-->PONE-D-25-48105-->-->Effectiveness of a Pedagogical Module for The Process of Weaning from Mechanical Ventilation in Advanced Nursing Education-->-->PLOS One

Dear Dr. AWANGHARUN,

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: -->--> -->-->Dear Editorial Office,

Three reviewers have revised this manuscript.

Considering their comments, major revisions are required.

Please submit your revised manuscript by Apr 03 2026 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 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'.
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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.

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We look forward to receiving your revised manuscript.

Kind regards,

Javier Fagundo-Rivera, PhD

Academic Editor

PLOS One

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Additional Editor Comments:

Dear Authors,

Three reviewers have revised this manuscript.

Considering their comments, major revisions are required.

[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: Partly

Reviewer #3: Yes

**********

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

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

**********

-->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

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: No

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: SEE DOCUMENT ATTACHED

This manuscript reports the development and evaluation of a pedagogical module for the process of weaning from mechanical ventilation in advanced nursing education within a cardiothoracic intensive care unit in Malaysia. The authors assess effectiveness using pre test and post test theoretical scores and qualitative feedback from instructors and students. I have evaluated the manuscript according to the official PLOS ONE criteria.

Reviewer #2:

Comments

•The manuscript repeatedly claims the use of a regression discontinuity design (RDD). However, the actual implementation does not meet the essential methodological criteria of RDD, including:

No modeling of the running variable

No graphical or regression-based discontinuity analysis

No local linear regression or bandwidth justification

Arbitrary cut-off score (70) without theoretical or empirical justification

What is presented is effectively a non-randomized pre–post quasi-experimental study, not a true RDD.

Recommendation:

Either reframe the design explicitly as a quasi-experimental pre–post study, or properly implement and report RDD analysis following established guidelines.

Failure to correct this will be considered a methodological misrepresentation.

•Total sample size is extremely small (N = 24), with an imbalanced control group (n = 5).

No power analysis or justification for sample adequacy is provided.

Claims of effectiveness and generalizability are not supported by this sample size.

•The manuscript repeatedly reports p = .000, which is statistically incorrect.

Recommendation:

Replace all instances of “p = .000” with p < 0.001

Emphasize effect sizes and confidence intervals, not only p-values

•Control Group Analysis Is Inadequate

Although a control group is mentioned:

No clear between-group comparison is presented

Analyses focus almost exclusively on within-group pre–post changes

Control group outcomes are underreported and analytically underused

•Reliability indices (e.g., Cronbach’s alpha)

Whether the instruments truly measure critical thinking, decision-making, and judgment?

Provide detailed psychometric evidence or clearly state that the measures assess knowledge performance, not higher-order cognitive skills.

•The manuscript contains:

Frequent grammatical errors

Redundant phrasing

Long, repetitive paragraphs

Informal or non-academic expressions

Recommendation:

Substantial English language editing by a professional academic editor is required.

•The Author Summary section reads as a professional biography rather than a scientific summary, which is not aligned with PLOS ONE conventions.

Recommendation:

Remove biographical content and Focus on study rationale, methods, and key findings

•Ethics approval is mentioned but inconsistently reported across sections

Data availability statement contradicts PLOS ONE policy by implying restricted access

Recommendation:

Harmonize ethics statements across manuscript and submission form . Clearly state how and where anonymized data can be accessed, or justify restrictions.

Reviewer #3:

Thank you for the opportunity to review this manuscript. The study addresses an important educational gap in advanced nursing practice and provides preliminary evidence that a structured pedagogical module may improve nurses’ knowledge and decision‑making regarding weaning from mechanical ventilation.

What are the main claims of the paper and how significant are they for the discipline?

The present study develops and implements a pedagogical module for the process of mechanical ventilation weaning (WPMV) in a cardiothoracic ICU (ICU). It uses a quasi-experimental design (discontinuous regression), in which there is a significant improvement in knowledge/skills, critical thinking and decision-making in the intervention group (n=19), with an increase in average grade from 52.9% to 90.5% (p≤0.001). The topic is relevant for nursing education in critical care.

QUESTIONS:

1. Are the claims properly placed in the context of the previous literature? Have the authors treated the literature fairly?

The manuscript presents a theoretical pedagogical framework (Johns, Taba, Gagné) and cites studies and clinical guides related to the subject of study. However, it is proposed that the authors add in the text why the design used for the study is suitable and how it aligns with the methodological literature.

