The Therapeutic Nurse–Patient Relationship in Hemodialysis: A Pilot Mixed-Method Study on the Perceived Quality of Nurses’ Attitudes and Caring Behaviors

Round 1

Reviewer 1 Report

The title of this paper is clear and reflects its content.

The abstract is sufficiently informative. Please consider better explaining the sentence: “in the third part of the questionnaire was composed by open-ended questions”. For example, explaining the topic investigated with the third part of the scale.

The Introduction section clearly introduces the paper's subject, research context, and relevance. No further comment about it.

The methods section is sufficiently informative. However, I suggest better explaining some aspects. For example, it is not mentioned that the tool is self-reported. Moreover, the following sentences The design is a mixed method with a descriptive cross-sectional quantitative part and an exploratory descriptive qualitative part. The convenience sample consists of nurses who work in the above-mentioned units and were willing to participate in the study should be changed in The design is a mixed method with a descriptive cross-sectional quantitative and exploratory descriptive qualitative part. The convenience sample consists of nurses working in the above-mentioned units willing to participate in the study [line 114-117]. Finally, the authors describe that the sample was composed of nurses working in the above-mentioned units willing to participate in the study. But how were they recruited? By an introductory conversation? Please explain it.

The results were clearly presented just as the Discussions section that relates the findings of this paper to existing knowledge. I would suggest broadening the study limitations mentioned by the authors (self-reported tool, characteristics of the tool...) and better explaining how a northern Italian – monocentric - sample may influence the results.

The conclusion section should be improved. The results obtained from the study may be better emphasised in the clinical context. The authors correctly underline the importance of education and the attention needed, but how could you consider your conclusions in the meantime?

Author Response

We would like to thank the reviewer for the valuable comments.

We provided to add the requested informations among the methods, added the limitations section and improved the conclusions as suggested.

 

R1: The title of this paper is clear and reflects its content.

A: We would like to thank the reviewer for the precious feedback

R: The abstract is sufficiently informative. Please consider better explaining the sentence: “in the third part of the questionnaire was composed by open-ended questions”. For example, explaining the topic investigated with the third part of the scale.

A: The authors are sincerely grateful for the valuable and punctual annotation indicated by the reviewer; we have better explained the sentence indicated in the abstract explaining the topic investigated with the third part of the scale

R1: The Introduction section clearly introduces the paper's subject, research context, and relevance. No further comment about it.

A: We would like to thank the reviewer for the precious feedback

R1: The methods section is sufficiently informative. However, I suggest better explaining some aspects. For example, it is not mentioned that the tool is self-reported. Moreover, the following sentences The design is a mixed method with a descriptive cross-sectional quantitative part and an exploratory descriptive qualitative part. The convenience sample consists of nurses who work in the above-mentioned units and were willing to participate in the study should be changed in The design is a mixed method with a descriptive cross-sectional quantitative and exploratory descriptive qualitative part. The convenience sample consists of nurses working in the above-mentioned units willing to participate in the study [line 114-117]. Finally, the authors describe that the sample was composed of nurses working in the above-mentioned units willing to participate in the study. But how were they recruited? By an introductory conversation? Please explain it.

A: Thank you for the valuable comments. We integrated the incomplete information in the methods mentioning that the tool is self-reported, changing the sentence indicated with the follow: The design is a mixed method with a descriptive cross-sectional quantitative and ex-ploratory descriptive qualitative part. We adopted a convenience sampling, consisting of nurses working in the above-mentioned units willing to participate in the study, re-cruited through an introductory conversation carried out before obtaining informed consent

R1: The results were clearly presented just as the Discussions section that relates the findings of this paper to existing knowledge. I would suggest broadening the study limitations mentioned by the authors (self-reported tool, characteristics of the tool...) and better explaining how a northern Italian – monocentric - sample may influence the results.

A: Thank you so much for the opportunity to improve this aspect. We expanded the study limitations as indicated with the periphrase: This study has some limitations. First of all, the sample size was quite small, even if it reached most of the nurses of the dialysis departments involved (23/26). Nevertheless, the findings can be representative of only one highly specialized hospital in northern Italy; several aspects could have influenced the results, such as the organizational culture of the hospital, the philosophy of the operating unit, the practices and habits of the staff in approaching patients, and the peculiarities of the setting itself. Furthermore, the tool used for data collection also represents a limitation, as it is a not validated self-reported tool, with answers expressed using a 5-point Likert scale, which could induce respondents to passively choose the central value of 3 in case of indecision rather than trying to lean on one side or the other of the scale, contrary to what would happen, for example, with a 4-point Likert scale. For further investigations this tool should be validated in the Italian context. The authors believe that extending the research to other centers throughout the country could provide further suggestions and more representative results.

