“Healing hands: Understanding physiotherapists’ knowledge, attitudes and barriers on pressure injury prevention in the medical wards in Jordan”

Enas A. Assaf; Rahaf Alkhresheh; Taher Assaf; Suhair Al-Ghabeesh; Ramasubbamma Ramaiah

doi:10.1371/journal.pone.0344480

Peer Review History

Original SubmissionJuly 16, 2025
23 Oct 2025 Decision Letter - Maheshkumar Baladaniya, Editor Dear Dr. Assaf, 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. Please submit your revised manuscript by Dec 07 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. 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'. 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We look forward to receiving your revised manuscript. Kind regards, Maheshkumar Baladaniya 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: This research was funded by the Deanship of Scientific Research at King Khalid University; Grant number "RGP 2/263/46". Please state what role the funders took in the study. If the funders had no role, please state: "The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." If this statement is not correct you must amend it as needed. Please include this amended Role of Funder statement in your cover letter; we will change the online submission form on your behalf. 3. Please amend the manuscript submission data (via Edit Submission) to include author Al-Ghabeesh S 4. Please amend your authorship list in your manuscript file to include author suhair Al-Ghabeesh 5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. 6. 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. 7. 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: Need to make changes as advised by reviewers. [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? Reviewer #1: Yes Reviewer #2: Yes ******** 2. Has the statistical analysis been performed appropriately and rigorously? -->?> Reviewer #1: Yes Reviewer #2: Yes ****** 3. Have the authors made all data underlying the findings in their manuscript fully available??> The PLOS Data policy Reviewer #1: Yes Reviewer #2: Yes ****** 4. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: Overall Assessment The topic is timely and relevant given the growing emphasis on multidisciplinary approaches in healthcare and the scarcity of data from Middle Eastern contexts. However, it would benefit from further refinement in the discussion, statistical interpretation, and contextualization of findings within broader global and regional literature. Introduction The introduction could better emphasize the research gap—why physiotherapists in medical wards (as opposed to ICUs or rehabilitation units) have been overlooked. It could benefit from a clear statement of study objectives or hypotheses at the end. “Therefore, this study aimed to assess physiotherapists’ knowledge, attitudes, and perceived barriers toward pressure injury prevention in Jordanian medical wards and identify associated demographic factors.” Methods Convenience sampling of 36 physiotherapists limits external validity; this limitation should be discussed earlier in the manuscript. The statistical analysis section needs a brief mention of how missing data (if any) were handled. Clarify whether the regression model controlled for confounders or if it was unadjusted. Results The results section sometimes repeats data already visible in tables. Summaries could be more interpretive rather than descriptive. Ensure consistency between reported p-values (e.g., 0.00 should be written as p < 0.001). Discussion The discussion lacks a multidisciplinary systems perspective—for example, collaboration between physiotherapists, nurses, and wound care teams could be more deeply analyzed. Broader international comparison (outside the Middle East) would strengthen the global relevance. Recommend acknowledging limitations related to social desirability bias and self-reported measures. The discussion section comprehensively interprets findings but lacks a broader multidisciplinary perspective linking physiotherapists’ preventive and rehabilitative roles to overall patient well-being. Incorporating literature highlighting the evolving preventive and psychosocial dimensions of physiotherapy would strengthen the scientific depth and contextual relevance of the discussion, emphasizing physiotherapists’ integral role in holistic pressure injury prevention. Add below phrase. “The evolving role of physiotherapists extends beyond rehabilitation, encompassing preventive and psychosocial health dimensions [Nasif et al., 2025 https://doi.org/10.31579/2578-8868/359 ]. Such multidisciplinary engagement supports patient-centered approaches essential in pressure injury prevention.” Conclusion and Implications The conclusion could benefit from more specific, evidence-backed recommendations (e.g., integrating PI prevention modules into physiotherapy curricula). Add a sentence emphasizing the study’s contribution to regional literature and how it can inform future interventional research. Reviewer #2: Methods: Sample size: The rationale provided through GPower appears to be at odds with the final figure 36 participants. Determine if this represented the entire eligible population or if difficulties in recruitment restricted participation. Instrument: The process of adapting the questionnaire is clearly outlined, yet additional information is required about translation, cultural adjustments, and pretesting specific to the Jordanian setting. Data Analysis: While statistical tests like t-test, ANOVA, regression are appropriate, the assumptions normality, multicollinearity are not addressed. Think about adding confidence intervals and effect sizes for important findings. Result: Explain the application of percentages compared to raw numbers to guarantee uniformity among tables. The regression analysis is clearly displayed but would improve by including standardized