-->PONE-D-25-50691-->-->Barriers to adherence to endotracheal tube suctioning guidelines among intensive care nurses at a Tanzanian national hospital: A qualitative study-->-->PLOS ONE

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Additional Editor Comments:

-->The manuscript has been evaluated by two reviewers, and their comments are available below.-->-->

The reviewers have raised a number of concerns. They feel request you include local statistics on ICU staffing ratios, equipment availability, and/or training frequency, and like to you to strengthen the study aim by explicitly linking to practical, policy, or clinical implications.-->--> -->-->Upon internal evaluation of the review s provided, we kindly request you to disregard the reviewer report provided by Reviewer 2. No amendments are required in response to reviewer 2’s comments"-->-->

Could you please carefully revise the manuscript to address all comments raised by Reviewer 1?

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Reviewer’s Responses to Questions-->

-->Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

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Reviewer #1: Yes

Reviewer #2: Yes

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

Reviewer #1: N/A

Reviewer #2: Yes

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Reviewer #1: No

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: 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: First, I would like to thank the authors for their effort in addressing this important topic.

General:

• English editing is necessary.

Introduction and Background:

• Link ETS non-adherence to patient outcomes (rates of ventilator-associated pneumonia (VAP) or ICU mortality) to emphasize significance in low-resource settings?

• Compare global adherence rates and challenges to those in resource-limited settings like Tanzania. Highlight differences in staffing, equipment, and guideline dissemination

• The background notes that non-adherence exists and that knowledge deficits have been observed in Tanzania. However the barriers themselves are not sufficiently detailed and the rationale for a qualitative exploratory approach is implied but not explicitly stated.

o Clearly articulate the research gap, including systemic, behavioral, and contextual barriers.

o Justify the qualitative design by emphasizing the need for in-depth, context-specific understanding.

• Include local statistics on ICU staffing ratios, equipment availability, or training frequency.

• Strengthen the study aim by explicitly linking to practical, policy, or clinical implications.

Methods:

• Participant Recruitment and Sample Size:

o Briefly describe how saturation was determined (e.g., no new codes or themes emerging after a specific number of interviews).

o State whether there were any refusals or dropouts.

• Data Collection:

o Explain how field notes were used in the analysis (e.g., to contextualize verbal responses, capture nonverbal cues).

• Data analysis:

o Clarify how disagreements in coding or theme development were resolved.

o Provide a brief rationale for the final three themes and six subthemes.

Results:

• Ensure that quotes are evenly distributed across participant responses to avoid over-representing particular individuals. For instance, ensure that perspectives from both Nursing Officers (NOs) and Assistant Nursing Officers (ANOs) are equally reflected.

• Provide a table showing the number of participants who contributed to each theme or subtheme.

• Expanding on how themes were validated. For example, briefly mention if the themes were reviewed by participants or if the analysis was triangulated with other sources to enhance credibility.

• Explicitly link each theme back to the broader research question and its implications for practice. For example, under Resource Barriers, emphasize how the lack of equipment or staff directly compromises adherence to evidence-based ETS practices and patient outcomes.

• Exploring demographic influences and practical implications in greater depth. For example, do less experienced nurses report different challenges compared to more experienced ones? Do Nursing Officers face different barriers than Assistant Nursing Officers? This analysis would add depth to the results.

• Consider explicitly discussing the interplay between themes. For example, how do resource barriers exacerbate human and behavioral challenges, such as resistance to change?

Discussion:

• Apply a more critical comparative approach by emphasizing how the Tanzanian context diverges from previous research findings. In addition, several citations could be more effectively contextualized to illustrate how they specifically inform or contrast with the current study’s results, rather than simply reinforcing them.

