PONE-D-25-36942Causal mapping of psychological and occupational risk factors for suicidal ideation in psychiatric nurses using Bayesian networks: A multicenter cross-sectional studyPLOS ONE

Dear Dr. Ma,

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ACADEMIC EDITOR:  

Dear Authors, the manuscript requires minor revisions. Please respond to the reviewers point by point.

Best regards

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PLOS ONE

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This work was supported by the Ministry of Science and Technology of the People’s Republic of China (grant number 2022ZD0211700), the Key Research and Development Project of Zigong Science and Technology Program (grant number 2023YLWS11), the 135 Project from West China Hospital of Sichuan University (grant numbers 2023HXFH006, 2023HXFH040), and the Postdoctoral Research Fund of West China Hospital, Sichuan University (grant number 2024HXBH135).

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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

Reviewer #3: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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

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

Reviewer #1: No

Reviewer #2: Yes

Reviewer #3: 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: Recommendations for Manuscript ID PONE-D-25-36942 Title: “Causal mapping of psychological and occupational risk factors for suicidal ideation in psychiatric nurses using Bayesian networks: A multicenter cross-sectional study” for the Plos One Journal.

General Comments

From my point of view, it is a very interesting topic and simultaneously it seems that to the best of my knowledge is an empirical research aimed to present that psychiatric nurses represent a high-stress occupational group that experiences elevated levels of suicidal ideation (SI), which necessitates greater attention to their mental health. A total of 1,835 psychiatric nurses participated in the study, completing questionnaires that assessed depressive symptoms (PHQ-9), SI, quality of work-related life (QWL), and occupational burnout. Multivariate logistic regression and phenotypic network analyses, were conducted to identify factors associated with SI and explore the interactions and possible causal directions among depressive symptoms, burnout, QWL, and SI. The findings indicate that 11.33% of psychiatric nurses reported experiencing SI in the past two weeks. The multivariate logistic regression analysis identified emotional exhaustion, depersonalization, personal accomplishment, stress at work, general well-being, and home-work interface were significant as predictors of SI. In the symptom network, the top five symptoms directly connecting SI were psychomotor changes, guilt, sad mood, low energy, and appetite changes. Pathways were observed from sad mood, general well-being, and work-home interface to job and career satisfaction, as well as from sad mood, low energy to emotional exhaustion and SI. The study highlights the importance of targeting sad mood, psychomotor changes, low energy, emotional exhaustion, and work-related stress to reduce the risk of SI among psychiatric nurses.

The paper contains the following sections: Introduction, Methods, Results, Discussion.

However, I find some recommendations:

1. The Manuscript needs careful English proofreading because there are some shortcomings. For instance, the article “the” is sometimes missing in front of nouns, the message in some paragraphs is not clear enough. It looks like the first part was written by one author with a greater command of the English language, and the rest of the paper was written by someone else. The numerous grammar errors made this a difficult paper to read. It was strange to see the authors refer to tables that were not submitted. I was unable to find any supplementary material to the submission, so I think this was truly omitted by the authors. Please read the manuscript carefully.

2. The abstract must contain the main purpose of the paper, the research method used in the research and the main contributions.

3. It would be very useful to add in the "Introduction" section the purpose, objectives and hypothesis of the research. I consider that a weak point of the paper is that the authors did not show the novelty of the paper compared to other works. That is why, I consider that the introduction should specify the novelty of the paper compared to other papers published in this area.

4. Literature review and Conclusion sections cannot be missing from the paper.

5. The research is well based on science and the results are in agreement with the theoretical part.

6. I believe that the authors should also include other indicators from Descriptive Statistics.

7. I think that the literature needs to be improved with other recent works, refers to rural tourism. That is why I recommend the authors to refer to other recent works indexed in Web of Science, Scopus, Emerald and Cambrige Journals. We suggest that the authors cite papers published in Web of Science Journals such as:

a. https://doi.org/10.3390/jrfm14070336

b. https://doi.org/10.1007/s13132-023-01565-6

c. https://doi.org/10.3390/fractalfract8010032

8. In conclusion, the article should be improve. It should also be enhanced with a review of the literature adequate to the subject and a broader interpretation and commentary of the research results.

Reviewer #2: The article does not specify the criteria for inclusiveness and exclusivity of the selection of respondents. A complete description of the respondents is not provided.

The demographic and age distribution is not clear and therefore it is not clear whether the existing sample is sufficiently scientifically reliable and whether it corresponds to the general population.

Reviewer #3: Suicidal ideation (SI) is more common among psychiatric nurses, a high-stress occupational group that requires more attention to their mental health. The study focuses on a significant topic. My observations are given below:

(1) The study title is okay.