beta coefficients and confidence intervals. Certain p-values are presented as 0.00, they ought to be stated as < 0.001. Discussion: Elaborate on the implications for policy and clinical training what targeted actions can organizations implement to enhance multidisciplinary pressure injury prevention? Add a brief section discussing how this research contributes to the current literature and suggest areas for future studies, such as intervention trials and larger national samples. Explicitly recognize the limitations of the small sample size, the singular setting, and the self-reporting bias. Result: Add a more emphatic statement linking enhanced knowledge and guideline application by physiotherapists to measurable patient-care results. Refrain from including new details or references to literature in this section ****** 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: 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: Comments.docx https://doi.org/10.1371/journal.pone.0344480.r001
Revision 1
21 Nov 2025 Author Response Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS 1. 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 done accordingly 2. Thank you for stating the following financial disclosure: This research was funded by the Deanship of Scientific Research at King Khalid University; Grant number "RGP 2/263/46". The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript." included in the cover letter 3. . Please amend the manuscript submission data (via Edit Submission) to include author Al-Ghabeesh S 4. Please amend your authorship list in your manuscript file to include author Suhair Al-Ghabeesh done 5. Please include captions for your Supporting Information files at the end of your manuscript, and update any in-text citations to match accordingly. Please see our Supporting Information guidelines for more information: http://journals.plos.org/plosone/s/supporting-information. Done. 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. yes, done 7. 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. All references were checked one by one for retraction, and no retractions were reported either on the journal page or Google Scholar, however, I found one reference irrelevantly inserted and removed. Thank you for this important note. reviewer one Overall Assessment The topic is timely and relevant given the growing emphasis on multidisciplinary approaches in healthcare and the scarcity of data from Middle Eastern contexts. However, it would benefit from further refinement in the discussion, statistical interpretation, and contextualization of findings within broader global and regional literature. Introduction The introduction could better emphasize the research gap—why physiotherapists in medical wards (as opposed to ICUs or rehabilitation units) have been overlooked. It could benefit from a clear statement of study objectives or hypotheses at the end. Thank you for your comments: Added more global and international literature to both the introduction and the discussion Introduction, the study aim was changed and we took your clearer statement. Thank you Methods Convenience sampling of 36 physiotherapists limits external validity; this limitation should be discussed earlier in the manuscript. The statistical analysis section needs a brief mention of how missing data (if any) were handled. Clarify whether the regression model controlled for confounders or if it was unadjusted. a. A convenient sample limitation had been added in the method section b. In the study, we collected data from all 36 physiotherapists targeted in the three hospitals. During data cleaning, it was confirmed that all 36 returned questionnaires were fully completed. We added a sentence to the "Statistical analysis" section to clarify this. c. The multivariate regression models were adjusted. As described in the "Statistical analysis" section and presented in Table 6, all independent variables (demographic factors: gender, age, marital status, monthly income, work experience, training, using guidelines, and unproportional providers) were entered simultaneously into the regression models for each of the three outcome variables. Statistical analysis section were modified accordingly. Results The results section sometimes repeats data already visible in tables. Summaries could be more interpretive rather than descriptive. Ensure consistency between reported p-values (e.g., 0.00 should be written as p < 0.001). Done. We have revised the results text for Table 5 to be more interpretive and less descriptive. We also corrected all 'P = 0.00' values to 'P < 0.001' in the text and tables for statistical consistency Discussion The discussion lacks a multidisciplinary systems perspective—for example, collaboration between physiotherapists, nurses, and wound care teams could be more deeply analyzed. Broader international comparison (outside the Middle East) would strengthen the global relevance. Recommend acknowledging limitations related to social desirability bias and self-reported measures. The discussion section comprehensively interprets findings but lacks a broader multidisciplinary perspective linking physiotherapists’ preventive and rehabilitative roles to overall patient well-being. Incorporating literature highlighting the evolving preventive and psychosocial dimensions of physiotherapy would strengthen the scientific depth and contextual relevance of the discussion, emphasizing physiotherapists’ integral role in holistic pressure injury prevention. Add below phrase. “The evolving role of physiotherapists extends beyond rehabilitation, encompassing preventive and psychosocial health dimensions [Nasif et al., 2025 https://doi.org/10.31579/2578-8868/359 ]. Such multidisciplinary engagement supports patient-centered approaches essential in pressure injury prevention.” Discussed further and highlighted