2. Do the data and analyses fully support the claims? If not, what other evidence is required?

The study uses a cutoff point 70 in a pretest made before the intervention, to create "weak" (n=19) and "skillful/control" (n=5) groups. Since the analyses are pre-post with paired samples, it is proposed to the authors the implementation of comparisons between both groups and adjustment by confusing.

On the other hand, the authors used Kolmogorov-Smirnov and Shapiro-Wilk for the determination of normality. Being a small sample (n<50 or n<30), the test of choice would be Shapiro-Wilk for its greater power and precision. In this case, the authors confirm the normality of the sample (p>0.05), but in Table 8: normality test, it is indicated that the Shapiro-Wilk test (pretest) shows p=0.015 (not normal), which contradicts the assumption of normality and requires the use of non-parametric tests.

It is also proposed to the authors if it is possible to detail the instruments used in the training (exam specifications/skills, validity, reliability, rubrics, items, examples)

3. PLOS ONE encourages authors to publish detailed protocols and algorithms as supporting information online. Do any particular methods used in the manuscript warrant such treatment? If a protocol is already provided, for example for a randomized controlled trial, are there any important deviations from it? If so, have the authors explained adequately why the deviations occurred?

The documents provided as supplementary material justify the methodology used in the development of the study.

4. If the paper is considered unsuitable for publication in its present form, does the study itself show sufficient potential that the authors should be encouraged to resubmit a revised version?

Yes. The manuscript shows a clear design, solid statistical results and a relevant educational contribution to advanced training in CICU nursing. The document demonstrates clear potential for publication if reviewed.

5. Are original data deposited in appropriate repositories and accession/version numbers provided for genes, proteins, mutants, diseases, etc.?

The authors indicate that the data is stored privately and securely.

6. Does the study conform to any relevant guidelines such as CONSORT, MIAME, QUORUM, STROBE, and the Fort Lauderdale agreement?

No, the study does not declare adherence to any of these guidelines.

7. Are details of the methodology sufficient to allow the experiments to be reproduced?

Partially. It would be missing to implement the aspects that are requested in the review to provide the study with greater methodological clarity.

8. Is any software created by the authors freely available?

It does not apply.

9. Is the manuscript well organized and written clearly enough to be accessible to non-specialists?

Yes.

10. Is it your opinion that this manuscript contains an NIH-defined experiment of Dual Use concern?

No.

**********

-->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: No

Reviewer #3: No

**********

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Attachments

Attachment

Submitted filename: renamed_f80ce.docx

-->PONE-D-25-48105R1-->-->Effectiveness of a Pedagogical Module for The Process of Weaning from Mechanical Ventilation in Advanced Nursing Education-->-->PLOS One

Dear Dr. AWANGHARUN,

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:  -->-->

Dear Authors,

Thank you for submitting the revised version of your manuscript following the first round of external peer review.

After careful evaluation, it is evident that the revision remains incomplete. Specifically, you have not provided responses to any of the comments raised by Reviewer 1, and several comments from Reviewer 2 also remain unaddressed. Furthermore, Reviewer 3 has expressed dissatisfaction with the responses concerning the statistical aspects of the study. The issues identified raise substantive concerns regarding the integrity and robustness of the methodology, as the detected errors may significantly affect the validity of the study’s findings.

We are therefore returning the manuscript to you for a further and final round of revision. Please be advised that, should the revised submission fail to adequately address all reviewer concerns, rejection of the manuscript will be strongly considered.

We urge you to carefully and thoroughly respond to each reviewer comment explicitly and individually. Please avoid summarizing or merging responses, as clear, point-by-point replies greatly facilitate the review process and ensure transparency in your revisions.

We look forward to receiving your revised manuscript.

Sincerely,

Academic Editor

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

Please submit your revised manuscript by Jun 08 2026 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 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.

As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only  the individual author can complete the verification step; PLOS staff cannot  verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Javier Fagundo-Rivera, PhD

Academic Editor

PLOS One

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

Additional Editor Comments:

Dear Authors,

Thank you for submitting the revised version of your manuscript following the first round of external peer review.

After careful evaluation, it is evident that the revision remains incomplete. Specifically, you have not provided responses to any of the comments raised by Reviewer 1, and several comments from Reviewer 2 also remain unaddressed. Furthermore, Reviewer 3 has expressed dissatisfaction with the responses concerning the statistical aspects of the study. The issues identified raise substantive concerns regarding the integrity and robustness of the methodology, as the detected errors may significantly affect the validity of the study’s findings.