• Briefly mention limitations of the methods (e.g., single-site study, potential for social desirability bias in interviews

Reviewer #2: Buyi et al. present a well-structured qualitative study exploring barriers to adherence to endotracheal tube suctioning (ETS) guidelines among ICU nurses at a Tanzanian national hospital. The authors employ semi-structured interviews and thematic analysis to identify three key themes: resource barriers, human and behavioral challenges, and guideline accessibility and usability. The study is timely and relevant, especially for improving evidence-based nursing practices in resource-limited settings.

The manuscript is well written and methodologically sound, but I have several comments regarding its enhancement of the study’s transparency, credibility, and replicability.

Background

The authors provide a clear and compelling rationale for the study. The problem statement is well articulated, the authors describe endotracheal tube suctioning (ETS) as a critical procedure in ICU settings, emphasizing its role in maintaining airway patency and preventing complications like ventilator-associated pneumonia (VAP). The research gap clearly states that while non-adherence to ETS guidelines is recognized, the specific barriers in the Tanzanian ICU context remain underexplored. The author also reviews existing literature on ETS guidelines and adherence challenges, citing global studies that document suboptimal compliance.

Purpose or research question

The purpose of the study is clearly stated: to explore the barriers to ETS guideline adherence among ICU nurses at Muhimbili National Hospital (MNH), Tanzania. However, the article did not mention specific research questions that guide the inquiry and clarify its objectives.

Methods

The use of an exploratory qualitative design is appropriate. The authors followed Braun and Clarke’s thematic analysis framework, which is suitable and well executed. The Standards for Reporting Qualitative Research (SRQR) in the manuscript is generally well-structured and addresses many key elements. However, several components are either missing or underreported, which could affect the transparency and completeness of the study.

Moreover, the manuscript lacks sufficient detail on researcher characteristics and reflexivity. The reflexive journaling is briefly mentioned, there is no clear description of the interviewer’s background, gender, training, or relationship to participants. This information is essential to understanding potential biases and the influence of the researcher on data collection and interpretation. Given the hierarchical nature of hospital settings, potential power dynamics should be acknowledged and discussed. This would enhance transparency and help readers assess the influence of the researcher on data collection and interpretation.

Participant recruitment and sample size

Purposive sampling was used, and the sample size (17) was justified through data saturation. The demographic table is clear and informative. However, the manuscript does not mention whether any participants declined to participate or dropped out. This should be clarified.

Additionally, while sampling saturation is mentioned, the process used to determine saturation whether it was code saturation or meaning saturation is not explained. Clarifying this would strengthen the justification for the sample size.

Data Collection

Semi-structured interviews were conducted in Kiswahili, audio-recorded, and transcribed verbatim. Field notes were taken, and member checking was performed. These are strengths. However, the manuscript does not specify whether repeat interviews were conducted, nor does it mention the presence or absence of non-participants during interviews. These details should be added.

Data Analysis

The inductive thematic analysis is rigorous and well described. Collaborative coding and bilingual verification of translations strengthen the validity of findings. However, the manuscript does not mention whether any qualitative data analysis software (e.g., NVivo, Atlas.ti) was used. Including this information would enhance methodological transparency.

Findings

Themes and subthemes are clearly presented and supported by rich participant quotations. The discussion is well integrated with existing literature and reflects the realities of the study context. The conclusions are consistent with the data and offer practical recommendations.

Discussion

The manuscript addresses several key elements expected in qualitative research reporting. The authors begin with a clear summary of the main findings, identifying three thematic barriers to guideline adherence, and effectively connect the results to existing literature, showing how their findings support and expand upon previous studies. However, while they acknowledge the study’s limited generalizability, the discussion of broader applicability could be more developed. The manuscript does identify its unique contribution by highlighting the systemic nature of non-adherence in a Tanzanian ICU context, which adds valuable insight to the field of nursing practice in resource-limited settings. Overall, the discussion is coherent and well-integrated, though it could benefit from a more explicit articulation of theoretical implications and potential for policy or practice impact beyond the study site.

Ethical Considerations

Ethical approval and informed consent procedures are clearly described. Participants were informed of their rights, and confidentiality was maintained. This section is well handled.

