The Impact of Clinical Experience in Advanced Practice Nursing Education—A Cross-Sectional Study of Norwegian Advanced Practice Nurses’ Perspectives

Round 1

Reviewer 1 Report

In its current form, the manuscript demonstrates several substantial weaknesses that undermine its potential for publication in an international journal at this stage.

Key areas of concern include:

Abstract: it is no need to cite the software used for the analysis in the abstract; further, it is not clear what the ICC is assessing in this context (both in methods and results).  The abstract doesn't explicitly state whether the answers were analyzed in the overall sample or separated by groups. What does the ICC of .71 signify? The abstract lacks a discussion section, which usually interprets the results, provides insights into the implications, and compares the findings with previous research. This should be addressed in the full paper. Conclusions: There is no clear conclusion in the abstract summarizing the main takeaways, the potential impact on policy or practice, or the need for future research. This should be included to give readers a clear understanding of what the study ultimately contributes to the field.

 

Introduction:

a. While the information is adequate, the introduction may benefit from improved flow and cohesion between the different paragraphs. For instance, the transition from global issues to national guidelines and previous studies might be made smoother with some linking sentences or an overarching framework. And, context of Norway should be contextualized in the European area (tuning project, European movements in this regard) Such as EFN or ESNO?). This additional info would provide a more solid base to understand the background for an international readership.

b. While the authors mention the "underdeveloped" evidence base and "methodological limitations" in a 2023 scoping review, they do not explicitly state how their study aims to address or overcome these limitations. Including such a statement could strengthen the rationale for the study, which is weak in this version. Additional work to clarify the need for this study might be useful to increase the relevance of the study.

 

Methods:

1. Using the researchers' Facebook profiles and personal networks for recruitment might introduce selection bias, as the participants may not be representative of the population of APNs and APN students in Norway.

2. The context seems to be very generically mentioned

3. Lack of a sample size calculation might be considered a major flaw.

4. The simplified thematic analysis section could be expanded with more details to improve transparency. For example, clarifying how codes and themes were derived and whether multiple researchers were involved in the coding process.

5. Including information on when the data were collected and the duration of the collection period would provide context for the study.

6. Typos and Language Consistency: There are some minor typos and inconsistencies in language (e.g., "development og questionnaires" instead of "development of questionnaires"; "cirrucula" instead of "curricula").

7. Information regarding ethical approvals, informed consent, and data confidentiality would be essential in this section, as these are standard research protocols that need to be adhered to.

8. Most important aspect: the developed questionnaire has no signs of validity. Even the assessment using Cronbach’s alfa without a theoretical structure and an assessment of dimensionality can be misleading. The authors declared to adhere to the STROBE; however, it is not clear how missingness was handled in the analytics. It should be noted that the details on how qualitative data were analyzed and how they relate to the quantitative findings are very limited. Consideration of inferential statistical methods to go beyond description and make claims about relationships, differences, or effects within the data should be stated.

 

Results: this statement,” The Cronbach’s alpha of the questionnaire was .82, and the ICC in average measures was .71 (p<.001).” without a theoretical framework is without any significance in terms of meaning. The sample is dramatically unbalanced, making it impossible to meet the expectations given by the study’s aims. The subheading “Other analyses” seems to be not sustained by any theoretical base and seems totally exploratory.

Discussion: The results seem to strongly favor the notion that clinical experience is essential. Although disadvantages are mentioned, they are briefly stated and not explored in depth, especially by taking into account the current literature.

 

Limitations: Even if no validated questionnaire exists, some exploratory analytics would have helped to address the concerns about the adequacy of the performed measurements. The current analytical approach seems to me not suitable for an international journal. 

There are some minor typos and inconsistencies in language (e.g., "development og questionnaires" instead of "development of questionnaires"; "cirrucula" instead of "curricula").

Author Response

Response to reviewer I

I thank the reviewer for the concrete and constructive comments to the paper.  I hope that the revisions made are deemed appropriate. Please see my responses to the comments below. The revisions are also shown in the manuscript with track changes.

