PONE-D-23-05087

Continuing professional development opportunities for Australian endorsed for scheduled medicines podiatrists - what’s out there and is it accessible, relevant, and meaningful? A cross-sectional survey.

PLOS ONE

Dear Dr. Martin,

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 address all comments raised by both reviewers.
• Please review the CHERRIES reporting format as identified by reviewer two and incorporate this into your data reporting.
• Of specific note, both reviewers identified issues with how the data is currently reported and the construction of the discussion. These points will require careful consideration in your review for the manuscript to be considered for publication.
• The discussion will need to be developed in a concise manner as both reviewers indicated the general nature and length of the discussion

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Matthew Carroll, PhD., MEdL., MPod., BHSc, SFHEA

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: Partly

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

Reviewer #1: Yes

Reviewer #2: No

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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: #General comments

- I thank the authors for their efforts in conducting this research and preparing this manuscript.

- The authors present a cross-sectional survey of podiatry prescribers in Australia. Their aim is to understand how this population are utilising CPD, and their perceptions on accessibility, relevance, and meaningfulness. Appropriate ethics approval was obtained. I note that a pre-print has been published.

- The overall conceptual framework is clear and the methodology generally matches the research question. While I believe some aspects of the methodology could be improved, the final results appear to be novel and should be useful for informing CPD development for podiatry prescribers in Australia. However, as it is currently written, the findings are interpreted mainly for the Australian context, and more could be done to connect the results with broader literature and be more appealing to the international readership of PLOS ONE. I provide more detailed comments below:

#Introduction/background

- Clearly introduces the topic, the importance of non-medical prescribing, and the context of this in Australia.

- Unless I missed it, I do not believe ESM is written out in full next to the first time the abbreviation is used.

#Methods

- Study design is clear.

- Participants and recruitment is appropriate.

- The survey design process would have benefited from additional features of high-quality survey development. For example, refer to Artino et al 2014 AMEE Guide 87. Further, I would have liked to see additional use of theory to guide the development of the questions, although the authors refer to the CPDIS, after looking at their survey questions it is unclear to me how the CPDIS was used. This is important as linkage to theory would allow the authors to better discuss their findings relevant to the large body of CPD literature. I appreciate that it is now too late to go back to change the survey design process, however the authors could consider whether they could better describe some of the steps they did take with a view of convincing the reader of the quality of the survey tool, and also consider how this could be discussed in the limitations.

- Data analysis, the analysis methods for the qualitative data is not clear to me. I would have liked reference to a specific qualitative analysis approach so that it can be understood how the analysis actually took place.

#Results

- The results text reports career length using mean, but Table 1 reports as median, consider if this should be made consistent.

- Is it possible to report the n of respondents for each state together with the total n of ESM in the state? I suspect this data should be available and would provide context for interpreting the numbers.

- I am concerned that some participants undertook <10 hrs of CPD given in the introduction you’ve stated that at least 10 hrs is a requirement for registration.

- Consider if it would be more useful to provide all 5-pts of the 5-pt Likert scale in your Figures. I believe you would have space. I would also find it helpful is the exact n of responses for each category was also included on the figure. This can be easily overlayed onto the bar chart.

- In the results you use the word ‘theme’ several times. To me, this implies the use of thematic analysis, which I do not believe you have done. I suggest using another word if you did not actually use a theme-generating method.

#Discussion/Conclusion

- There is an absence of reference to other literature in the discussion. I would like to see the results described relative to other studies looking at essentially ‘satisfaction’ with CPD. This could be in other countries, other professions, or other topics. I would like to know whether the findings are unique to pod ESM CPD, or whether this is a common problem of CPD in general.

- There is a very strong Australian podiatry focus in the discussion which would be better suited to a podiatry specific journal. I’d like to see greater consideration of how providing CPD is considered by other professions and in other jurisdictions to engage a wider readership. The underlying concept appears to be CPD access in extended scope areas.

- In one paragraph you refer to a “dearth of access to mentors”. This does not appear consistent with the results showing strong use of mentors, and I do not believe you capture data that would allow you to make any claim about access to mentors.

#Writing

- Overall a clear writing style. There is a fair bit of content in the manuscript owing the range of ideas looked at in the survey, which did make it tricky to follow at times. I believe with some careful consideration of what content is essential to the overall message from the manuscript, as well as editing, the word count for the existing content could be reduced by 15-20%, particularly in the discussion. This would allow for inclusion of some of my suggestions without making the manuscript too long.

Reviewer #2: Introduction

Relevant concepts er discussed to develop the rationale. One concept introduced in the last section of the discussion but not developed in the introduction is the relevance of the Kirkpatrick model. I have made further comments on this in the discussion section

Data collection

Can you please refer to the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2004 Sep 29;6(3):e34. doi: 10.2196/jmir.6.3.e34. Erratum in: doi:10.2196/jmir.2042. PMID: 15471760; PMCID: PMC1550605.

Please complete the CHERRIES form and include it as a supplementary file

There are statements that require clarity in this section that will be aided by the completion and reporting of your results in alignment with CHERRIES. For example, you state “ Email reminders were sent to targeted participants to maximise completion rates” you will need to clarify how many and to what groups they were sent. You also note there was no time stamp cut-off period was implemented for participants to complete the survey. I assume that each participant had 5 weeks to complete the survey from the date they opened it? As opposed to the survey closing for all participants after 5 weeks.

