, especially in leadership, and a supportive work environment could increase resilience in workers during and after the pandemic [9, 10] In addition, by improving the work environment, nurses may be able to maintain a positive outlook even during the temporary crisis of the pandemic [11]. Comment #3 Background Page 6, line 99. Does this measurement tool (HWE-AT) have a cutoff score? How is the score obtained from the scale interpreted? It should be explained briefly. Response Thank you for your comment. We added a statement that the scale is a five point Likert scale and discussed the cutoff score of each question. ------Revised Manuscript------ P5, Line88 each item is rated on a five-point Likert scale, ranging from 1 (strongly disagree with the statement) to 5 (strongly agree with the statement) [14]. As for the score cutoff, the HWE-AT score guidelines determine that 1.00-2.99 is “Needs Improvement”, 3.00-3.99 is “Good”, and 4.00-5.00 is “Excellent” [15]. Comment #4 Methods/ Content validity What technique was content validation done (Davis?) Page 8, line 141. It is the expert opinion experienced in the hospital setting? Or were those with intensive care experienceselected? Response Thank you for your comment. We added the following sentence. ------Revised Manuscript------ P8, Line140 All of these experts have more than ten years of experience as critical care nurses. Comment #5 Participant Selection for Construct Validity Is the delivery of care in intensive care units in Japan cascaded according to the severity of the patient condition? Which level (1st, 2nd or 3rd level) of the nurses participating in the study work in the intensive care unit? Response Thank you for your comment. There is no criteria dividing the ICU by severity of illness in Japan. Comment #6 Results Pilot testing Were 40 nurses participating in the study included in the sample of the study at this stage? It must be disclosed. Response Thank you for your comment. Forty nurses who participated in the study were not include in the sample of the study at this stage. We added the following sentence. ------Revised Manuscript------ P8, Line135 In case of repeated tests, the same participant was not allowed to answer the survey again. Comment #7 Sample size Page 10, line 184. Has the sample size been confirmed by the Kaiser- Meyer-Olkin test as to whether the sample size is sufficient for factor analysis? Before the discussion, the characteristics of the final form should be given briefly. It is as if any item was removed from the Japanese scale and the sub-factor structure was preserved. Response Thank you for your comment. We determined the sample size using the Kaiser-Meyer-Olkin test. For this analysis, the sample size was sufficient. We added the following sentence and supplemental file 1. ------Revised Manuscript------ P10, Line 190 We also used Kaiser-Meyer-Olkin test to confirm that the sample size was appropriate [21]. P14, Line 252 We also evaluated the measures of sampling adequacy (MSA) using the Kaiser-Meyer-Olkin test for each item, and the results indicate that sample size was sufficient for factor analysis (meritorious:0.87~ marvelous:0.95), as shown in S1 Table. P26, Line 345 　　　　　　　　　　　　　　　　　　　　　　　　　 Also, the result of sample size by using Kaiser-Meyer-Olkin test was appropriate [21]. Comment #8 Clinical Implications/Research Implication Page 17, lines 301-302. “standard” should be explained, whether a unit falls below the standard will be evaluated according to a written/valid procedure or according to the score obtained from the scale! Response Thank you for your comment. There are criteria based on the scoring guideline; thus we added the following sentences. ------Revised Manuscript------ P27, Line367 The HWE-AT score guidelines determine that 1.00-2.99 is “Needs Improvement”, 3.00-3.99 is “Good”, and 4.00-5.00 is “Excellent” [15]. If a unit falls below the standard, issues can be identified, and steps can be taken to resolve them. Moreover, AACN had previously surveyed HWE on a five-point scale between 2006 and 2018 [32]. Using the HWE - AT-J, we will be able to evaluate the current state in each unit. Comment #9 Figure 1 “Testeing” should be fixed Response P7, Line 106 Thank you for your comment. We fixed Fig 1. Reviewer #2 Comment #1 Since HWE-AT-j is an evaluation method derived from the original HWE-AT, it is necessary to discuss the comparison with the original HWE-AT (distribution of the sample, factor loading for each question, etc.). Response Thank you for your useful comment, we discussed the comparison with the original HWE-AT. Comment #2 The author started the analysis with confirmatory factor analysis. Please explain why you did not consider factor structure, factor loading,etc. in the exploratory factor analysis. Response Thank you for your reasonable advice. We considered performing the EFA again; however, we decided not to perform this analysis because of the following reasons: 1. The original the HWE-AT was not developed using EFA. 2. The purpose of this study was to assess construct validity and reliability of the HWE-AT-J. Revising the original HWE-AT was not within the purpose of this study. 3. Thus far, no studies performed EFA on the HWE-AT in any language. Also, we determined that our study’s purpose will be achieved using only CFA. We added the reasons we did not perform EFA in the method section. ------Revised Manuscript------ P11, Line201 We did not perform exploratory factor analysis (EFA) because as far as we know the HWE - AT was not developed using EFA [23]. Moreover, the purpose of this study was to consider structural equivalence between the Japanese version and the original version. Therefore, we chose to perform CFA. Comment #3 The reader cannot evaluate the ceiling effect and floor effect from table2. Please make it a general table (mean, SD). Response Thank you for your useful comment. We revised table 2 according to your comment to make it easier to understand for the readers. We deleted the ceiling and floor effects as a part of the result and discussion, and revised Table 4. We also added new sentences. ------Revised Manuscript------ Revised table2 ・P18, Line282 These sentences were deleted. ・P17, Line266 The authors checked for ceiling and floor effects; when SD was added or subtracted from the mean value, none of the items exceeded