Comment 1: In its current form, the manuscript demonstrates several substantial weaknesses that undermine its potential for publication in an international journal at this stage. Key areas of concern include:

Abstract: it is no need to cite the software used for the analysis in the abstract; further, it is not clear what the ICC is assessing in this context (both in methods and results). 

Response: I thank the reviewer for this input, and have omitted the citation to the software used.

 

Comment 2: The abstract doesn't explicitly state whether the answers were analyzed in the overall sample or separated by groups.

Response: The answers were analyzed in the overall sample. To clarify, the n has been added to the abstract; “Between 91.5 and 98.3 percent of the respondents (n=1213) agreed that clinical nursing experience leads to…”

 

Comment 3: What does the ICC of .71 signify?

Response: I thank the reviewer for this question. Ideally, the average inter-item correlation for a set of items should be between .20 and .40, suggesting that while the items are reasonably homogenous, they do contain sufficiently unique variance. This indicates that the items may be only capturing a small bandwidth of the construct. Hence, this has been added to the limitations section. Please see manuscript with track changes.

 

Comment 4: The abstract lacks a discussion section, which usually interprets the results, provides insights into the implications, and compares the findings with previous research. This should be addressed in the full paper.

Response: I thank the reviewer for this input. Unfortunately, little research has been conducted on this topic. Based on my experience, there is no discussion section in the abstract. Relevant research has been presented and discussed in the discussion section. Please see manuscript with track changes.

 

Comment 5: Conclusions: There is no clear conclusion in the abstract summarizing the main takeaways, the potential impact on policy or practice, or the need for future research. This should be included to give readers a clear understanding of what the study ultimately contributes to the field.

Response: I thank the reviewer for this input, and have consequently revised the conclusion section of the abstract. Please see manuscript with track changes.

 

Comment 6: Introduction: a. While the information is adequate, the introduction may benefit from improved flow and cohesion between the different paragraphs. For instance, the transition from global issues to national guidelines and previous studies might be made smoother with some linking sentences or an overarching framework.

Response: I thank the reviewer for this input, and have tried to smoothen the introduction. Please see manuscript with track changes.

 

Comment 7: And, context of Norway should be contextualized in the European area (tuning project, European movements in this regard) Such as EFN or ESNO?). This additional info would provide a more solid base to understand the background for an international readership.

Response: I thank the reviewer for this suggestion, and have included a contextualization of Norway in the introduction, as well as an European perspective. Please see manuscript with track changes.

 

Comment 8: b. While the authors mention the "underdeveloped" evidence base and "methodological limitations" in a 2023 scoping review, they do not explicitly state how their study aims to address or overcome these limitations. Including such a statement could strengthen the rationale for the study, which is weak in this version. Additional work to clarify the need for this study might be useful to increase the relevance of the study.

Response:  I thank the reviewer for this comment and perspective. The challenge is that no studies beyond the study of Burns et al referred in the background section has explored this issue in advanced practice nursing educations. I hope the revisions made will clarify the need for the current study. Please see manuscript with track changes.

 

Comment 9: Methods: 1. Using the researchers' Facebook profiles and personal networks for recruitment might introduce selection bias, as the participants may not be representative of the population of APNs and APN students in Norway.

Response: I totally agree on this comment. This has also been stated under the limitations section. However, as a Professor with many roles, e.g. as a member of the county board of the Norwegian Nurses Association, and of the country board of the Norwegian Association of Nurse Anesthetists, I have a broad network. I have also observed that this recruitment strategy is broadly used, as indicated in a 2017 systematic review. The limitations section has been revised accordingly, including reference to this review. Please see manuscript with track changes.

 

Comment 10: 2. The context seems to be very generically mentioned

Response: I thank the reviewer for this input, and have extended the description of context in the revised manuscript.

 

Comment 11: 3. Lack of a sample size calculation might be considered a major flaw.