Data analysis

Please report all Likert-based data in a Table as median with IQR. You have compacted the results into three-item stacked bar charts but this provides no representation of the mean or spread of data. This comment applies to (Q17, 24, 25). Could you also consider a between-group analysis (ESM podiatrists vs Podiatric surgeons) as this would add some richness to the data?

What methods were used to analyse open-ended responses

Results

Overall the results lack clarity and consistency of reporting. Please review all data for consistency and appropriateness with particular attention to measures of central tendency (mean vs median)

You will also need to add some of the detail to clarify the reporting of the survey results into the results section. Currently, it is very unclear surrounding detail for example incomplete responses vs non-responses. Completion of the CHERRIES form will aid this process.

In Figures 1 and 4 you present data based on agree, neutral or disagree yet your questions used a 5-point Likert scale. Your methods provide no information surrounding the handling of this data.

You state respondents were representative of all states and territories except the ACT and Tasmania. This should be reworded to responses were received from all states.

Discussion

Much of the discussion is a repeat of the results. Consequently, it is unclear what the most significant and important findings are. The discussion tries to encompass all results rather than narrowing down to the most important or interesting findings. Following numerous read-throughs it is still unclear what the most important results were. The discussion could be written more concisely around three or four major findings as currently, the discussion is very lengthy.

More consideration of other work/research that has been published around CPD and podiatry is required. There is no discussion or comparison to other countries.

The discussion refers to the Kirkpatrick model specifically shifting CPD evaluation towards levels 3 and 4. This paragraph lacks underpinning, the readers will have no knowledge unless you introduce the model and what levels 3 and 4 would represent in terms of the ESM CPD framework. Consider how you will introduce the readers to the Kirkpatrick model, you may need to do this in the introduction.

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Reviewer #1: Yes: Jonathan Foo

Reviewer #2: No

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Continuing professional development opportunities for Australian endorsed for scheduled medicines podiatrists - what’s out there and is it accessible, relevant, and meaningful? A cross-sectional survey.

PONE-D-23-05087R1

Dear Dr. Martin,

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.

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Kind regards,

Matthew Carroll, PhD., MEdL., MPod., BHSc., SFHEA

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Please note reviewer 1 has made some comments for consideration of the authorship team. However you are not required to addresss any of these comments.

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: (No Response)

Reviewer #2: 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 #2: (No Response)

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

Reviewer #1: Yes

Reviewer #2: (No Response)

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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 #2: (No Response)

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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 #2: (No Response)

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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: Thank you for the revisions made. I can see that you’ve taken on board the suggestions and made significant improvements to this manuscript. In particular, the methods section is now clear.

I would like to encourage you to again consider refining your writing and how you craft the narrative of your manuscript. As previously mentioned, there are a lot of ideas presented which makes it difficult to follow. While it is much improved, I believe it can be improved further. Firstly, at a writing craft level, this includes considering how you structure your sentences to aid alignment between sections and logical flow within sections. There are a number of peripheral sentences that could be removed or combined without affecting the overall ideas of the study, and only serve to distract the reader. Secondly, at a conceptual level, this can be done through thinking critically about other literature and your results, in particular considering how to present your findings such that they are most useful to others who want to continue improving CPD. I provide a few specific examples below:

Line 433 – as a clinician, I am not surprised at the lack of goal setting and suggest that the rate you reported may be very similar to general health professionals. While you suggest a number of reasons why this may be happening, it would be helpful for you to link your suggestions to literature, considering whether anyone else has specifically researched the topic of lack of goal setting in CPD.

Line 438 – your claim here that CPD activity is selected based on accessibility does not appear to match the information reported in the results. “The three most common reasons participants undertook their selected CPD activity was a clinical situation or interaction they had experienced (n = 13), it pertained to an area of interest (n = 13), or the ESM CPD activity was accessible (n = 13).” To me, this makes accessibility equal to a particular learning need (i.e. experience) and interest, but in your discussion you’ve neglected to mention these reasons. Please consider if you’ve overinterpreted results to fit your desired narrative, and whether this needs to be moderated somewhat. I also note that this same interpretation is made in the conclusion Line 516.

Line 445 – you state the evidence for CPD is mixed, but I would like to see a more critical appraisal of the literature related to your study. For example, Line 440 mentions that CPD was found to be not relevant or meaningful. How does this match with previous literature? Is the issue of relevance or meaningfulness unique to ESM CPD? Or is it an issue more broadly in CPD? This is critical as it informs how we think about improving the situation.

Line 490 – to better cater for the international readership, consider whether it is useful to specifically state that no responses were received from TAS and ACT. The state boundaries will mean little to anyone outside of Australia, and even as somebody in Australia I cannot make any real meaning from these sentences (i.e. what is the implication?) My suggestion is to either a) remove specific mention of states in the discussion and simply refer to the limitation that responses were not received from all jurisdictions, or b) make some effort to explain why it may be the case that no responses were received. Additionally, for the limitations paragraph, the writing would be easier to read if you signpost for each separate limitation. E.g. Firstly… Secondly… Thirdly…

Once again, congratulations on your work. I am satisfied with the revisions and am happy to defer to the editors decision regarding the final manuscript. I do not need to review this again.

Reviewer #2: (No Response)

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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: Yes: Jonathan Foo

Reviewer #2: Yes: Matthew R. Carroll

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