-->PONE-D-25-58744-->-->Path analysis of Factors Associated with Nurses’ Pain Management Practice in Older Adults with Cognitive Impairment: a cross-sectional study-->-->PLOS One

Dear Dr. Niyomyart,

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Academic Editor

PLOS One

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Additional Editor Comments

Dear Authors,

Thank you for your submission to PLOS ONE. The reviewers have identified several important points and raised a number of issues that need to be carefully addressed before we can consider your manuscript further.

We look forward to receiving your revised manuscript.

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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: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #4: No

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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: Yes

Reviewer #3: Yes

Reviewer #4: 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: Overall significance

• The manuscript examines a significant and underexplored domain: the pain management practices of nurses concerning older adults with cognitive impairment, employing a theoretically informed path analysis. The integration of Social Cognitive Theory and the analysis of self-efficacy as a mediator significantly contributes to nursing and gerontological pain literature, especially in the Thai context.

• The manuscript requires professional English language editing.

• The references are up-to-date and appropriate for publication.

• Clarity and Structure: The manuscript is well organized and clearly articulated. Certain sections would benefit from enhanced conciseness.

Abstract

It is advisable to briefly indicate the cross-sectional and secondary analysis characteristics of the study in the Methods section to improve transparency.

Background

• The background offers a compelling rationale, underpinned by pertinent and current literature.

• The transition from prevalence to clinical consequences to nursing challenges is coherent.

Suggestions:

• Some paragraphs (pages 11–12) are dense and could be streamlined by reducing overlapping citations.

• Clearly identify the existing knowledge gap by noting that previous path analyses or mediation models have not investigated these variables in older adults with cognitive impairments.

• Explicitly reference and interpret Figure 1 in relation to the hypothesized paths.

Methods

• Study Design: Add a brief justification for why secondary analysis was suitable for addressing the current research aim.

• Tools: Clarify how adding new items to TENAP Part B may affect comparability with prior studies.

• Data Analysis: The statistical approach is appropriate and well justified.

• Briefly state how assumptions for SEM (normality, multicollinearity) were assessed.

Results:

• The results are presented clearly and sequenced logically.

Discussion:

• The discussion is clearly articulated, and the interpretation of self-efficacy as a mediator is notably robust.

• Reduce redundancy in the discussion of knowledge, collaboration, and experience throughout various paragraphs.

• To improve international relevance, explicitly compare findings with non-Asian or Western contexts.

Limitations:

• Add a brief note on common method bias due to self-report measures.

Conclusion:

• Refrain from repeating detailed findings; rather, highlight the significance of noting essential points.

Reviewer #2: Objective does not state clearly what is the goal of study?, what research will achieve/outcome after finding relationships. it is not clear. the study needs more strong need assessment as to what happen due to limited knowledge of pain management in terms of cognitive impairment elderly clients?, Discuss factors behind direct and indirect relation among variables and impacts in quantifiable data, more studies from different countries is required in discussion. adding the impact is crucial in discussion. recommendation is required in separate heading, the topic is vital to understand and explore more on pain management, appreciated to develop the research. the study can also explore views from patient their perceptions to relate further the impact.

Reviewer #3: This study focuses on nurses' pain management practices in this population, which closely aligns with clinical needs and holds practical relevance. However, the following areas still require improvement:

1.Inconsistent use of terminology: For example, “collaborative perception” and “perception of collaboration” are used interchangeably. It is recommended to unify the terms throughout the manuscript.

2. The model explained only 37% of the variance. It is suggested that the discussion briefly addresses other potential factors influencing pain management practices, such as organizational culture and resource support.

3. The findings support that improving nurses’ self-efficacy can enhance pain management practices. It is recommended to explicitly propose targeted training strategies in the “Conclusion” or “Recommendations” section, such as scenario-based simulation and reflective practice.

4. All participants were female. It is suggested that this limitation be further explained in the discussion, and future studies should consider including male nurses or nursing populations with different educational backgrounds.

Reviewer #4: This manuscript addresses an important and underexplored topic: factors associated with nurses’ pain management practices for older adults with cognitive impairment. The topic is clinically relevant, theoretically grounded, and aligned with PLOS ONE’s scope. The use of Social Cognitive Theory and path analysis provides a coherent conceptual framework, and the sample size appears adequate for the proposed analyses. Overall, the study has merit; however, several issues should be addressed to improve clarity, rigor, and transparency before the manuscript can be considered for publication.

Major comments

The Introduction would benefit from structural consolidation. Currently, background information, literature review, and conceptual framing are distributed across multiple sections with some repetition. These sections could be merged into a single, more concise Introduction that progresses from (1) the clinical importance of pain management in older adults with cognitive impairment, to (2) existing evidence on nurses’ knowledge, attitudes, collaboration, and experience, and (3) the theoretical grounding in Social Cognitive Theory leading to the study aim. This restructuring would improve flow, reduce redundancy, and enhance readability without loss of content.

Conceptual justification of the model

The manuscript states that Social Cognitive Theory (SCT) guided the model; however, only a subset of SCT constructs (knowledge/attitudes, collaboration, self-efficacy) are operationalized. Other core SCT components such as outcome expectations, observational learning, and reinforcement are not included. The authors should strengthen the theoretical justification explaining why the selected constructs were prioritized and how collaboration and years of experience conceptually map onto SCT domains. This clarification would strengthen the conceptual coherence of the model.

