Peer Review History

Original SubmissionMay 8, 2020
Decision Letter - Michio Murakami, Editor


Factors Contributing to Healthcare Professional Burnout During the COVID-19 Pandemic:

A Rapid Turnaround Global Survey


Dear Dr. Morgantini,

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 see "Additional Editor Comments."

Please submit your revised manuscript by Jul 27 2020 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 When you're ready to submit your revision, log on to and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

  • 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'.
  • 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 to enhance the reproducibility of your results. assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:

We look forward to receiving your revised manuscript.

Kind regards,

Michio Murakami

Academic Editor


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 and

2. Thank you for stating the following in the Acknowledgments Section of your manuscript:

The project was supported by the National Center for Advancing Translational Sciences, National

Institutes of Health, through Grant UL1TR002003. We acknowledge the support received from

Sandra Morales-Mirque, Dr. Craig Niederberger and Dr. Ervin Kocjancic.

We note that you have provided funding information that is not currently declared in your Funding Statement. However, funding information should not appear in the Acknowledgments section or other areas of your manuscript. We will only publish funding information present in the Funding Statement section of the online submission form.

Please remove any funding-related text from the manuscript and let us know how you would like to update your Funding Statement. Currently, your Funding Statement reads as follows:

The authors received no specific funding for this work.

3. Please amend the manuscript submission data (via Edit Submission) to include author Heng Wang.

4. Please amend your authorship list in your manuscript file to include author Heng Want

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:

Additional Editor Comments (if provided):

1. As reviewers pointed out, the authors need to expain participants and recruitment method in more details.

2. The authors need to describe the validity and reliablility of the outcome.

3. It is questionable to compare the level of prevalene in this study (51.4%) with the value (40%) in the other study. Were the same measurement outcome used in this study and the cited study?

4. The authors need to describe the limitations in more details. The limitations may include sample selection biases and validity and reliability of outcomes. If possible, the authors are expected to add how the biases potentlay affected the results and how the authors did the efforts to reduce the biases. Plus, the authors need to add that the causalty is not clarified due to a nature of observational study.

5. Although I recommended the authors to incorporate "Reseach in context" into Introduction and Discussion, although PLOS ONE guidelines are quite flexible and it is not an absolute requirement for the authors to remove this section.

[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: No


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

Reviewer #1: No

Reviewer #2: Yes


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: General

• Limited questionnaire, but not much that can be done about this

• Needs multivariate regression, including demographic variables


• Geographical spread is impressive

• Method needs to state definition of burnout

Research in Context

• The ‘Evidence before this study’ merely states a search strategy without stating what the established knowledge was before the study was conducted


• This is a minor point. The authors state in the first sentence ‘novel coronavirus (COVID-19)’. The name of the novel coronavirus is SARS-CoV-2, whereas the name of the disease is COVID-19. This should be corrected.


• The scope of the study in terms of geography and translation into 18 languages is impressive

• It is a shame that validated self-report rating scales were not used, rather than 40 questions based on expert opinion

• Were demographic data collected from respondents? This is not mentioned in the Methods.

• I am not familiar with the burnout literature, but having the main outcome as a single question on self-report burnout seems like an unstable measure that would show high intra-individual variability. It would have been more helpful to use a validated tool, e.g. as listed here:

• Only participants who responded completely were included in the regression were included. This is reasonable, but it is important to assess whether completers differed from non-completers in any important ways.

• Before participants were asked whether they were ‘burned out’ by their work, were they given any definition of being ‘burned out’?


• 2707 valid responses were received. The manuscript should state how many invalid responses were received.

• Bivariate associations were reported between burnout and various other factors. It would be important to see a multivariate analysis to see which factors were independently associated with burnout.

• In particular, I cannot see any attempt made to examine demographic associations with burnout. These need to be included in a regression model, as they might be significant confounders.


• The 3rd sentence mentions factors that typically increase the likelihood of HCP burnout. This needs a citation.

• The 2nd paragraph rather overreaches itself by stating that burnout could be ‘prevented or minimised’. Given that burnout is always prevalent at a certain rate, it is highly improbable that it could be prevented. Minimisation of burnout may be possible, but this is not demonstrated by this paper, which does not examine interventions. This must be stated more cautiously.

• Paragraph 3 states that ‘HCPs who worked extensively during the SARS pandemic in Beijing later demonstrated posttraumatic stress symptoms’. Surely this is only some HCPs.