R1: The conclusion section should be improved. The results obtained from the study may be better emphasised in the clinical context. The authors correctly underline the importance of education and the attention needed, but how could you consider your conclusions in the meantime?

A: Thank you so much for highlighting this aspect. We expanded the conclusions with a reflection about staffing (One possible viable solution in the immediate term is to ensure adequate staffing with an even skill mix across shifts.)

Reviewer 2 Report

Dear Authors,

The reviewed work raises a significant professional problem and the presented topic is important for nursing. It has been prepared methodologically correctly, however, a study conducted on a small group of 23 nurses working in one hospital raises concerns. I believe that the study would gain value if the study group came from several units of the whole country or region and if it was larger in number.

Author Response

The authors are sincerely grateful for the valuable and punctual annotations indicated by the reviewer, who raised a concern that constitutes both a limitation of the study and a potential opportunity to repeat the study involving other dialysis centers nationwide. This study was intended to be an initial approach to the topic in a single center before testing the instrument on a larger population for its multicentric validation; we provided to clarify this aspect among the limitations. We have implemented this reflection in the limits and conclusions as a possible starting point for conducting a multicenter study.

Reviewer 3 Report

Very interesting topic, the researchers did a great job to assess the quality of nurses' perceived caring attitudes and behaviours and to determine their perceptions regarding the importance of the therapeutic relationship with the assisted patients. However, the article could be strengthened through:

 

Line 33, update the estimation with a recent reference.

https://www.sciencedirect.com/science/article/pii/S2157171621000666

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9073222/#:~:text=Due%20in%20part%20to%20the,million%20individuals%20worldwide%20in%202017.

 

Line 112, “IRCCS” Introduce every acronym before using it in the text. The first time you use the term, put the acronym in parentheses after the full term.

Line 141, “STROBE” Introduce every acronym before using it in the text.

Have you conducted a pilot study for the developed questionnaire?

Elaborate on how you determine the sample size.

Validity and reliability for the study and the pilot study need to be addressed.

Add more current references from the literature.

Good luck

Author Response

The authors are sincerely grateful for the valuable and punctual annotations indicated by the reviewer; we have updated the epidemiological data with the most recent references, we have appropriately extended the acronyms in the text and we have integrated the bibliographic references.

Regarding the points:

R3: Line 33, update the estimation with a recent reference.

https://www.sciencedirect.com/science/article/pii/S2157171621000666

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9073222/#:~:text=Due%20in%20part%20to%20the,million%20individuals%20worldwide%20in%202017.

A: A: The authors are sincerely grateful for the valuable and punctual annotations indicated by the reviewer, we have updated the epidemiological data with the suggested references

R3: Line 112, “IRCCS” Introduce every acronym before using it in the text. The first time you use the term, put the acronym in parentheses after the full term.

&

Line 141, “STROBE” Introduce every acronym before using it in the text.

A: Thank you for highlighting this aspect. We have appropriately extended the acronyms in the text

R3: Have you conducted a pilot study for the developed questionnaire?

&

Validity and reliability for the study and the pilot study need to be addressed.

A: Thank you so much for the opportunity to clarify this aspect. A pilot study was not conducted to validate the questionnaire because this study was intended to be an initial approach to the topic in a single center before testing the instrument on a larger population for its multicentric validation

R3: Elaborate on how you determine the sample size.

A: Thank you so much for the opportunity to clarify this aspect. For the reasons mentioned above, sample size was not calculated because all nurses from both dialysis units of the hospital were involved

R3: Add more current references from the literature.

A: Thank you for the opportunity to improve the overall quality of the manuscript. We added some current references on this topic.

Round 2

Reviewer 2 Report

Thank you very much for the corrections made. The article in this version has gained in quality.

Author Response

The authors are sincerely grateful for the support received from the reviewer, we share that the quality of the article is significantly better than the first version

Reviewer 3 Report

 

Elaborate on how you determine the sample size.

Validity and reliability for the study and the pilot study need to be addressed.

Author Response

The authors are sincerely grateful for the reviewer's comments and the opportunity to further improve the paper.

All changes are highlighted in red

R: Elaborate on how you determine the sample size

A: Thank you for this recommendation. We did not perform any kind of sample size estimation, due to the pilot nature of the study. We clarified this aspect in the paragraph Materials and Methods

R: Validity and reliability for the study and the pilot study need to be addressed

A: Thanks for your recommendation. Unfortunately, we could only perform one validity test, namely construct validity. We showed the results of this analysis on Table 3. In light of your suggestion, we replaced the label of the Table from “Correlations” to “Results of the construct validity testing”. We then, tested reliability by measuring Cronbach’s alpha on the response to the items