the maximum value of 5 or were below the minimum value of 1, as shown in Table 2. Therefore, the results showed no significant bias in the distribution of responses to each questionnaire item. ・P26,Line343 Additionally, there is no ceiling or floor effect; thus, the scale is considered acceptable. These sentences were added. ・P17, Line270 The authors determined that the ceiling effect was observed when 0% to 14% of respondents rated “5”. The floor effect was determined when 7% to 40% of respondents rated as “0”. We found Q3, Q 4, Q7, Q8, Q10, Q14, Q16, Q17, and Q 18 had floor effects. ・P25, Line329 　Floor effects were observed in the following items (Q3, Q4, Q7, Q8, Q10, Q14, Q16, Q17 and Q18). As consistent with the original scale, a five-point Likert scale was used to measure the items. The result reflects the current situation of Japanese nursing practice that is hierarchical in nature. Therefore, the floor effect does not hamper the generalization of the scale adequacy. Comment #4 In table 5, Cronbach's increases when Q10 is deleted. Please explain this in the discussion. Is it the same trend in the original paper? Response Thank you for your critical comment. The original paper[1] does not show internal consistency in detail, and we do not think it is comparable.Our study purpose was to use the same specification method as the original study, and to maintain consistencey with the original HWE-AT study, we did not remove any specific questions. 1. Connor JA, Ziniel SI, Porter C, Doherty D, Moonan M, Dwyer P, et al. Interprofessional use and validation of the AACN Healthy Work Environment Assessment Tool. Am J Crit Care. 2018;27(5): 363–371. https://doi.org/10.4037/ajcc2018179. Comment #5 (line 241) There is no mention of this in table2. Please correct it. Response Thank you for your comment. We mentioned Table 2 in text. ------Revised Manuscript------ These sentences were deleted. ・P17, Line275 The mean scores, standard deviations, and factor loadings are presented in Table 2. These sentences were added. ・P17, Line276 The mean scores and standard deviations are shown in Table2. Comment #6 Please list Χ2 and df in table3. The researcher is free to use any index to some extent, but Χ2 is usually necessary. Response Thank you for your comment. We added X2 and df values in Table 3. ------Revised Manuscript------ Revised table3 P20, Line286 Comment #7 What is the reason why the factor loading in table3 is not standardized? In other papers, standardized factor loading is used. Response Thank you for pointing that out. We changed the standardized factor loading as table2. ------Revised Manuscript------ Revised table2 ・P18, Line282 Comment #8 In Japan, what is the difference between a certified nurse and a specialist?　 What kind of license is it? Please describe. Response Thank you for asking this question. In Japan, a CN has received at least 600 hours of training in a specific field, and a CNS has completed a master's degree in a specific field. ------Revised Manuscript------ P24, Line323 A Certified nurse (CN) is those who received at least 600 hours of training in a special field and who have often served as leaders of a unit because of their specialized knowledge and expertise. Also, a Certified Nurse Specialist (CNS)has completed a master’s degree in a specific field. Comment #9 The percentages for staff and administration in table 4 are blank. Please correct it. Response Thank you very much for letting us know. We revised the tables and combined the information in Table 4 with Table 1. ------Revised Manuscript------ Revised table1 ・P14, Line261 Comment #10 Why don't you combine the characteristics in table 1 and 4 into the same table? This is a suggestion. Response Thank you for your comment. We combined Tables 1 and 4, and renumbered the tables accordingly. ------Revised Manuscript------ Revised table1 ・P14, Line 261 #11 Please attach the Japanese version of the questionnaire (HWE) prepared by the author to the supporting information. Response Thank you for your comment. We attached the Japanese version of HWE as a supplemental file 2. ------Revised Manuscript------ S2 Table Reference Red articles were added after first submission 1. Massoudi DAH, Hamdi DSSA. The consequence of work environment on employees productivity. IOSR JBM. 2017;19(1): 35–42. https://doi.org/10.9790/487X-1901033542. 2.Thing R, et al. WHO Healthy Workplace Framework and Model Synthesis Report; 2010. Available: https://apps.who.int/iris/bitstream/handle/10665/113144/9789241500241_eng.pdf. 3.McHugh MD, Rochman MF, Sloane DM, Berg RA, Mancini ME, Nadkarni VM, et al. Better nurse staffing and nurse work environments associated with increased survival of in-hospital cardiac arrest patients. 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Beth U, Connie B, Linda C,et al.Crinical care nurse work environment 2018: Findings and implications.2019; 39(2), 67-84. https://doi.org/10.4037/ccn2019605. mp Attachments Attachment Submitted filename: Response to Reviewers.docx https://doi.org/10.1371/journal.pone.0268124.r002
25 Apr 2022 Decision Letter - Fatih Özden, Editor Development and Initial Validation of the Japanese Healthy Work Environment Assessment Tool for Critical Care Settings PONE-D-21-39634R1 Dear Dr. Kitayama, 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, Fatih Özden, PhD Academic Editor PLOS ONE Additional Editor Comments (optional): 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 #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 #1: Yes Reviewer #2: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes 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 #1: Yes 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 #1: Yes 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 #1: (No Response) 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 #1: No Reviewer #2: No https://doi.org/10.1371/journal.pone.0268124.r003
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4 May 2022 Acceptance Letter - Fatih Özden, Editor PONE-D-21-39634R1 Development and Initial Validation of the Japanese Healthy Work Environment Assessment Tool for Critical Care Settings Dear Dr. Kitayama: 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. Fatih Özden Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0268124.r004

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