Nurses’ perspectives on their communication with patients in busy oncology wards: A qualitative study

E. Angela Chan; Pak Lik Tsang; Shirley Siu Yin Ching; F. Y. Wong; Winsome Lam

doi:10.1371/journal.pone.0224178

Peer Review History

Original SubmissionJune 11, 2019
7 Aug 2019 Decision Letter - Janhavi Ajit Vaingankar, Editor PONE-D-19-16364 Re-examining psychosocial care through nurse-patient communication in busy oncology wards: A qualitative study PLOS ONE Dear Dr Chan, 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. For your revision, you may wish to refer to the COREQ guidelines on reporting of qualitative research, as a number of comments from the reviewers highlight this limitation in the manuscript. In particular, please emphasize on how saturation was assessed in this work and elaborate further on the development and finalisation of the thematic map. We would appreciate receiving your revised manuscript by Sep 21 2019 11:59PM. 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The PLOS ONE style templates can be found at http://www.journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and http://www.journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf 1. Please include a copy of the interview guide used in the study, in both the original language and English, as Supporting Information, or include a citation if it has been published previously. [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: Partly Reviewer #2: Partly ******** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #2: No ****** 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 ****** 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: 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: This is an interesting article. I suggest that the title is reviewed so the focus is nurse-patient communication in oncology wards. There needs to be a clearer focus on skilled communication throughout the essay this should be the focus. An anonymised table of who the participants are and how long they have worked in oncology should be included. It isn't clear why focus groups and interviews are both used in the study as nurses can give different accounts according to which method is used. The focus of the article should be on the nurses response to patients' emotions and their own emotional response. This focus would fit with theoretical work related to 'emotional labour' please see the work of Pam Smith, which is a seminal text on nurses emotional labour. More information is needed on what findings from the first part of the study are relevant to the current study. More reflexivity is needed on the data collected from the focus groups and the data from individual interviews. It isn't clear how the data were coded and how psychosocial care, values and emotions were coded from the data. There needs to be explanations of how comparisons were made between the different types of data. More information is needed on what codes were considered significant and patterned these need to be identified. A thematic map is referred to again this map needs to be discussed and the process of developing this map further explored. More information is needed on how the final three themes were agreed. The most interesting part of the data analysis is around nurses' experience of emotional control. It seems that nurses used preventative communication strategies to avert the possibility of complaints or frustrated patients and their families. Once discussing patients' emotions nurses were able to express the strategies they used in communication with those who were distressed in this way. In particular there is a focus on patients expressing anger. The data analysis should focus on the nurses descriptions of connection and disconnection how they facilitated or blocked patients from expressing strong emotion. Please see the work of Wilkinson et al related to barriers to communication. Although the nurses prioritise physical care they also identify their role in going back to communicate with patients who are distressed. There are some expressions where nurses identify their lack of skill in dealing with patient emotions this needs picking up on and relating to what preparation these nurses have had in terms of training as well as years of practice. There is evidence that nurses pass the blame for the situation to others such as the characteristics of the patient or shift the blame for the situation to others. There is evidence that the nurses struggled with how to handle strong emotion and did not have the skills to deal with this. The discussion brings out the importance of proactive strategies and this is positive. The discussion should be more focused on the positive strategies but also on the difficulties that nurses experience in handling strong emotions. This later point is not only related to time pressures. Reviewer #2: This study explores the experiences of nursing communication with respect to emotional concerns based on a series of interviews and focus groups. The methodology description does not provide the theroretcial framework underpinning the qualitative methodology employed in the study. The description of the conduct of the focus groups is unnecessary and the manuscript would benefit from a description of the questions asked - the supplementary table only includes a copy of the two scenarios used to orientate participants not the interview schedule. Under participants the authors stae that 11 participants is sufficient to reach theretical saturation - how was this establsihed. Was there any check that saturation was reached. Typically saturation is determined empirically - interviews are conducted until no further themes can be identified and this is then checked by conducting a further interviews to confirm. It is uncler whether the two reviewers coding the data independently and how differences were reconciled. Overall there needs to be much greater detail provided for the methodology and rigor checks. The results : unsure of the context for lines 187-190 - this paragraph does not seem to fit the context of the surrounding text. The presentation of themes are descriptive rather than a thematic analysis and there are too few quotes or discussion of the complexity of diffrent nursing experiences. ****** 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. 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: Yes: Anne Arber 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 be viewed.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step. https://doi.org/10.1371/journal.pone.0224178.r001
Revision 1
