Experiences with Negative Behavior and Incivility: Perspectives of Unlicensed Assistive Personnel and Registered Nurses

Round 1

Reviewer 1 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

The manuscript can be published in the revised form

Author Response

Thank you for your positive feedback. We appreciate your thorough review of our work.

Reviewer 2 Report (Previous Reviewer 3)

Comments and Suggestions for Authors

The authors have addressed my previous comments, which were only minor issues. After proofreading the English, I believe this paper is suitable for publication. For instance, some sentences are unclear: «Peer debriefing amongst the research team was used to ensure trustworthiness and maintain rigor due to the anonymous nature of the survey results member checking was not possible.»

Comments on the Quality of English Language

Minor editing of English language required.

Author Response

Thank you for this feedback we have revised this sentence for further clarity as suggested. The sentence now reads “Peer debriefing amongst the research team was used to ensure trustworthiness and maintain rigor of qualitative data analysis. Due to the anonymous nature of the survey results member checking with participants to ensure accuracy and validity of interpretations of qualitative results was not possible.” See lines 143-147.

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

I have reviewed your manuscript titled "Strategies to Promote Civility: Perspectives of Unlicensed Assistive Personnel and Registered Nurses." I appreciate the opportunity to contribute to the evaluation of your research. Overall, the study addresses an important topic related to uncivil behavior in the hospital setting and presents valuable findings. However, I have identified some areas that require attention and improvement before considering its publication in our journal.

1. Table 2 provides relevant information about the sample, but its current format may be confusing. Separating the samples by commas can lead to confusion rather than clarity. I suggest modifying the table format so that each sample is in a separate column, facilitating the reading and understanding of the data.

2. Statistical Analysis: In Table 2, comparisons between two groups are presented, but statistical hypothesis tests do not support them. It is essential to determine whether the observed differences between the groups are statistically significant or could be due to chance. I recommend conducting appropriate statistical analyses to support the comparisons and ensure that the reported differences are genuine.

3. Qualitative Section: The qualitative section of the study appears to consist mainly of descriptions of participants' responses without adequate integration. Instead of providing an in-depth understanding of the context of the variables, qualitative quotes seem to be stacked, and there is a limited exploration of the relationship between emerging themes. I suggest better organizing qualitative quotes and integrating them to create a coherent narrative offering deeper insight into participants' perspectives.

In addition to these specific recommendations, addressing the lack of study registration is essential, which should be mentioned and justified in the manuscript.

Overall, I believe that your study has the potential to make a valuable contribution to the literature on uncivil behavior in hospital settings. However, it is crucial to address the areas for improvement mentioned above to ensure the quality and clarity of the work. I am confident that with the appropriate revisions, your manuscript can be suitable for publication in our journal.

I look forward to receiving the revised version of your manuscript and evaluating how these suggestions have been addressed. I am available for any further clarification you may need.

Sincerely,

Author Response

Thank you for taking the time to review our manuscirpt and provide such helpful feedback. Attached you will find a table which addresses all points as requested. We look forward to your additional feedback of the revised manuscript.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

GENERAL COMMENTS

I find the study lacks depth of analysis. It presents results in the simplest way: Percentages, means and standard deviations. There is not a single comparison, no discrimination between people who suffered incivility behaviors or any deeper analysis of differences between the sample.

In the initial paragraphs of Materials and Methods section the authors include scales such as Rosenberg Self-esteem or the International Personality Item Pool instrument, but then, no data related to these scales is presented in the manuscript.

If the authors had presented information about self-esteem and personality traits of their sample, the study could have been interesting. Unfortunately, in the form that the manuscript is presented, as a simple description of negative and incivility behavior, it is, in my opinion, not acceptable to be published.

My advice to the authors would be to select the most relevant information: what are the most frequent behaviors, who received these negative behaviors, which demographic variable or work roles received more negative behaviors or incivility, and then try to explain why.

The analysis of each item is another aspect that I would change in the manuscript. I suggest the authors highlight the most frequent and less frequent behaviors, choosing the extremes in a way that shows which behaviors occur often and which of them seldom occur.

Write the manuscript thinking that it could be read by people outside USA. For example, the reference to the “N” word and its very offensive nature may not be understood outside the USA.