Model modification and path removal

The manuscript notes that the initial model was just-identified and that the path from years of experience to pain management practice was removed to improve model fit. This modification requires clearer justification. Please clarify whether this decision was theory-driven or guided by model diagnostics (e.g., modification indices). Post-hoc model changes should be explicitly justified to avoid concerns about data-driven model fitting.

Interpretation of mediation using cross-sectional data

Although bootstrapped mediation was conducted appropriately, the cross-sectional design limits causal inference. Throughout the Results and Discussion, causal wording such as “influences,” “improves,” or “leads to” should be softened and replaced with language such as “is associated with” or “is consistent with an indirect relationship.” This clarification is important to avoid overstating causal conclusions.

Measurement considerations and self-report bias

All key variables, including pain management practice, were measured using self-report instruments. This raises the possibility of social desirability and common-method bias. While this limitation is acknowledged, it should be more explicitly emphasized. The authors are encouraged to discuss how future studies could incorporate observational measures, audits, or objective indicators of practice.

Modification of the TENAP instrument

The manuscript describes substantial adaptation of the TENAP instrument, including adding new items and expanding its scope from assessment to management. While psychometric testing is reported, the authors should more clearly acknowledge that this represents an expanded or modified version of the original instrument. Clarification is needed regarding construct equivalence and comparability with prior TENAP-based studies.

Statistical reporting clarity

Please clarify whether coefficients reported in tables and figures are standardized or unstandardized.

Ensure consistency in reporting correlation coefficients (Pearson vs. Spearman) and notation.

Some confidence intervals appear wide relative to the reported coefficients and should be double-checked.

Minor formatting inconsistencies (spacing, p-value notation) should be corrected.

Generalizability

The study sample consists entirely of female nurses from two hospitals in Thailand. While this reflects the local workforce context, the authors should more clearly acknowledge limits to generalizability beyond similar cultural and healthcare settings.

Minor comments

-Minor grammatical and stylistic issues are present throughout the manuscript and should be corrected during revision.

-Keywords should be standardized (e.g., “nurses’ pain management” rather than “nurse’ pain management”).

-Figures would benefit from clearer labeling and explicit indication of standardized coefficients.

-Some repetition in the Discussion could be reduced to improve clarity and conciseness.

Summary

This study addresses a relevant clinical and educational issue and applies an appropriate analytical approach. With clearer theoretical justification, more cautious interpretation of mediation effects, improved reporting transparency, and minor editorial revisions, the manuscript would be suitable for publication.

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Reviewer #1: No

Reviewer #2: Yes: Zaibunissa

Reviewer #3: No

Reviewer #4: No

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Attachments

Attachment

Submitted filename: PLOS revision.docx

-->PONE-D-25-58744R1-->-->Path analysis of Factors Associated with Nurses’ Pain Management Practice in Older Adults with Cognitive Impairment: a cross-sectional study-->-->PLOS One

Dear Dr. Niyomyart,

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 May 15 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,

Ahmed Abdelwahab Ibrahim El-Sayed

Academic Editor

PLOS One

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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 your revision. Your manuscript has now been carefully assessed. However, several issues have been raised by the reviewer during this round, which need to be addressed carefully before we can consider your paper further

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Reviewers' comments:

Reviewer's Responses to Questions

-->Comments to the Author

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Reviewer #1: All comments have been addressed

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-->2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented. -->

Reviewer #1: Partly

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

Reviewer #1: Yes

**********

-->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

**********

-->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

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-->6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)-->

Reviewer #1: Abstract: Keywords are not fully aligned with MeSH terminology.

Literature Review and Conceptual Framework: Figure 1 is not sufficiently explained or integrated into the text.

Methods

· Participant flow, inclusion/exclusion criteria, and response rate are not clearly reported.

· No a priori sample size calculation or statistical power analysis is clearly justified.

Measurement Validity and Reliability

· Scoring procedures and interpretation of scale direction are inconsistently described.

· The modification of the TENAP instrument is insufficiently justified in terms of construct validity.

· The comparability with previous studies using the original instrument is not adequately addressed.

· The manuscript does not report the presence, proportion, or handling of missing data.

Results

· Descriptive statistics lack consistent formatting across tables.

· Tables do not consistently include footnotes explaining scale ranges and score interpretation.

· Percentages are inconsistently reported (decimal places vary).

· Table titles do not consistently report sample size (N).

· Variable labels are inconsistently formatted.

· Use of commas instead of decimal points violates international reporting standards.

· Structural model results are presented clearly; however, confidence intervals and effect sizes are not fully integrated into the narrative.

· The non-significant paths are not adequately contextualized.

· The explained variance (37%) is not critically interpreted.

Discussion

· Direct and indirect relationships are not sufficiently explained mechanistically.

· Limited comparison with international (non-Asian) studies reduces global relevance.

· Some statements approach causal interpretation despite a cross-sectional design.

· Residual redundancy is present across discussion sections.

Implications and Recommendations

· A separate “Recommendations” section is not provided despite the reviewer’s request.

· Practical implications remain general and lack actionable strategies.

· Clinical, educational, and policy-level implications are not clearly differentiated.

References

· The reference list does not consistently follow the journal’s required citation style.

· The manuscript relies heavily on region-specific sources, limiting global applicability.

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Reviewer #1: No

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Path analysis of Factors Associated with Nurses’ Pain Management Practices in Older Adults with Cognitive Impairment: a cross-sectional study

PONE-D-25-58744R2

Dear Author,

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.

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PLOS One

Additional Editor Comments (optional):

Dear Authors,

Thank you for your revision. I have finished my review to your revision, and I can accept your manuscript for publication in its current form at PLOS ONE.