Reviewer #2: This study reports the prevalence and the risk factors of burnout among healthcare professionals from several countries during the COVID-19 pandemic. The topic is extremely important and the study provide several valuable suggestions to prevent healthcare professionals’ burnout. However, the study design has several serious weaknesses, which limit the validity of their results.

1. As for burnout or mental health status of healthcare professionals during the COVID-19 pandemic, several studies have already been published (e.g. Wu et al., 2020 (J Pain Symptom Manage. doi: 10.1016/j.jpainsymman.2020.04.008); Barello et al., 2020 (Psychiatry Res 290:113129. doi: 10.1016/j.psychres.2020.113129)). Furthermore, there are a lot of studies reporting healthcare professionals’ burnout or mental health issues during the other pandemic, disaster, or in non-disaster settings. Authors should explain the necessity of their study, unexplored research gaps, in the introduction.

2. Please give a more detailed description of the methods used to identify potential participants. How to identify social media groups restricted to HCPs, how many groups were identified and recruited? Were there any inclusion criteria for the groups? Is it possible to estimate the number of potential participants to this survey? Response rate? The authors should report how to distribute their questionnaire.

3. According to the questionnaire and Table 4, the respondents include students, administrative staffs, not a healthcare professional. Were these respondents included in the analyses?

4. The representativeness of the respondents to their survey was not maintained. Therefore, discussion on the prevalence of burnout is impossible based on their data.

5. Burnout was assessed using a single item scale translated into several languages. The reliability and validity of the translated scales, as well as those of cutoff point of 5, were not reported. It is impossible to compare the prevalence of burnout measured by this scale between countries using different languages. Furthermore, the authors assessed only emotional exhaustion and not assessed the other two dimensions of burnout (depersonalization and personal accomplishment). To compare the prevalence of emotional exhaustion and that of burnout is meaningless.

6. Please report the number of respondents who were categorized into high vs low-middle income countries. Is it appropriate to divide the 60 countries into these two groups? Did the authors try to analyze their data with the other categorization of countries? There are many differences among countries, such as the phase of the pandemic, its fatality rate, strategies for COVID-19 adopted, medical system, resources, etc. If authors choose the categorization based on the country’s income level, they should explain its importance on their study. Figure 2 shows the great differences between US and Italy or Sweden among high-income countries. Although the data of the other countries were not reported, the high prevalence of burnout in high-income countries might almost stem from the data in US.

Minor comments

7. Page 4, line 7

Burnout is usually assessed in three dimensions: emotional exhaustion, depersonalization, and personal accomplishment. The authors’ definition of burnout seemed uncommon. Please explain the definition of “personal achievement” or provide the references.

8. Page 6, line 16

The results of the comparison between nurses and physicians reported in the text (OR=1.47) were different from those in Figure 2 (OR=1.12, ns).

9. The authors declared they received no specific funding for this work in the Financial Disclosure section (through online system?) but they acknowledged that their project was supported by the National Center for Advancing Translational Sciences, National Institutes of Health. They should also report the role of the funder.


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: Dr Jonathan P Rogers

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.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, 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 PLOS at Please note that Supporting Information files do not need this step.

Submitted filename: Review 1.docx
Revision 1

We are truly grateful and humbled for the constructive criticism and suggestions we received from the Editor and the Reviewers.

We believe that your contribution has truly improved the quality of our work and we have learnt important lessons from your feedback.

I extend to you the sincere gratitude of all authors.

Best regards,

Luca Morgantini

Submitted filename: Response to Reviewers letter.docx
Decision Letter - Michio Murakami, Editor

Factors Contributing to Healthcare Professional Burnout During the COVID-19 Pandemic:

A Rapid Turnaround Global Survey


Dear Dr. Morgantini,

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 for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at

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

Kind regards,

Michio Murakami

Academic Editor


Additional Editor Comments (optional):

Reviewers' comments:

Formally Accepted
Acceptance Letter - Michio Murakami, Editor


Factors Contributing to Healthcare Professional Burnout During the COVID-19 Pandemic: A Rapid Turnaround Global Survey

Dear Dr. Morgantini:

I'm 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 let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, 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

If we can help with anything else, please email us at

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Michio Murakami

Academic Editor


Open letter on the publication of peer review reports

PLOS recognizes the benefits of transparency in the peer review process. Therefore, we enable the publication of all of the content of peer review and author responses alongside final, published articles. Reviewers remain anonymous, unless they choose to reveal their names.

We encourage other journals to join us in this initiative. We hope that our action inspires the community, including researchers, research funders, and research institutions, to recognize the benefits of published peer review reports for all parts of the research system.

Learn more at ASAPbio .