Response: I agree on this issue. However, it would be a challenge to perform such calculation, due to not using a validated questionnaire, not allowing for deciding the difference of interest, standard deviations etc. The lack of sample size calculation has been stated under the limitations section. Also, the N and hence the tables have been updated, due to having received several more responses (N=1769). After re-analysis of the free-text responses, no new themes or aspects were identified, supporting the initial analysis.

 

Comment 12: 4. The simplified thematic analysis section could be expanded with more details to improve transparency. For example, clarifying how codes and themes were derived and whether multiple researchers were involved in the coding process.

Response: I thank the reviewer for this comment. I have expanded the description of the thematic analysis. However, the analysis was conducted on free-text responses (some quite short) and not based on qualitative interviews. Also, the analysis was performed by one researcher only. This has been described as a limitation.

 

Comment 13: 5. Including information on when the data were collected and the duration of the collection period would provide context for the study.

Response: Thank you, this has been included.

 

Comment 14: 6. Typos and Language Consistency: There are some minor typos and inconsistencies in language (e.g., "development og questionnaires" instead of "development of questionnaires"; "cirrucula" instead of "curricula").

Response: I am very sorry for this issue (auto-correct), and the manuscript has been thoroughly proof-read.

 

Comment 15: 7. Information regarding ethical approvals, informed consent, and data confidentiality would be essential in this section, as these are standard research protocols that need to be adhered to.

Response: I thank the reviewer for this input, and have included information about these issues in the revised manuscript.

 

Comment 16: 8. Most important aspect: the developed questionnaire has no signs of validity. Even the assessment using Cronbach’s alfa without a theoretical structure and an assessment of dimensionality can be misleading. The authors declared to adhere to the STROBE; however, it is not clear how missingness was handled in the analytics.

Response: I agree on this issue, and this has been stated as a major limitation of the study. However, the questions included have been presented, and respondents were given the opportunity to respond in free-text to extend their perspectives. Missing values were not calculated, and n (%) have been presented in the tables. This has been prompted in the revised manuscript. Please see manuscript with track changes.

 

Comment 17: It should be noted that the details on how qualitative data were analyzed and how they relate to the quantitative findings are very limited. Consideration of inferential statistical methods to go beyond description and make claims about relationships, differences, or effects within the data should be stated.

Response: I thank the reviewer for this input. However, the aim of this study was to describe the respondents’ perspectives, and not to explore any associations or to compare between groups. In my opinion this would not be of interest, due to the responses being so similar across specialties.

 

 Comment 18: Results: this statement,” The Cronbach’s alpha of the questionnaire was .82, and the ICC in average measures was .71 (p<.001).” without a theoretical framework is without any significance in terms of meaning. The sample is dramatically unbalanced, making it impossible to meet the expectations given by the study’s aims.

Response: I thank the reviewer for this input, and have consequently omitted these analyses throughout. The limitation of using a researcher-developed, not validated questionnaire remains, and I hope that the presentation of the questions, the analysis of free-text responses, and the results is sufficient.

 

Comment 19: The subheading “Other analyses” seems to be not sustained by any theoretical base and seems totally exploratory.

Response: I thank the reviewer for this input. The “Other analyses” section is the results from the thematic analysis (sub-heading from the STROBE guidelines). I have changed this to “Free text-responses” in the revised manuscript.

 

Comment 20: Discussion: The results seem to strongly favor the notion that clinical experience is essential. Although disadvantages are mentioned, they are briefly stated and not explored in depth, especially by taking into account the current literature.

Response: I thank the reviewer for this input. As stated, previous research on this issue is limited. The existing research only support the advantages of clinical experience. Also, the responses were mainly positive. The reason may of course be selection bias. However, I identified one study claiming that prolonged education pathways may be a disadvantage. This has been included in the revised manuscript.

 

 Comment 21: Limitations: Even if no validated questionnaire exists, some exploratory analytics would have helped to address the concerns about the adequacy of the performed measurements. The current analytical approach seems to me not suitable for an international journal.

Response: I agree on this issue. However, the aim was not to validate a questionnaire. I hope that this will be of interest to an international audience anyway, due to that the questions are presented, and due to the opportunity of free-text responses. The limitation in the opportunity to generalize the findings have been presented.