Data Availability

The authors confirm that all relevant data are available within the manuscript and supporting files, including the interview guide and transcript excerpts. This satisfies journal requirements.

Presentation and Language

The manuscript is written in standard English and is easy to follow. Minor typographical and formatting issues should be corrected during revision.

I recommend minor revisions for this manuscript to improve reporting clarity, researcher reflexivity, and alignment with the SRQR checklist.

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Reviewer #1: No

Reviewer #2: No

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Attachments

Attachment

Submitted filename: Reviewer Report.docx

Barriers to adherence to endotracheal tube suctioning guidelines among intensive care nurses at a Tanzanian national hospital: A qualitative study

PONE-D-25-50691R1

Dear Dr. Ndile,

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,

Marianne Clemence

Staff Editor

PLOS One

Additional Editor Comments (optional):

Please note that it is not necessary to address the comments of Reviewer 3 to meet our publication criteria.

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 #2: All comments have been addressed

Reviewer #3: (No Response)

Reviewer #4: 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 #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: 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 #2: Yes

Reviewer #3: Yes

Reviewer #4: 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 #2: Yes

Reviewer #3: Yes

Reviewer #4: 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 #2: (No Response)

Reviewer #3: Manuscript Title

Barriers to adherence to endotracheal tube suctioning guidelines among intensive care nurses at a Tanzanian national hospital: A qualitative study

Major Comments (Minor Revisions Needed)

1. Redundancy and Editing Issues

There are visible duplications and formatting artifacts (likely from track changes):

Example:

“Endotracheal tube suctioning (ETS) is a frequently performed… Endotracheal tube suctioning (ETS) is among the most frequently performed…”

Recommendation:

Remove duplicated sentences in Background section.

Carefully clean manuscript for:

Repeated phrases

Track-change remnants

Formatting inconsistencies

2. Clarity of Abstract (Minor Language Issue)

3. Consistency in Terminology

Some inconsistencies observed:

“Human & behavioural challenges” vs “Human and behavioral challenges”

“Guideline accessibility & usability” vs “Guideline accessibility and usability”

Recommendation:

Use consistent terminology throughout (prefer journal style: and instead of &)

4. Quantification Concern in Qualitative Study

In response to reviewer:

Table of number of participants per theme not included

While justification is valid, journals like PLOS ONE often accept light quantification.

Recommendation (optional but strong):

Add supplementary table showing:

Number of participants contributing to each theme/subtheme

This will strengthen transparency and credibility

5. Link Between Results and Implications

Although addressed in discussion, some sections of results remain purely descriptive.

Suggest minor enhancement:

Add one linking sentence per theme indicating:

“This has implications for patient safety/practice…”

6. Language Polishing (Minor)

Some sentences are still slightly verbose or repetitive.

Example:

“This study revealed three key barriers… Resource barriers… were the most critical…”

Minor Comments

1. Methods Section

Good description of saturation, but could be sharper:

Add: “No new codes/themes emerged after the 15th interview…” (if applicable)

2. Ethics Section

Well written, but could be condensed slightly for brevity.

3. References

Minor formatting inconsistencies:

Spacing issues

Duplicate citation numbering style in some places

Ensure strict PLOS ONE referencing format

4. Tables

Table 2 is good but could be improved:

Align bullets consistently

Ensure formatting uniformity

Overall Recommendation

Minor Revision (close to acceptance)

The manuscript is well-structured, methodologically sound, and addresses an important gap in ICU nursing practice in resource-limited settings. Reviewer comments have been adequately addressed in most sections. Only minor refinements in clarity, consistency, and presentation are required.

Reviewer #4: Thank you for addressing all the comments so thoroughly. The paper has been greatly improved by the additions and amendments made in response to the review. Well done. An important paper that adds to the body of knowledge.

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Reviewer #2: Yes: Junaidy Suparman Rustam

Reviewer #3: Yes: Noorul Amin

Reviewer #4: Yes: Angela Flynn

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