3 Sep 2019 Author Response Responses to reviewers’ commments Reviewers’ comments Responses you may wish to refer to the COREQ guidelines Thanks for the suggestion, COREQ was used as a guide. Include a copy of the interview guide used in the study, in both the original language and English, as Supporting Information, or include a citation if it has been published previously. Copies of the interview guide are included as supporting document. Title is reviewed so the focus is nurse-patient communication in oncology wards. There needs to be a clearer focus on skilled communication throughout the essay Thanks for the suggestion. The title has been revised with a focus on nurse-patient communication in oncology wards. An anonymised table of who the participants are and how long they have worked in oncology should be included. An anonymized table is included. Reason for why focus groups and interviews are both used in the study as nurses can give different accounts according to which method is used. Similar to other researchers, both methods were combined for practical considerations, that is individual interviews were offered to accommodate the busy schedule of the nurse participants, who were unable to attend the focus group (Rees et.al.2003,Taylor 2005). Focus of the article should be on the nurses response to patients' emotions and their own emotional response, which fit with theoretical work related to 'emotional labour' Thanks for the suggestion, literature on emotional labor and work from Prof. Pam Smith has been reviewed and intergrated into the article. More information is needed on what findings from the first part of the study are relevant to the current study. More information has been included in the paper. This primarily refers to the use of findings from patients’ perceptions of their nurse-patient communication in the same oncology wards (first part of the study) to stimulate discussion with nurses. After the guide questions, nurses were asked to reflect on the patients’ vignettes and to share their views on nurse-patient communication in the oncology wards. Please see the work of Wilkinson et al related to barriers to communication. Thanks for the suggestion. Further reading on Wilkinson’s work has been integrated into the discussion. Reviewers’ comments Responses More reflexivity is needed on the data collected from the focus groups and the data from individual interviews. Thanks for the suggestion, reflexivity on the data collected is included. How the data were coded and how psychosocial care, values and emotions were coded from the data. There needs to be explanations of how comparisons were made between the different types of data. More information is needed on what codes were considered significant and patterned these need to be identified. Thanks for the suggestion. The data process is made more explicit and comparison of different data was provided. Further information is provided on the significant codes and identified patterns. A thematic map is referred to again this map needs to be discussed and the process of developing this map further explored. More information is needed on how the final three themes were agreed. 1. The development of the thematic map is included as figures. Information on how the final three themes were agreed upon is included in the data analysis section. The methodology description does not provide the theoretical framework underpinning the qualitative methodology employed in the study. Thanks for the comment. A theoretical understanding underpins the use of interviews as a qualitative methodology is included. The description of the conduct of the focus groups is unnecessary and the manuscript would benefit from a description of the questions asked Thanks for the suggestion. The description of the focus group is removed. The supplementary table only includes a copy of the two scenarios used to orientate participants not the interview schedule. The interview guide is included. Under participants the authors stated that 11 participants is sufficient to reach theoretical saturation - how was this established? Thanks for the questions. Changes were made for more clarity and check was made for the saturation. Unclear whether the two reviewers coding the data independently and how differences were reconciled. Overall there needs to be much greater detail provided for the methodology and rigor checks. Thanks for the comments. More clarity was made to show that two reviewers have coded the data independently and for any discrepancies, they would be discussed at the regular meetings. COREQ is used as the guide to check the process. Results - lines 187-190 - this paragraph does not seem to fit the context of the surrounding text. The presentation of themes are descriptive rather than a thematic analysis and there are too few quotes or discussion of the complexity of different nursing experiences. The paragraph has been removed and more quotes were included for the discussion of the complexity of different nursing experience. Rees CE, Ford JE, Sheard CE. Patient information leaflets for prostate cancer: which leaflets should healthcare professionals recommend? Patient Education and Counseling. 2003;49:263-72. Taylor B. The experiences of overseas nurses working in the NHS: Results of a qualitative study. Diversity in Health and Social Care. 2005;2:17-27. Attachments Attachment Submitted filename: GRF paper responses to reviewers comments PLOS One.docx https://doi.org/10.1371/journal.pone.0224178.r002
8 Oct 2019 Decision Letter - Janhavi Ajit Vaingankar, Editor Nurses' perspectives on their communication with patients in busy oncology wards: A qualitative study PONE-D-19-16364R1 Dear Dr. Chan, We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements. Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication. Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at https://www.editorialmanager.com/pone/, click the "Update My Information" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org. If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and 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. With kind regards, Janhavi Ajit Vaingankar Academic Editor PLOS ONE Additional Editor Comments : Authors have addressed limitations highlighted by the two reviewers. Appropriate reporting guidelines were followed. Additional information pertaining to reflexivity, coding framework, saturation and results are useful. 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 ******** 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: Yes ****** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A ****** 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: Yes ****** 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: Yes ****** 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: The authors have addressed all the points raised by the reviewers in an in-depth manner. The focusing of the article around proactive and defensive communication now works well. There is now a good discussion and integration of the theory of emotional labour. ****** 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: Yes: Anne Arber https://doi.org/10.1371/journal.pone.0224178.r003
Formally Accepted
15 Oct 2019 Acceptance Letter - Janhavi Ajit Vaingankar, Editor PONE-D-19-16364R1 Nurses' perspectives on their communication with patients in busy oncology wards: A qualitative study Dear Dr. Chan: I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department. If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. 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. For any other questions or concerns, please email plosone@plos.org. Thank you for submitting your work to PLOS ONE. With kind regards, PLOS ONE Editorial Office Staff on behalf of Ms Janhavi Ajit Vaingankar Academic Editor PLOS ONE https://doi.org/10.1371/journal.pone.0224178.r004

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