We are therefore returning the manuscript to you for a further and final round of revision. Please be advised that, should the revised submission fail to adequately address all reviewer concerns, rejection of the manuscript will be strongly considered.

We urge you to carefully and thoroughly respond to each reviewer comment explicitly and individually. Please avoid summarizing or merging responses, as clear, point-by-point replies greatly facilitate the review process and ensure transparency in your revisions.

We look forward to receiving your revised manuscript.

Sincerely,

Academic Editor

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

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 #3: 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: Partly

Reviewer #3: (No Response)

**********

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

Reviewer #1: Yes

Reviewer #3: (No Response)

**********

-->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

Reviewer #3: (No Response)

**********

-->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: No

Reviewer #3: (No Response)

**********

-->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:

This manuscript presents the development and evaluation of a pedagogical module for the weaning process from mechanical ventilation in advanced nursing education within a cardiothoracic intensive care unit context. The study addresses an important topic in clinical education and provides original data derived from a structured educational intervention. The revised version shows improvement in several technical and reporting aspects. However, significant methodological and interpretative concerns remain before the manuscript can be considered for publication.

Major Comments

Alignment of Conclusions with Evidence

The conclusions extend beyond the data presented. The manuscript claims that the pedagogical module contributes to reducing clinical complications and legal risks. These outcomes were not measured in the study. The data are limited to theoretical test scores and qualitative feedback. The conclusions should be restricted to educational outcomes such as knowledge acquisition and perceived improvement in cognitive skills. Statements related to clinical outcomes and legal implications should be removed or clearly reframed as speculative.

Study Design and Group Allocation

Participants were assigned to groups using a cut off score of 70 determined by the researcher. This threshold remains insufficiently justified. There is no theoretical or empirical rationale provided to support this decision. This raises concerns about internal validity and potential bias in group allocation. A clearer justification is required, or the limitation should be explicitly acknowledged and discussed.

In addition, the control group consists of only five participants. This severely limits the strength of any comparative interpretation. The manuscript should address the implications of this imbalance and avoid overinterpretation of differences between groups.

Statistical Analysis and Interpretation

The inclusion of additional analyses such as the Wilcoxon Signed Rank Test and effect size calculations represents an improvement. However, these results are not adequately interpreted. Effect sizes are reported but not discussed in terms of magnitude or practical significance. Confidence intervals are presented in tables but are not integrated into the narrative.

The analysis remains focused on within group comparisons. The absence of robust between group analysis limits the strength of the conclusions. The manuscript would benefit from a clearer explanation of the analytical strategy and its limitations.

Conceptual Clarity and Measurement

Key constructs such as critical thinking, decision making, and clinical judgment are central to the study but remain insufficiently defined. The manuscript does not clearly explain how these constructs were operationalized or measured within the theoretical tests and assessments. Clear definitions and alignment between constructs and measurement tools are necessary to support the validity of the findings.

Discussion and Interpretation

The Discussion section remains largely descriptive and reiterates results rather than providing critical interpretation. There is limited engagement with existing literature on nursing education and mechanical ventilation training. The authors should strengthen this section by contextualizing their findings within current evidence and by discussing alternative explanations.

Limitations are not sufficiently developed. The manuscript should explicitly address the small sample size, single center design, non randomized allocation, short duration of follow up, and reliance on theoretical outcomes.

Data Availability and Compliance

The data availability statement remains unclear and does not fully comply with journal policy. The manuscript states that data are stored securely by the authors, which suggests restricted access. At the same time, it indicates that data are available within the manuscript and supporting files. This inconsistency should be resolved. The authors must provide a clear statement ensuring that data are accessible without restriction or justify any limitations in accordance with journal guidelines.

Language and Presentation

The manuscript remains intelligible but requires further language editing. Grammatical errors and awkward phrasing are still present. Professional editing is recommended to improve clarity and readability. Repetition across sections should be reduced, particularly in the Results and Discussion.

Minor Comments

Some terminology is used inconsistently and should be standardized throughout the manuscript. Tables and figures would benefit from clearer labeling and more concise captions. The Methods section could be streamlined to improve readability.

Reviewer #2: comments that have not been responded.

