PONE-D-25-34423 The role of human factors in paramedics’ clinical judgement – A modified Delphi study PLOS ONE

Dear Dr. Poranen,

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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Congratulations, Our reviewers have returned favorable comments on your manuscript. The have made some recommendations that I agree will significantly improve your paper, and I am confident that we wil be able to move forward after the reviewer's concerns are addressed. I have included comments below.

Respectfully, David Wampler PhD

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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

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

Reviewer #1: 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: 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

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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: The authors continue their work amidst a deeply needed task: seeking to understand the significant factors that drive or hinder our paramedic colleagues in the field. If we can understand the highest-leverage issues, we’re more likely to serve as a positive force in medical direction, training, or administrative tasks.

Paper flowed well; I enjoyed reading it, and suspect others will also.

Please forgive attempts to note minor editing/formatting issues that would be the purview of the editor(s); I assume they’re quite busy and offer my observations as I see them.

Major comment(s):

Results, page 9 of manuscript, lines 220-226, also discussion, page 23, lines 481-492: (Bottom line up front, please add to strengths/limitations) One of the only criticisms I had about this excellent work pertains to selection bias/healthy volunteer effect/survivorship bias – the fact that the ‘expert’ participants were largely self-selected, and skewed (possibly?) older (acknowledging the requirement to have at least 5 years in EMS, and the fact that one had to have a bachelor’s degree to begin with) means there won’t be as many younger people available to participate – but perhaps more importantly, in Wald statistic fashion, we only know what was most important to 47-ish people willing to speak up about it. Those who left the profession earlier in the career, or those who elected not to enroll, there’s no reason not to think those people wouldn’t prove systematically different to the enrollees. All those words said, ultimately the work reveals themes deemed important by those who remained committed to the career and motivated enough to respond, allowing subsequent lines of inquiry.

General comment: Methods changed in the middle of the work – no adequate consensus manifested, so the threshold was (appropriately) “modified;” it goes like that sometimes. Just ensure the methods section adequately reflects that adjustment; currently it’s something of a surprise in the results section (though alluded to, somewhat, with mention of medians in lines 190-193).

Minor comment(s):

Introduction section, page 3 of manuscript, line 54: Consider Oxford comma following “under time pressure”

Introduction “ “, line 57: Consider comma after “social care services,” alternatively a semicolon, or nothing as so desired

Methods, page 7 of manuscript, line 168: (Feb 2024) seemed out of place – was this when the data was analyzed, or the version number of SPSS used was released? Recommend either “IBM SPSS Statistics for Windows, Version XX.0 (IBM Corp., Armonk, NY)” or swap to the specific release date in parentheticals… assuming of course that I’ve correctly parsed your intent

Discussion, page 21, lines 439-440: I would contend that the risks of violence against EMS personnel are well established (citations follow); while it’s not necessarily in the scope of the paper to drive the point of prevalent violence against our prehospital colleagues, I’d suggest we can move beyond stating the violence risks “may” be common, or merely a feeling – they're quite substantial, at least in places it’s been looked at.

Workplace violence prevention for paramedicine clinicians: Proposed U.S. bill addresses a data collection gap. (2023, April 18). Journal of Emergency Medical Services. https://www.jems.com/ems-management/legal-issues/workplace-violence-prevention-for-paramedicine-clinicians-proposed-u-s-bill-addresses-a-data-collection-gap/ (Salient reference therein: Maguire BJ, Al Amiry A, O’Neill BJ. Abstract 3278 – An examination of injuries and illnesses among paramedicine clinicians; using U.S. Department of Labor data to identify risks and compare risks to other occupational groups. American Public Health Association Conference; 2022; Boston, MA.)

Rahimi, M., Fallah Kharmandar, P., Aghababaeian, H., Sotoudeh, F., Afshari, A., & Hasani-Sharamin, P. (2020). Prevalence of workplace violence types against personnel of emergency medical services (EMS): A systematic review and meta-analysis. Health Promotion Perspectives, 10(1), 28–35. https://doi.org/10.15171/hpp.2020.06

McGuire, S. S., Gazley, B., Crowe, R. P., Bentley, M. A., O’Neil, C., & Koller, C. A. (2024). Workplace violence against emergency medical services (EMS): A prospective 12-month cohort study evaluating prevalence and risk factors within a large, multistate EMS agency. Prehospital Emergency Care. Advance online publication. https://doi.org/10.1080/10903127.2024.2411020

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Reviewer #1: Yes: Ian L Hudson, DO, MPH

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The role of human factors in paramedics’ clinical judgement – A modified Delphi study

PONE-D-25-34423R1

Dear Dr. Poranen,

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,

David Wampler

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Dr. Anna Poranen

Congratulations, our reviewers have indicated that your work is ready to move forward in the publication process.

I would like to personally thank you for your contribution to PLOS One!

Congrats,

David Wampler, PhD

Academic Editor

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

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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

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

Reviewer #1: 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: No

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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

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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: Overall: As before, an excellent study focused on the perceptions of the end-users, who ultimately do the work and face the uncertainty; understanding what weighs on their ability to execute professionally and remain resilient should concern every conscientious medical director and EMS administration.

Comments were thoughtfully considered and modifications implemented where authors deemed appropriate. Remaining points found are miniscule (and apologies if these were present before and I simply focused on other things):

Phrasing of the sentence in line 110-111, "Both types of units are mainly used for phone-based requests for care instructions by paramedics..." inscrutable to me, though I may simply be slow today. Unclear how a HEMS unit gets use for phone-based requests for care instructions by paramedics; are we discussing that both types of units are summoned for on-site care i.e., treat-and-release/no-load/patient initiated refusal of conveyance calls?

Line 140: "The literature review process is shown in S1 file." Recommend either: a) definite article before S1 i.e., "is shown in [the] S1 file," or b) drop 'file' i.e., "... is shown in S1." or c) spell it out "... is shown in Supplement 1 (S1)." It's small, but it was enough to pull me out of the flow.

Thanks for generating this meaningful work.

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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: Ian L. Hudson, DO, MPH

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