the importance of the physiotherapist and the ref. were added for it's significant Conclusion and Implications The conclusion could benefit from more specific, evidence-backed recommendations (e.g., integrating PI prevention modules into physiotherapy curricula). Add a sentence emphasizing the study’s contribution to regional literature and how it can inform future interventional research. this was added Reviewer two Methods: Sample size: The rationale provided through GPower appears to be at odds with the final figure 36 participants. Determine if this represented the entire eligible population or if difficulties in recruitment restricted participation. Instrument: The process of adapting the questionnaire is clearly outlined, yet additional information is required about translation, cultural adjustments, and pretesting specific to the Jordanian setting. Data Analysis: While statistical tests like t-test, ANOVA, regression are appropriate, the assumptions normality, multicollinearity are not addressed. Think about adding confidence intervals and effect sizes for important findings. Sample size: The sample size were the entire physiotherapist working in the three studied hospitals, as they were all interested in participating in the study; moreover, those physiotherapists were assigned to cover the entire hospital department as well. Therefore, During the study period, the number of physiotherapists meeting our eligibility criteria (working in medical wards at the three participating governmental hospitals) was finite. We therefore adopted a census approach and invited all eligible physiotherapists. The final sample of 36 represents the entire eligible population available at that time; consequently, the a-priori GPower calculation served only as initial planning guidance and was superseded by the census design. We have clarified this in the Methods. Instruments This was added as the questionnaire is written and administered in English. And a pilot study was conducted as well We revised Table 6 to report, for the knowledge and attitude outcomes, the adjusted unstandardized coefficients (B), 95% confidence intervals, and standardized coefficients (β), alongside model fit statistics; p-values are consistently formatted. The perceived barriers model did not reach overall significance (F = 1.93, p = .09), so to avoid over interpretation we kept its presentation parsimonious in the main table; we are happy to add β and 95% CIs for barriers in a supplement if preferred. (See revised Table 6.) Result: Explain the application of percentages compared to raw numbers to guarantee uniformity among tables. The regression analysis is clearly displayed but would improve by including standardized beta coefficients and confidence intervals. Certain p-values are presented as 0.00, they ought to be stated as < 0.001. Across all descriptive tables, categorical variables are reported uniformly as count and percentage [n (%)]. Percentages are consistently calculated using the total sample size (N = 36) as the denominator because there were no missing data for the variables presented. Discussion: Elaborate on the implications for policy and clinical training what targeted actions can organizations implement to enhance multidisciplinary pressure injury prevention? Add a brief section discussing how this research contributes to the current literature and suggest areas for future studies, such as intervention trials and larger national samples. Explicitly recognize the limitations of the small sample size, the singular setting, and the self-reporting bias. Done, the recommendations were further elaborated focusing multidisciplinary approach in future studies for improving PI prevention Sample size limitation was acknowledged and discussed in the limitations section Result: Add a more emphatic statement linking enhanced knowledge and guideline application by physiotherapists to measurable patient-care results. Refrain from including new details or references to literature in this section In the Results, we added a concluding sentence to the regression summary: “Overall, guideline use and prior PI training were associated with higher knowledge.” This emphasizes the observed relationship using only our data. Attachments Attachment Submitted filename: response file.docx https://doi.org/10.1371/journal.pone.0344480.r002
23 Feb 2026 Decision Letter - Maheshkumar Baladaniya, Editor <p>"Healing Hands: Understanding Physiotherapists' Knowledge, Attitudes and Barriers on Pressure Injury Prevention in the Medical Wards in Jordan" PONE-D-25-37371R1 Dear Dr. Assaf, 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. For questions related to billing, please contact billing support . 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, Maheshkumar Baladaniya Academic Editor PLOS One Additional Editor Comments (optional): Manuscript it acceptable for publication. Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 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??> 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 Reviewer #1: Yes Reviewer #2: Yes ****** 5. Is the manuscript presented in an intelligible fashion and written in standard English??> Reviewer #1: Yes Reviewer #2: Yes ****** Reviewer #1: After re-evaluation of the revised manuscript and the detailed point-by-point responses, I find that the authors have effectively incorporated all suggested changes. The revisions have strengthened the manuscript, and it is now ready for acceptance. Reviewer #2: The authors have adequately responded to reviewer comments, and the revised version is scientifically sound, clearly written, and suitable for publication in PLOS ONE. ****** 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: No ******** https://doi.org/10.1371/journal.pone.0344480.r003
Formally Accepted
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