PONE-D-24-54289How patients experience nurse-doctor collaborative care at specialist clinics: A qualitative studyPLOS ONE

Dear Dr. Foo,

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:

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

Please submit your revised manuscript by Mar 12 2025 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,

Mohd Ismail Ibrahim, MCom.Med

Academic Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

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

2. Thank you for stating the following financial disclosure:  [The Lee Foundation, Singapore]. At this time, please address the following queries:

a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c) If any authors received a salary from any of your funders, please state which authors and which funders.

d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

3. In this instance it seems there may be acceptable restrictions in place that prevent the public sharing of your minimal data. However, in line with our goal of ensuring long-term data availability to all interested researchers, PLOS’ Data Policy states that authors cannot be the sole named individuals responsible for ensuring data access (http://journals.plos.org/plosone/s/data-availability#loc-acceptable-data-sharing-methods).

Data requests to a non-author institutional point of contact, such as a data access or ethics committee, helps guarantee long term stability and availability of data. Providing interested researchers with a durable point of contact ensures data will be accessible even if an author changes email addresses, institutions, or becomes unavailable to answer requests.

Before we proceed with your manuscript, please also provide non-author contact information (phone/email/hyperlink) for a data access committee, ethics committee, or other institutional body to which data requests may be sent. If no institutional body is available to respond to requests for your minimal data, please consider if there any institutional representatives who did not collaborate in the study, and are not listed as authors on the manuscript, who would be able to hold the data and respond to external requests for data access? If so, please provide their contact information (i.e., email address). Please also provide details on how you will ensure persistent or long-term data storage and availability.

4. 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.

Additional Editor Comments (if provided):

[Note: HTML markup is below. Please do not edit.]

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

Reviewer #3: Yes

**********

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

Reviewer #1: Yes

Reviewer #2: N/A

Reviewer #3: N/A

**********

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

Reviewer #3: Yes

**********

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

Reviewer #3: 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: I appreciate your work and enjoyed reviewing it. I have a couple of comments on the methodology section:

1. Please provide any specific reference on how you decided that a sample of 27 with a response of 12 is enough for generating valid results of your qualitative research work.

2. How was an agreement reached to establish consensus on the themes among the authors?

Reviewer #2: Peer Review:

Study Overview, Abstract and Introduction:

The study under review explores how patients experience nurse-doctor collaborative care in specialist clinics, addressing a significant and evolving care model relevant to both primary and specialist medical communities. It qualifies as original research, offering meaningful contributions to the literature on interprofessional collaboration (IPC). The study's strengths include a robust background context, thoughtful consideration of reflexivity, and efforts to reduce extraneous subjectivity in its methodology.

The abstract effectively outlines the study’s major themes, highlights its focus on thematic analysis, and summarizes the main findings, all while adhering to word count requirements. However, refinement in phrasing is recommended. For instance, while the abstract identifies major points of the study, the statement “major themes within article and guidelines for thematic analysis” could be more explicitly tied to specific findings to improve clarity and impact.

Strengths of the Introduction include:

Clear Structure: The introduction provides a well-organized rationale for the study, establishing the relevance and importance of IPC care models in both literature and clinical practice.

Contextual Relevance: The section integrates prior research on patient experience (PX), trust in healthcare systems, and opposing perspectives on the IPC care model, offering a balanced context for the study.

Research Aim: The research aim is clearly articulated, providing readers with a direct understanding of the study’s purpose and objectives.

Balanced Perspectives: The introduction acknowledges opposing viewpoints regarding PX in IPC care, adding depth and rigor to the discussion.

Critique of the Introduction include:

Ambiguity in Sentence Structure: The sentence, “While some patients appreciated the holistic support offered by the nurse-doctor collaborative care model, patients whose disease status was still active seemed eager to control their symptoms through drug treatment managed by the doctor,” lacks clarity. It implies a dichotomy in patient experiences but does not clearly connect these sentiments to broader themes or findings. Contextualizing in discussion or rephrasing is recommended to ensure the point is well-articulated and supports the study’s framework.

Conclusion Statement: The concluding assertion, “Interprofessional collaboration enhances patient care in specialist clinics,” reads more as an opinion rather than a conclusion supported by evidence from the analysis. Consider revising this statement to objectively reflect specific findings or themes emerging from the study.

Specific Recommendations:

-Clarify the sentence about patient perspectives to ensure it aligns with the study's analytical framework and contributes to the broader discussion of PX in IPC care.

1. Original Research

This study demonstrates originality by investigating patient experiences within the context of interprofessional collaborative nurse-doctor care models in specialist clinics. This is a topic that provides valuable insights into this evolving area of healthcare delivery.

2. Novelty of Results

While there are opportunities to reference the study as amore novel contribution to literature, the presented work builds upon existing research on interprofessional collaboration in primary care settings. However, the study's focus on specialist contexts is less extensively explored in the literature. This suggests a novel contribution to the field by extending current understanding to a relatively understudied area

Specific recommendations:

More explicitly state the novelty of the research in areas of application for reader to understand or in its role of solely being explored in specialty settings.

3. Technical Standards and Methodology

The study appropriately utilized Braun and Clarke's reflexive thematic analysis, demonstrating a clear understanding of reflexivity within the methodological framework. Coding and theme development were well-described. While the rationale for the shift from three initial themes to two final themes with sub-themes was partially explained, further clarification on this decision-making process is recommended. Acknowledging the researchers' own reflexivity provides valuable contextual information that may have influenced data interpretation.

Specific recommendations for methodology that require further attention:

The inclusion of specialist clinics engaging in interprofessional collaboration (IPC) practices is valuable, however, recommend a more detailed description/rationale of the criteria used for specialty clinic selection.