 

Comment 22: Comments on the Quality of English Language

There are some minor typos and inconsistencies in language (e.g., "development og questionnaires" instead of "development of questionnaires"; "cirrucula" instead of "curricula").

Response: Thank you. This has been revised.

Author Response File: Author Response.docx

Reviewer 2 Report

The reviewed manuscript deals with a rather important topic concerning the education of APN nurses in the context of their professional experience. The topics are relevant in the context of the continuing increase in demand for highly qualified nursing staff.

I rate the project, the idea and the matter-related content, as well as the practical value of the study and manuscript as good. The development and the use of a proprietary questionnaire with a good Cronbach's alpha coefficient is noteworthy.

However, I have a few comments/questions:

1. Despite the rather high prevalence of the APN population (92%) vs students (8%) - has a statistical analysis been done regarding the differences in responses in these two populations? Such an analysis could better show the differences of opinions in these two groups.

2.  In 'Limitations', the author pointed out that the survey project did not involve asking respondents about their age, gender, or years of work experience. In my opinion, future research should at least take into account years of work experience.

3.   In my opinion, it is not justified to present the Author's profile (or references to his/her person and professional/scientific experience) in the text of the manuscript. The manuscript should refer to the content of the results obtained, the interjections used by the Author are unnecessary and do not affect the content value of the text (e.g. lines 105 and 106, 318 and 319).

4.       I suggest moving the 'Limitations' paragraph in the discussion to the end of the discussion.

Author Response

Response to reviewer II

I thank the reviewer for the concrete and constructive comments to the paper.  I hope that the revisions made are deemed appropriate. Please see my responses to the comments below. The revisions are also shown in the manuscript with track changes.

 

Comment 1: The reviewed manuscript deals with a rather important topic concerning the education of APN nurses in the context of their professional experience. The topics are relevant in the context of the continuing increase in demand for highly qualified nursing staff. I rate the project, the idea and the matter-related content, as well as the practical value of the study and manuscript as good. The development and the use of a proprietary questionnaire with a good Cronbach's alpha coefficient is noteworthy.

Response: I thank the reviewer for acknowledging the importance and practical value of this manuscript.

 

Comment 2: However, I have a few comments/questions: 1. Despite the rather high prevalence of the APN population (92%) vs students (8%) - has a statistical analysis been done regarding the differences in responses in these two populations? Such an analysis could better show the differences of opinions in these two groups.

Response: I thank the reviewer for this input. However, there are very few students (n=125) versus APNs (n=1633), so a comparison in my opinion would not provide any contrasting information. One approach could be to exclude the students from the sample, which I of course would do if the reviewers think so. I would also like to inform that, since the first submission of the manuscript, further respondents have submitted their answers (first submission N=1213, second submission, N=1767). Hence, the analyses and tables/thematic analysis have been repeated and adjusted accordingly.

 

Comment: 2.  In 'Limitations', the author pointed out that the survey project did not involve asking respondents about their age, gender, or years of work experience. In my opinion, future research should at least take into account years of work experience.

Response: I totally agree on this issue. I have added this aspect to the “Implications for further research” section.

 

Comment 2: 3.   In my opinion, it is not justified to present the Author's profile (or references to his/her person and professional/scientific experience) in the text of the manuscript. The manuscript should refer to the content of the results obtained, the interjections used by the Author are unnecessary and do not affect the content value of the text (e.g. lines 105 and 106, 318 and 319).

Response: I thank the reviewer for this input and suggestion, and have omitted this from the revised manuscript. Please see manuscript with track changes.

 

Comment 3: 4.       I suggest moving the 'Limitations' paragraph in the discussion to the end of the discussion.

Response: The structure of the paper aligns with the STROBE guidelines for reporting of cross-sectional studies.

