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PONE-D-23-16186From moral distress to resilient ethical climate among general practitioners: fostering awareness. A qualitative pilot studyPLOS ONE

Dear Dr. Saerens, 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.

1.  Kindly provide a  brief and more relevant justification for focusing on primary care physicians in your study. 2.  Kindly re-evaluate your coding methodology and the resulting themes. Perhaps consider  re-arranging your findings in traditional themes and sub-themes, and then correlate these with your mind-map analysis. Perhaps as a form of method triangulation?3. In your methods section briefly elaborate on issues such as validity, including external validity of the study, attempts to achieve data saturation (or why data saturation could not be achieved). Also briefly describe reliability and trustworthiness of the study data and reflexivity.4. Then, kindly summarize the strengths and limitations of the study in the sections on " Study limitations".5. In your Discussion section, kindly elaborate further to distinguish and better characterize 'moral resilience' and 'moral distress' with particular reference to the findings from this study, in the context of other studies in the literature.6. Kindly provide relevant examples of moral distress among physicians/ primary care physicians as opposed to nursing contexts.7. Kindly address all other issues , comments, and recommendations by the peer-reviewers.

Please submit your revised manuscript by Dec 14 2023 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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We look forward to receiving your revised manuscript.

Kind regards,

Sylvester Chidi Chima, M.D., L.L.M, LLD

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: N/A

Reviewer #2: N/A

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

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

Reviewer #1: Yes

Reviewer #2: No

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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: Dear authors,

Thank you very much for the opportunity to read your paper. This article has the potential to

make a valuable contribution to such an important topic. It was well structured and provided

valuable information on a current and essential subject. However, I have some suggestions.

Introduction

p.4, lines 47-48

"The EC then, logically, is a major contextual determinant in the development of a health professional's MD." How? Can we, authors give some examples?

P.4, lines 57-58

"Consequently, MD has been linked to individual effects (emotional, physical, spiritual and behavioural), care quality indicators, burnout and job leave intentions (8-16)."

Cited most references seem to be related to nursing contexts. The mechanisms or experiences regarding burnout and job leave intention due to moral distress between physicians and nurses can be different. Please describe or add unique experiences among physicians based on previous studies.

p.5, lines 61-64

As the authors described 'moral resilience' on page 5, lines 61-64, its concept has been more highlighted nowadays. However, readers can be curious about the backgrounds and recent studies on moral resilience among healthcare professionals or in the context of healthcare settings. Furthermore, moral resilience is one of the main concepts of the present research. Thus, please refer to them.

Methods

Please describe the validity of the present study, like rigour or trustworthiness.

Results

P21, lines 382-385

"Leisure time, hobbies, getting enough sleep or using substances are named as strategies to reinforce carrying capacity: We take a drink in the evening to flush out the day. I think that's a normal way of doing things."(D8)"

How does this statement support the description of moral resilience? I wonder what the differences are between the concepts of moral resilience and stress management or coping skills to deal with job stress. They must be distinguished.

P20, lines 369-405

Especially for those descriptions on page 20, lines 369-405, based on the citation and descriptions of moral resilience in the present manuscript, several readers can beg to differ from the authors' interpretations of moral resilience. I recommend that the authors should reconsider those interpretations of moral resilience or delete these descriptions.

Discussion

In previous literature, the concepts of professional autonomy and moral courage are the essential factors influencing moral distress. For instance, limited professional autonomy can be one of the organisational constraints at a macro level, and lack of moral courage can be related to how to deal with ethical situations or cope with moral distress. However, it seems that they would not be explored in the present research. I am curious about why and how the authors consider such a gap between the present study and the previous study. Please describe them in the discussion section.

Reviewer #2: Thank you for the opportunity to review this interesting paper on moral distress and ethical climate among primary care physicians in Belgium.

I think the topic is interesting, particularly in the way we manage healthcare delivery after the pandemic started. In the present form, the manuscript is not ready for publication. There are some further clarifications needed for some terms used, conceptualization, methods, findings and implications.

Firstly, I feel you need a better justification for interviewing primary care physicians about this topic.

Secondly, I find the results confusing – mainly because there are too many concepts and sub-themes that seem to overlap on another. The results seem to be presented as a list of codes arranged in mind map themes; it gives the impression the data have not been synthesized, lacking in coherent narrative and context. I think it could be presented in a better way.

There are some limitations to your study including external validity and you need to write something on reflexivity.

Lastly there is an important part in the discussion about what “resilience” means; it can easily be interpreted as “gaslighting”. You can easily blame the person for their moral distress without considering what the organization and health care policies can change to reduce it.

I think a revision can be done easily - the main piece of work is to take another look at your coding and try to present a coherent story. I find the mind map unnecessarily complicated - a simple chart presenting the main themes and subthemes should suffice.

Please see attached a full report.

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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: Yes: Dr Richard Ma

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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.]

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Attachments

Attachment

Submitted filename: Thank you for the opportunity to review this interesting paper on moral distress and ethical climate among primary care physicians in Belgium.docx

PONE-D-23-16186R1From moral distress to resilient ethical climate among general practitioners: fostering awareness. A qualitative pilot studyPLOS ONE

Dear Dr. Saerens,

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.

1. Please check and correct all new comments/queries raised by Reviewer 2 as detailed below:

 "Line 240 - i think you mean "venting" rather than "ventilating". Same in line 475, you use "venting" later in that paragraph.

Line 270 - table 2 - instead of "job leave" do you mean resignation?

Line 446 - instead of "qualitative care" do you mean quality of care?

Line 625 - I think "exploratory" might be a better word."

2. Kindly check and correct any other typographical and grammatical errors in your revised manuscript before resubmission.

Please submit your revised manuscript by Jun 29 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,

Sylvester Chidi Chima, M.D., L.L.M, LLD.

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.

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

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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: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: N/A

**********

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

**********

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 your effort. This revised manuscript will contribute to the healthcare academic field.

Reviewer #2: Thank you for your resubmission and rebuttal. I am satisfied the authors have addressed reviewers' comments comprehensively. I think the manuscript is much clearer. Congratulations.

I only have some minor comments:

Line 240 - i think you mean "venting" rather than "ventilating". Same in line 475, you use "venting" later in that paragraph.

Line 270 - table 2 - instead of "job leave" do you mean resignation?

Line 446 - instead of "qualitative care" do you mean quality of care?

Line 625 - I think "exploratory" might be a better word.

**********

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: Dr Richard Ma

**********

[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.

From moral distress to resilient ethical climate among general practitioners: fostering awareness. A qualitative pilot study

PONE-D-23-16186R2

Dear Dr. Saerens,

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.

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Kind regards,

Sylvester Chidi Chima, M.D., L.L.M.

Academic Editor

PLOS ONE