•Control Group Analysis Is Inadequate

Although a control group is mentioned:

No clear between-group comparison is presented

Analyses focus almost exclusively on within-group pre–post changes

Control group outcomes are underreported and analytically underused

•Reliability indices (e.g., Cronbach’s alpha)

Whether the instruments truly measure critical thinking, decision-making, and judgment?

Provide detailed psychometric evidence or clearly state that the measures assess knowledge performance, not higher-order cognitive skills.

Reviewer #3:  (No Response) ACADEMIC EDITOR COMMENTS: Please, revise this comment by reviewer 3.

1) The study uses a cutoff point 70 in a pretest made before the intervention, to create "weak" (n=19) and "skillful/control" (n=5) groups. Since the analyses are pre-post with paired samples, it is proposed to the authors the implementation of comparisons between both groups and adjustment by confusing.

2) On the other hand, the authors used Kolmogorov-Smirnov and Shapiro-Wilk for the determination of normality. Being a small sample (n<50 or n<30), the test of choice would be Shapiro-Wilk for its greater power and precision. In this case, the authors confirm the normality of the sample (p>0.05), but in Table 8: normality test, it is indicated that the Shapiro-Wilk test (pretest) shows p=0.015 (not normal), which contradicts the assumption of normality and requires the use of non-parametric tests.

3) It is also proposed to the authors if it is possible to detail the instruments used in the training (exam specifications/skills, validity, reliability, rubrics, items, examples).

**********

-->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 #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.]

To ensure your figures meet our technical requirements, please review our figure guidelines: https://journals.plos.org/plosone/s/figures

You may also use PLOS’s free figure tool, NAAS, to help you prepare publication quality figures: https://journals.plos.org/plosone/s/figures#loc-tools-for-figure-preparation.

NAAS will assess whether your figures meet our technical requirements by comparing each figure against our figure specifications.

Attachments

Attachment

Submitted filename: renamed_c4ca4.docx

<div>PONE-D-25-48105R2-->-->Effectiveness of a Pedagogical Module for The Process of Weaning from Mechanical Ventilation in Advanced Nursing Education-->-->PLOS One

Dear Dr. AWANGHARUN,

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:  -->-->

Dear Authors,

Thank you for submitting the revised version of your manuscript, “Effectiveness of a Pedagogical Module for The Process of Weaning from Mechanical Ventilation in Advanced Nursing Education” (Manuscript Number: PONE-D-25-48105R2).

The reviewers acknowledge the substantial improvements made in response to the previous comments. In particular, they appreciate the clarification of the quasi-experimental design, the inclusion of additional statistical analyses, the improved discussion of limitations, and the more cautious interpretation of the educational outcomes. The manuscript addresses an important topic in advanced nursing education and is now considerably closer to publishable form.

However, several points still require attention before the manuscript can be considered for acceptance:

* Please reconsider the use of the term “control group,” as reviewers consider this concept methodologically questionable in the context of the current design. Terms such as “comparison group” may be more appropriate.

* Some sections, particularly the Author Summary, Introduction, and Discussion, still contain statements suggesting improvements in patient safety, reduction of complications, or direct clinical impact. These claims should be revised to remain fully aligned with the educational scope of the study and the acknowledged limitations.

* Please further moderate any overinterpretation of cognitive or clinical implications.

* The English language and overall writing quality should be improved, especially in the Discussion and Author Summary sections.

* Please consider explicitly including the main study limitations in the abstract.

In light of these remaining issues, the decision is Minor Revision.

We look forward to receiving your revised manuscript.

Best regards.

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

Please submit your revised manuscript by Jul 12 2026 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 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.

As the corresponding author, your ORCID iD is verified in the submission system and will appear in the published article. PLOS supports the use of ORCID, and we encourage all coauthors to register for an ORCID iD and use it as well. Please encourage your coauthors to verify their ORCID iD within the submission system before final acceptance, as unverified ORCID iDs will not appear in the published article. Only  the individual author can complete the verification step; PLOS staff cannot  verify ORCID iDs on behalf of authors.

We look forward to receiving your revised manuscript.

Kind regards,

Javier Fagundo-Rivera, PhD

Academic Editor

PLOS One

Journal Requirements:

If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

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:

Dear Authors,

Thank you for submitting the revised version of your manuscript, “Effectiveness of a Pedagogical Module for The Process of Weaning from Mechanical Ventilation in Advanced Nursing Education” (Manuscript Number: PONE-D-25-48105R2).