(2) The abstract needs revision. The abstract does a good job of summarizing the goal, methodology, and main conclusions of the study, but it is extremely technical and dense, which makes it difficult to read. While practical implications and novelty should be more prominently highlighted, excessive statistical detail could be trimmed. Increased clarity and reader engagement would result from a more focused emphasis on psychological significance.

(3) The introduction also needs minor revision. A thorough and thoroughly referenced background is provided in the introduction, which successfully places the study in the context of psychiatric nurses' risk of suicide. Nevertheless, it is excessively long and has repetitions that mask the main research void. It feels sudden and could be more smoothly integrated to go from general suicide risk to methodological options (network analysis, DAGs). Readability and theoretical coherence would be enhanced by more precise articulation of hypotheses and a greater emphasis on the psychological processes that connect burnout, QWL, and suicidal thoughts.

(4) The method again needs minor amendments. The methods section is thorough, shows exacting statistical and measurement procedures, and reports on the reliability of every instrument. However, generalizability may be limited due to the cross-sectional design, which limits causal inference, and the lack of discussion regarding the rationale behind the exclusive selection of psychiatric nurses from Sichuan Province. Although DAG and network analyses are novel, assumptions like multivariate normality need more convincing evidence. Deeper thought should be given to the selection bias and data validity issues brought up by the hiring process using a self-developed digital platform.

(5) The results need modifications. With its thorough analysis and integration of several statistical techniques, the results section provides deep insights into the connections between SI, burnout, QWL, and depressive symptoms. On the other hand, overly detailed figures and edge weights make it difficult to read and hide important points. Without a clear synthesis, some results are replicated in network and regression analyses. Interpretation would be strengthened by a stronger focus on the practical implications of effect sizes and a more distinct differentiation between statistical significance and clinical relevance. Simplifying would increase clarity without sacrificing the depth of the science.

(6) The discussion needs minor improvements. The discussion is comprehensive, clearly defining two main pathways and connecting findings to pertinent theories and earlier research. Integration of the Burnout-Depression Continuum Theory and the JD-R model is one of its strengths. Nevertheless, some passages are repetitive and excessively detailed, which lessens their impact. Its applicability would be increased by placing more focus on original contributions and useful intervention techniques. Although the limitations section is appropriate, it could more thoroughly address the possibility of response bias in delicate subjects like SI. All in all, a good but unduly long conversation.

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Reviewer #1: No

Reviewer #2: Yes: Agita Abele

Reviewer #3: Yes: Gyanesh Kumar Tiwari

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Causal mapping of psychological and occupational risk factors for suicidal ideation in psychiatric nurses using Bayesian networks: A multicenter cross-sectional study

PONE-D-25-36942R1

Dear Dr. Ma,

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,

Omar Enzo Santangelo

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewer #4:

Reviewer #5:

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 #4: (No Response)

Reviewer #5: 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 #4: Yes

Reviewer #5: Yes

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

Reviewer #4: Yes

Reviewer #5: 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 #4: Yes

Reviewer #5: 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 #4: Yes

Reviewer #5: 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 #4: Thank you for submitting the revised version of your manuscript. I have carefully reviewed the changes made in response to the previous comments, and I am pleased to see that you have addressed all of the concerns raised in a thoughtful and comprehensive manner. The manuscript has improved significantly in clarity, structure, and scientific rigor. The revisions enhance the overall quality of the work and contribute positively to the field. I believe the current version meets the standards required for publication. Congratulations on a job well done, and I wish you the very best with the publication.

Reviewer #5: Dear Author(s),

The manuscript entitled “Causal mapping of psychological and occupational risk factors for suicidal ideation in psychiatric nurses using Bayesian networks: A multicenter cross-sectional study” addresses an important and timely topic with high relevance to both psychiatric nursing and mental health research. The study is based on a large multicenter sample of psychiatric nurses, applying validated instruments and rigorous statistical approaches, including multivariate logistic regression, network analysis, and Bayesian modeling. This methodological combination allows the authors to move beyond simple associations and to explore potential causal pathways, which represents a significant strength and an original contribution to the literature.

The paper is now clearly written, logically structured, and in line with the journal’s formatting requirements. The abstract and introduction effectively present the purpose, objectives, and novelty of the research. The methods section is detailed and transparent, with inclusion/exclusion criteria and quality control procedures clearly described. The results are presented in a balanced way, with appropriate attention to both statistical and clinical significance. The discussion integrates the findings with theoretical frameworks such as the JD-R model and the Burnout–Depression Continuum, while also highlighting practical implications for interventions targeting mood disturbances, energy loss, and occupational stress among psychiatric nurses.

Overall, this is a well-executed and important study that provides novel insights and practical implications for the prevention of suicidal ideation in a vulnerable occupational group. I recommend acceptance of this manuscript for publication in PLOS ONE.

Sincerely,

Reviewer

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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 #4: No

Reviewer #5: No

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