PONE-D-22-07749Physician Exhaustion and Work Engagement During the COVID-19 Pandemic: The Role of Resources and Support InterventionsPLOS ONE

Dear Dr. Solms,

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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ACADEMIC EDITOR: Dear Authors

Thank you very much for your submission and the great effort put in the paper presented. 

We would be able to proceed further once reviewers and editor suggesions are adressed.Academic Editor suggestions:

• The design chosen does not allow for actual effectiveness estimations. However, if considering comparative effectiveness from repeated-measurements observational data, highly we encourage to consider adding propensity scores. Please avoid the use of the section interventions in the methods sections since not facing here a clinical trial or to be describe differently. Same goes for the effectiveness in the results section. Consider including the study design in the title and rephrase it. 
• Pay attention to table 1 suggestion from reviewer. Please consider moving some of the vast statistics table to the supplementary files also. Consider de use of a flow diagram. 
• Ensure to adapt STROBE to the CHERRIES (https://pubmed.ncbi.nlm.nih.gov/15471760/) to have the full view of the questionnaire process. 

Best regards

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Please submit your revised manuscript by Jun 30 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.

Please include the following items when submitting your revised manuscript:

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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.

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,

Juan A López-Rodríguez

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: Yes

Reviewer #2: Yes

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

Reviewer #1: Yes

Reviewer #2: 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: 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

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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: This is an original article investigating the role of resources and support Interventions in the development of work exhaustion among physicians during the COVID-19 pandemic. The study presents the results of original psychometric research in an intelligible fashion and is written in standard English. The methodology is explained in detail and is appropriate for this type of research. Statistical analyses are performed to a high technical standard and are described in sufficient detail. There are no ethical issues to be addressed. Conclusions are presented in an appropriate fashion and are supported by the data. My opinion is that this paper should be accepted for publication without further corrections.

Reviewer #2: General comments: The thematic of the research is interesting, and it was well conducted. However, adjustments in the writing of the article must be made before approval.

Introduction

• I felt the lack of a focus on the scenario of COVID-19 as an aggravating factor for the exhaustion of professionals, and make it clearer in the introduction which support interventions will be studied.

Methods

• I suggest removing the entire description of the population, including the table, since they are results, from the second paragraph of the methodology.

Results

• The description of the results is very extensive, and difficult to read. I suggest the authors to be more direct and clear in the results; a detailed description of the statistical issue isn’t necessary.

• Focus on how to support interventions would improve this situation, which is the objective of the study.

Discussion:

• I consider important to cite other studies carried out on the subject and to make comparisons with their results.

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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.

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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

[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-22-07749R1Physician Exhaustion and Work Engagement During the COVID-19 Pandemic: A Longitudinal Survey into the Role of Resources and Support InterventionsPLOS ONE

Dear Dr. Solms,

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.

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

ACADEMIC EDITOR:Thank you very much for this second effort in trying to address all reviewers comments. We finnaly had a third reviewer also having a look to your work who thinks it is a good job although some minor comments from the reviewer need to be review. We highly appreciate that you'd try discuss the comments regarding our second reviewer and be back to us as soon as possible. Best regardsJALRAcademic Editor

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

Please submit your revised manuscript by Oct 24 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.

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: 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,

Juan A López-Rodríguez

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 #1: All comments have been addressed

Reviewer #3: (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: Yes

Reviewer #3: Partly

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

Reviewer #1: Yes

Reviewer #3: Yes

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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 #3: Yes

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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 #3: Yes

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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: There are no issues to be addressed. My opinion is that this paper should be accepted for publication without further corrections.

Reviewer #3: Physician Exhaustion and Work Engagement During the COVID-19 Pandemic: A

Longitudinal Survey into the Role of Resources and Support Interventions

Based on the Job Demands-Resources theory, this longitudinal study investigated how monthly fluctuations in job demands and job and personal resources relate to exhaustion and work engagement and how support interventions are associated with these outcomes over time.

The hypotheses raised were that monthly workload was positively associated with monthly exhaustion (Hypothesis 1), and that monthly work resources and personal resources were positively associated with monthly work engagement (Hypothesis 2a and 2b). Finally, the authors hypothesized that monthly work and personal resources moderate the relationship between monthly workload and exhaustion in such a way that the relationship was weaker in months when physicians had more resources (Hypothesis 3a and 3b).