The reviewers acknowledge the substantial improvements made in response to the previous comments. In particular, they appreciate the clarification of the quasi-experimental design, the inclusion of additional statistical analyses, the improved discussion of limitations, and the more cautious interpretation of the educational outcomes. The manuscript addresses an important topic in advanced nursing education and is now considerably closer to publishable form.

However, several points still require attention before the manuscript can be considered for acceptance:

* Please reconsider the use of the term “control group,” as reviewers consider this concept methodologically questionable in the context of the current design. Terms such as “comparison group” may be more appropriate.

* Some sections, particularly the Author Summary, Introduction, and Discussion, still contain statements suggesting improvements in patient safety, reduction of complications, or direct clinical impact. These claims should be revised to remain fully aligned with the educational scope of the study and the acknowledged limitations.

* Please further moderate any overinterpretation of cognitive or clinical implications.

* The English language and overall writing quality should be improved, especially in the Discussion and Author Summary sections.

* Please consider explicitly including the main study limitations in the abstract.

In light of these remaining issues, the decision is Minor Revision.

We look forward to receiving your revised manuscript.

Best regards.

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Reviewers' comments:

Reviewer's Responses to Questions

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Reviewer #1: All comments have been addressed

Reviewer #3: All comments have been addressed

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Reviewer #1: Partly

Reviewer #3: Partly

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Reviewer #1: Yes

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #3: Yes

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Reviewer #1: No

Reviewer #3: Yes

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Reviewer #1: SEE DOCUMENT ATTACHED

The revised manuscript shows clear improvement compared with the previous submission. Several methodological and reporting concerns have been addressed appropriately, particularly regarding clarification of the quasi-experimental design, inclusion of additional statistical analyses, improved acknowledgment of study limitations, and a more cautious interpretation of findings. The study addresses an important topic in advanced nursing education and provides potentially valuable preliminary findings within a specialized clinical training context. However, several concerns remain partially unresolved, particularly regarding internal validity, conceptual overinterpretation of cognitive constructs, residual overstatement of clinical implications, and language quality. The manuscript is closer to publishable form, but additional moderate revision would further strengthen its methodological clarity and interpretive rigor.

Reviewer #3:

The authors have adequately responded to most key criticisms: The conclusions are now limited to educational results (knowledge and clinical reasoning), the study is now correctly presented as non-randomised pre-post quasi-experimental, the work is explicitly recognised as a pedagogical pilot study, includes explicit limitations (n small, a centre, non-randomised, etc.).

However, the manuscript presents methodologically relevant weaknesses, such as the design and sample size, where the "control group" remains conceptually questionable. This concept can be reformed by "comparison group" or similar.

On the other hand, drafting inconsistencies remain, since in several sections (Author summary, introduction and discussion) sentences still appear that suggest the improvement of patient safety, the reduction of complications and the clinical impact of the study, which partially contradicts the corrections already made by the authors.

It is also recommended to improve the writing of English, especially in the discussion and Author summary.

Likewise, it may be relevant to clarify the limitations of the study in the abstract.

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Reviewer #1: No

Reviewer #3: No

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Attachments

Attachment

Submitted filename: renamed_587b2.docx

Effectiveness of a Pedagogical Module for The Process of Weaning from Mechanical Ventilation in Advanced Nursing Education

PONE-D-25-48105R3

Dear Dr. AWANGHARUN,

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,

Javier Fagundo-Rivera, PhD

Academic Editor

PLOS One

Additional Editor Comments:

Dear Authors,

We are pleased to inform you that your manuscript PONE-D-25-48105R3: "Effectiveness of a Pedagogical Module for The Process of Weaning from Mechanical Ventilation in Advanced Nursing Education" has been accepted for publication in PLOS ONE.

The editors and reviewers have carefully evaluated your revised submission and are satisfied that the manuscript meets the journal's standards for publication. We appreciate your thoughtful responses to the reviewers' comments and the revisions made throughout the review process.

Your manuscript will now proceed to the production stage. You will receive further communications regarding copyediting, proof review, and publication scheduling from the PLOS ONE production team.

Thank you for choosing PLOS ONE for the publication of your work. We look forward to seeing your article published and contributing to the scientific literature.

Congratulations on the acceptance of your manuscript.

Sincerely,

Javier Fagundo-Rivera, PhD

Academic Editor

PLOS ONE

Reviewers' comments: -