The statement regarding SingHealth Central Institutional Review Board exemption should be clarified to include what specific data categorization applies to this.

The definition of "inactive" in the context of disease state should be further defined for period disease inactivity (e.g., no flare-ups within the past 12 months).

The study should provide more specific details on how the InterPACT framework was applied to categorize IPC within the context of the study's focus and its usage by healthcare professionals (HCPs) in self-assessment. The statement regarding the researchers' efforts to be unobtrusive in patient interactions should be further elaborated upon to clarify the extent of their observation during patient encounters.

Consistent use of grammar tense: Recommend consistent use of past tense throughout. The statement regarding the overlap between the first two themes requires rephrasing for improved clarity. In acknowledging the potential influence of researcher positionality on data interpretation, the use of "may have" instead of definitive statements would be more appropriate (e.g., "Non-HCP members' interpretations of the data may have been based on their positionalities…")."

4. Conclusions and Data Support

The study effectively delineated themes for reporting results. Conclusion was concise with mention of pertinent positives from analysis of data.

The following are specific recommendations:

-Study “strengths” section: Currently there is not a section referencing study strengths. The article could be strengthened by a more explicit discussion of study strengths. The acknowledgment of reflexivity in the research process is a notable strength.

-The choice of methodology, including the maximum variation selection strategy, requires a more explicit discussion of its strengths and limitations.

-Recommend the article acknowledge the potential limitations of reflexivity in the research process.

-Recommend the use of the term "research story" to describe data analysis be replaced with more scientifically rigorous terminology.

There is not a clear definition of "Patient Experience" and the criteria used to differentiate between "positive" and "negative" patient experiences.

-Caution and recommendation to restate use of descriptive terminology, such as "eager" or "reticent," to infer patient motivations to be carefully considered and contextualized to avoid potential misinterpretations.

-Lines 408 - 414 - Re-state terms like "the patient," "these patients," and "this group of patients," making it difficult to understand which specific demographic is being referred to. More consistent and precise descriptions of patient demographics are crucial to avoid misinterpretations.

-Line 422 - The use of the term "older patients" without defining the age threshold should be avoided.

-Line 431 - The statement regarding potential reticence among patients of Asian ethnicity should be further contextualized with specific references to relevant cultural norms within the medical community, if this is applicable to meaning.

-Line 443 - the phrase "Getting patients ready..." should be rephrased or contextualized further, as the definition of "patient preparedness" is not clearly defined in the article.

5. Overall Presentation

Overall, the article is presented in an intelligible manner with a logical sequence and structure that makes it easy to follow. Aforementioned recommendations to avoid subjectivity and for appropriateness in scientific presentation would be advised

6. Ethical Standards and Integrity

The research adheres to ethical standards, as demonstrated by the study design and intervention protocols. Participant consent was appropriately documented, and the use of pseudonyms to protect confidentiality was well explained.

-Further clarification is needed regarding the statement: “SingHealth Central Institutional Review Board provided review exemption for this study (CIRB Ref: 2023/2548).” Specifically, the authors should clarify whether this exemption impacted participant consent or any other ethical considerations related to the study.

7. Reporting Guidelines and Data Availability

Appendix included guidelines and interview tools. There was adherence to Braun and Clarke’s Reflexive Thematic Analysis Reporting Guidelines (RTARG).

Final Assessment

This is a novel study that has relevance in primary care and specialist medical communities. With revisions, as recommended, would support publication within PLOS.

Reviewer #3: Re: How patients experience nurse-doctor collaborative care at specialist clinics: A

qualitative study

Thank you for having me to review this paper.

Here’s some comments on the paper:

- Start line 65: I don’t see the necessary to abbreviate the “patient experience” into PX.

- Lines 73-74: “However, definitive association between IPC and positive patient outcomes have not been demonstrated in systematic reviews”: I think this sentence is only proper when this current study then conducted a systematic review rather than a qualitative study. Consider to paraphrase or remove “…in systematic review”

- Please move Table 1 to be cited somewhere in the results (analysis) section instead in method

- I did not see the reporting guidelines of this paper. Consider to look at Equator Network https://www.equator-network.org/) or COREQ (mentioned in the Equator as well). In COREQ, for example, the authors need to explain the credentials of the researchers and their experience/training in qualitative research methods. It is including who conducted the interviews and data analysis (not only their initials, but the background and their experience in conducting a qualitative studies). Even COREQ mention about the gender of the interviewer and data analysts.

- Line 172: “….averaging 5500 words” please consider to move some parts of the method section into the analysis (as commonly known as results). I found some duplication (such as the mention of Table 1” both in the method and analysis. Therefore, the authors need to consider which parts are methods, and which parts more suitable for the results section.

- Line 179: “…transcribed verbatim by QC” is there any supporting device for the transcribing process?

- Lines 190-192: Also consider to move this part to analysis (results)

- The process of the data analysis has been described clearly and in detail.

- How about the trustworthiness of the data? It should be described somewhere in the method section.

- Start from line 272: Please delete all of the name of the participants for the confidentiality, and consider to use a particular code, i.e. P1 for Participant 1.

- I have no further comment for the discussion part.

Thank you

**********

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.

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:  Nailah Abdulbaaqee MD, MPH

Reviewer #3: 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.

How patients experience nurse-doctor collaborative care at specialist clinics: A qualitative study

PONE-D-24-54289R1

Dear Dr. Foo,

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,

Mohd Ismail Ibrahim, MCom.Med

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: No

**********

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: .

Reviewer #2: All recommendations have been updated and are satisfactory. While not all data has been made public, a specified explanation for restricted data access is provided in accordance with the PLOS Data Policy. I support the acceptance of this article for publication.

**********

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:  Nailah Abdulbaaqee MD, MPH

**********