 

 

Author Response File: Author Response.docx

Reviewer 3 Report

Thank you for conducting a study about the education requirements for APNs. The study presents clinical significance and can be used to support the development of future programs. Consider the suggestions below to improve the quality of the study:

Methods:

1. Explain why the snowballing technique was used.

2. How was the questionnaire distributed to APN networks? Which networks were used?

3. Was the questionnaire tested before the it was sent to participants? If not, why not?

4. Why a sample calculation was not performed?

5. Which qualitative method was used to analyze the text responses?

Results

1. Review format of the Table 2 (centralized)

2. Line 147 should read Table 2

Discussion

The discussion did not compare the results of the study with the literature. It restated the findings without a deeper analysis. The discussion must be thoroughly rewritten. 

 

 

Author Response

Response to Reviewer III

I thank the reviewer for the concrete and constructive comments to the paper.  I hope that the revisions made are deemed appropriate. Please see my responses to the comments below. The revisions are also shown in the manuscript with track changes.

 

Comment 1: Thank you for conducting a study about the education requirements for APNs. The study presents clinical significance and can be used to support the development of future programs.

Response:  I thank the reviewer for acknowledging the clinical significance of the study.

 

Comment 2: Consider the suggestions below to improve the quality of the study: Methods:

1. Explain why the snowballing technique was used.

Response: I thank the reviewer for this suggestion, and have added some information in the revised manuscript. Please see manuscript with track changes.

 

Comment 3: 2. How was the questionnaire distributed to APN networks? Which networks were used?

Response: I thank the reviewer for asking for a clarification. The information/questionnaire was sent to the researchers’ own contacts, who were asked to share further. I have tried to clarify this in the revised manuscript. Please see manuscript with track changes.

 

Comment 4: 3. Was the questionnaire tested before the it was sent to participants? If not, why not?

Response: Unfortunately, the questionnaire was not piloted, and this has been underlined as a major limitation of the study. This was due to an urgency in gaining insight into different APNs’ perspectives on this issue, at the beginning of a new study semester.

 

Comment 5: 4. Why a sample calculation was not performed?

Response: This has been explained further in the revised manuscript. No validated questionnaire was used. Also, the sample is now at 1767 respondents, extending the inclusion of participants in other survey studies. A clarification and reference to this has been added to the revised manuscript. Please see manuscript with track changes.

 

Comment 6: 5. Which qualitative method was used to analyze the text responses?

Response: A thematic analysis in-line with recommendations from Braun & Clarke was used. This has been stated in the revised manuscript.

 

Comment 7: Results. 1. Review format of the Table 2 (centralized)

Response: Thank you. This has been reviewed.

 

Comment 8: 2. Line 147 should read Table 2

Response: Thank you. This has been revised.

 

Comment 9: Discussion. The discussion did not compare the results of the study with the literature. It restated the findings without a deeper analysis. The discussion must be thoroughly rewritten.

Response: I thank the reviewer for this input. The challenge is that no similar studies have been conducted, beyond those already presented. In the revised manuscript, I have tried to rewrite the discussion section, and hope this is deemed sufficient by the reviewer. Please see manuscript with track changes.

 

 

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Dear authors, I found the manuscript much improved in this version. My advice is to structure the discussion in the following way: key results, interpretation, future research, and limitations (without the need for subheadings that may be good for limitations only).

Author Response

Response to reviewer I

I thank the reviewer once more for the concrete and constructive comments to the paper.  I hope that the revisions made are deemed appropriate. Please see my responses to the comments below. The revisions are also shown in the manuscript with track changes.

 

Comment 1: Dear authors, I found the manuscript much improved in this version.

Response: I thank the reviewer for acknowledging the revisions.

 

Comment 2: My advice is to structure the discussion in the following way: key results, interpretation, future research, and limitations (without the need for subheadings that may be good for limitations only).

Response: I agree with the reviewer that this is a more obvious presentation. The current structure is based on the STROBE guidelines. However, restructuring does not remove any of the aspects of the STROBE. Hence, the discussion has been revised as suggested by the reviewer.

Author Response File: Author Response.docx

Reviewer 3 Report

Dear author

Thank you for revising your paper. 

Emilene

Author Response

I thank the reviewer for acknowledging the revisions, and as interpreted accept of the manuscript.