This is an interesting study, with important results and that adds to what already exists in the literature on this topic.

The authors included 378 medical specialists and residents in the analysis and obtained a good response rate (79.08%).

The authors said they used validated questionnaires to assess job demands (i.e., workload), job resources (e.g., job control), personal resources (e.g., psychological capital), emotional exhaustion, and work engagement. However, they chose to use only part of these questionnaires and, for example, the questionnaire that measures Burnout was not used. This is a major limitation of the study and I would like the authors to explain why this choice, if this is validated, because it put your results at risk.

Burnout is widely described in its tridimensionality: (1) emotional exhaustion, (2) depersonalization and (3) personal accomplishment. The emotional exhaustion subscale (nine items) assesses feelings of being emotionally overextended and exhausted by work. The MBI is a 22-item questionnaire that has shown to be reproducible and valid . The MBI evaluates three domains of burnout.

“Emotional exhaustion was measured with 3 items from the Dutch version of the Maslach Burnout Inventory-General Survey. An example item is: ‘I feel mentally drained from my work.’”

According to the authors, the emotional exhaustion burnout dimension was measured with 3 items from the Dutch version of the Maslach Burnout Inventory-General Survey. Why did the authors assess separately and not use, as usual, the complete questionnaire to assess Burnout? Personally, I've never seen it used separately. Can the authors explain whether this is validated? Better to put in the limitation of the study that Burnout was not measured as well as the others questionnaires.

“Work engagement was measured with 3 items from the Utrecht Work Engagement

Scale.”

Work engagement is considered the core factor that affects various outcomes at the organizational and individual levels including absenteeism, turnover rate, profitability, and productivity.

Work engagement was assessed by the 9-item Utrecht Work Engagement Scale (UWES-9). The UWES-9 was hypothesized to measure work engagement in three dimensions: vigor (3 items), dedication (3 items) and absorption (3 items). The items are scored on a 7-point Likert scale ranging from 0 (never) to 6 (every day).

“We used 4 items from the State-Trait Anxiety Inventory, and 2 additional items from the State-Trait Inventory for Cognitive and Somatic Anxiety”.

A common measure of state and trait anxiety, the State-Trait Anxiety Inventory is used extensively in psychological research. The STAI consists of two identical 20-item subscales: one measuring state anxiety and the other measuring trait anxiety. For the state scale, individuals are asked to rate their anxiety "in the moment" and for the trait scale, individuals are asked to rate their anxiety "in general".

According to your results, “workload was associated with exhaustion. All works resources, as well as personal resources, psychological capital and self-judgment were associated with work engagement”. This is an important result, a protective factor for Burnout and moral distress. I believe it can be better discussed, a proposal for better engagement and prevention of moral stress.

Job and personal resources can safeguard work engagement and mitigate the risk of emotional exhaustion. Also mitigate a risk of moral distress, according to literature. The literature shows a clear association between Burnout and moral distress. Although it is not the scope of this study, the authors could discuss its results (such as Work and personal resources) as prevention of moral distress as well. See the study by Fumis et al., 2017, for example.

Severe burnout syndrome is present in all critical care providers. A positive relationship was found between burnout and moral distress, and after regression analysis, moral distress was independently associated with burnout. (Fumis et al. Ann. Intensive Care (2017) 7:71).

“Our results reinforce the importance of professional interventions at the individual level in the fight against medical burnout”. Did the authors think of any suggestions? In view of the high prevalence of burnout among intensivists and, especially, after the pandemic, I believe that the authors can highlight some suggestions for greater engagement as a force to prevent burnout.

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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 #3: No

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[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.

Physician Exhaustion and Work Engagement During the COVID-19 Pandemic: A Longitudinal Survey into the Role of Resources and Support Interventions

PONE-D-22-07749R2

Dear Dr. Solms,

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,

Juan A López-Rodríguez

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 #3: All comments have been addressed

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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: Yes

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #3: 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 #3: Yes

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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 #3: Yes

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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: It is not necessary to make any further corrections. I suggest that the paper be accepted for publication.

Reviewer #3: Thanks for the authors have addressed all comments and the manuscript is now acceptable for publication.

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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 #3: No

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