PONE-D-24-04703Physiotherapy Under Pressure: A Cross-Sectional Study on The Interplay Between Perfectionism, Moral Injury, and BurnoutPLOS ONE

Dear Dr. Shanmugam,

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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We look forward to receiving your revised manuscript.

Kind regards,

Renato S. Melo, 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: Yes

Reviewer #2: Partly

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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: Abstract

- What is the period analyzed?

- What statistical tests were used?

Text

-The use of the Bayeux Tapestry to exemplify perfectionism did not seem within the context for the work in introduction

The introduction is too long and would need to be succinctly rewritten with the main points.

It is important to bring concepts and approaches directly to the profession As this is a research article on a specific population,

Some information is important, such as the means of inviting participants, the approach, the length of time in the profession considered.

The initial part of the discussion presents results.

Some questions could be relevant and be in the discussion: - how does the profession of physiotherapist differ from its equivalents in the United Kingdom? - what are the relevant laws that could support professional physiotherapists? - how do professional councils deal with this, is there any support for physiotherapists?

Reviewer #2: I would like to extend my gratitude to the authors for undertaking this significant endeavor and commend their valuable contributions to physical therapy research.

Your study addresses an important and timely issue within the field of physiotherapy, exploring the intricate relationships between perfectionism, moral injury, and burnout. The focus on physiotherapists in the UK adds valuable context to the existing literature. The discussions of your findings, especially in context for the NHS has practical real-world relevance. I found your analogy to the "Bayeux Tapestry" to be a creative analogy to tie the topic of perfectionism together in physical therapy.

Overall the manuscript starts with a well structured abstract gives a clear overview of the study objectives, methods, and key findings. The introduction and subsequent sections are comprehensive but there are several areas where improvements can be made for clarity, cohesion and rigor.

Bayeux Tapestry Analogy: The analogy is creative, but the transition between the history of the artifact and the topic of perfectionism could be smoother.

Moral Injury and Burnout sections: These sections are informative and lay the groundwork for the context, but there needs to be a more clear link between the constructs and the physiotherapy profession.

Sampling Method: The use of convenience sampling may limit the generalizability of your findings.

Missing Data: The claim of having no missing data is unusual for a study of this scale and nature. This claim warrants further explanation as missing data is a common issue in survey research

Exclusion Criteria: The lack of specified exclusion criteria may raise concerns about the validity and clarity of your findings.

It is essential for the authors to consider and address the reviewer's feedback in order to improve the clarity, cohesion, and rigor of the manuscript.

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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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Reviewer #1: No

Reviewer #2: Yes: Jennifer A Bent

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Attachments

Attachment

Submitted filename: Considerations.doc

Attachment

Submitted filename: PONE-D-24-04703 Reviewer Feedback 3.15.24 Marked Up PDF.pdf

PONE-D-24-04703R1Physiotherapy Under Pressure: A Cross-Sectional Study on The Interplay Between Perfectionism, Moral Injury, and BurnoutPLOS ONE

Dear Dr. Shanmugam,

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 Jul 08 2024 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,

Renato S. Melo, PhD

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 #2: (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 #2: (No Response)

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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

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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: 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: Dear authors,

it appears that the revisions were considered. The suggestion is that the conclusion could be more succinct.

Reviewer #2: The rewrite is excellent! The introduction flows beautifully, the models are clearly explained and contrasted, and the focus on SPP vs. OPP is well-justified. The sections on moral injury and burnout are much easier to read and understand. Overall, the paper is well-researched, informative, and engaging. Well done!

I only have a few small suggestions that would help reinforce the metaphor to reinforce the theme of precision and complexity of the Bayeux Tapestry that is the central challenge faced by physiotherapists.

They are as follows:

Lines 77-86

Consider Integrating the Bayeux Tapestry into this closing paragraph to help establish a direct comparison between the theme of precision and complexity and the therapist's work.

"This poses a challenge similarly to the embroiders of the Bayeux Tapestry, who meticulously crafted each threat to create a flawless masterpieces. Like the tapestry, physiotherapist must carefully consider numerous factors, meticulously weaving together individual patients needs with the intricate patterns of organizational demands. They are tasked with harmonizing these diverse needs and standards, striving for a tapestry of care that is both comprehensive and precise. However, this intricate balancing act, much like the creation of the tapestry, may introduce elements of unpredictability, potentially leading to discrepancies among the therapist, patient, and the organization, which could ultimately compromise the practioner’s ability to provide optimal care."

Line 90-92 Consider revising " Strict adherence to SOPs, reminiscent of the painstaking precision required to create the Bayeux Tapestry, can leave healthcare professionals vulnerable to heightened exhaustion and cognitive weariness as they strive for perfection

Lines 441-442 Consider adding back a subtle connection and reinforce the message:

This high prevalence of burnout, akin to a fraying thread in the meticulously woven tapestry of healthcare, has the potential to impact not only the well-being of physiotherapy professionals but also poses risks to patient care, staff dynamics, and the broader society.

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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 #2: Yes: Jennifer A Bent

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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.

Attachments

Attachment

Submitted filename: PONE-D-24-04703 Reviewer Feedback 3.15.24 Marked Up PDF.pdf

Physiotherapy Under Pressure: A Cross-Sectional Study on The Interplay Between Perfectionism, Moral Injury, and Burnout

PONE-D-24-04703R2

Dear Dr. Shanmugam,

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 will be generated when your article is formally accepted. Please note, if your institution has a publishing partnership with PLOS and your article meets the relevant criteria, all or part of your publication costs will be covered. Please make sure your user information is up-to-date by logging into Editorial Manager at Editorial Manager® and clicking the ‘Update My Information' link at the top of the page. If you have any questions relating to publication charges, 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,

Renato S. Melo, 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 #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 #2: Yes

**********

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

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: Dear Authors:

Your revised manuscript is a significant improvement and a testament to the tremendous work and dedication you have all put into it. The revised introduction and sections on alternative models is excellent. The moral injury and burnout sections along with the Shirom Melamed Burnout Measure helps to highlight the importance of assessing and addressing burnout in the the profession. Finally, the refined metaphors, carefully woven within your own tapestry now beautifully reinforces the central theme.

Overall, the changes you have implemented have greatly elevated this piece which makes it a valuable contribution to field. You have satisfied my concerns and I have no other comments other than to offer my congratulations and admiration for a job well done!

Cheers to you all! Enjoy a drink together!

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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 #2: Yes: Jennifer A. Bent

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