The manuscript is full of acronyms. It is necessary to write their meaning, at least the first time they are written in the manuscript.

Better description of the sample is needed, what are RNs and UAP?  I had to find out that they are registered nurses and unlicensed assistive personnel, do not force the reader to guess, it is better to clarify any acronym.

Please read carefully the author’s instructions and follow them.

TITLE: Should include the assessment of negative and uncivil aspects. “Strategies to Promote Civility” is a small part of the study and based on two questions only. Make the title reflect the study performed.

MATERIALS AND METHODS

Line 85, change Rosenburg to Rosenberg.

When authors described the internal consistency in each measure, I think it is better to describe the one obtained by them than the one obtained by other studies (reference 4, 7). Or at least write the range found by them.

Any item added to the standard measure used, as happens with the Nursing Incivility Scale, should be included in the manuscript, or alternativity in an annex to it.  

RESULTS

Authors present only percentages, means and standard deviations. I think that more statistical analyses should be performed, for example, chi squared comparing percentages, ANOVAs, Student´s t, Cohen´s d, to find out if the differences between the groups compared were significant. For example, between RNs and UAP. Or between different types of aggressions.

Table 2: the legend of Table 2 should specify that Alpha´s Cronbach for each factor included.

I found the results section very poor.

DISCUSSION

A manuscript with a poor results section cannot have a good discussion section.

REFERENCES

None of references are following journal´s format. Please review all references according to Instructions for Authors.

Author Response

Thank you for reviewing our manuscript we appreciated your helpful feedback. We have attached a table which addresses all feedback as requested. We look forward to your review of the revised manuscript and any additional suggestions you might provide. 

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

First, I would like to thank you for the opportunity to read your work. I found this study interesting, and the authors have collected quantitative and qualitative data. However, I found that this study lacks a robust theoretical background. It is my main issue concerning this paper.

I leave some comments and suggestions below, hoping they help improve the paper.

(1)    Abstract: The abstract needs to be improved. The authors need to clarify if they are analyzing the consequences for registered nurses and unlicensed assistive personnel of being victims of negative behaviours, such as incivility, bullying and violence from superiors, peers and clients. This is not clear in the abstract. In addition, the authors need to be more precise concerning this sentence: «Registered nurses, unlicensed assistive personnel and nursing leadership may benefit from system wide approaches to addressing negative behaviors such as incivility within the clinical environment.»  Which system-wide approaches? In addition, what do the authors mean by this sentence?: «This study was not registered»

(2)    Keywords: Some keywords seem missing, such as nursing and negative behaviors.

(3)    Introduction: Line 62-63 – add the references concerning the Negative Behaviors in Healthcare Survey (NBHC) and Nursing Incivility Scale (NIS). In addition, the authors need to define better what negative behaviors and incivility consist of. The literature review must be deepened.

(4)    Results: It will be essential to add a potential explanation for the response rate obtained: around 8.5% (309/3606).

Comments on the Quality of English Language

Nothing substantial to add.

Author Response

Thank you for reviewing our manuscript and providing such helpful feedback. Attached is a table which addresses all of your comments as requested. We look forward to any additional suggestions you may have upon review of the revised manuscript.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Manuscript Revision: 

Experiences with Negative Behavior and Incivility: Perspectives of Unlicensed Assistive Personnel and Registered Nurses

Reviewer comments:

The manuscript has been improved considerably and the authors have followed to the letter the suggestions I made in the first round of revision. However, the revised manuscript still contains small aspects that must be corrected:

1.      The authors use the Mann-Whitey U, a non-parametric comparison statistical index indicated only when the distribution of the sample in the variables assessed does not follow the curve-distribution (Gauss´ normal-curve distribution). Therefore, the authors must justify the use of this specific statistical index. If this is the case, they should mention in the manuscript that the sample did not follow the normal curve-distribution. However, if this was not the case, and the distribution follows the normal-curve, an ANOVA or T-test /Students´ t would be the right statistical tool to be used.

2.      Small errors:

a)      Table 2: the significant p is written with and without a 0 before the coma. Please include a 0 before the coma in any p value.

b)     Line 483: Change COVI-19 by COVID-19

c)      Line 495: Change Covid-19 by COVID-19 (with capital letters)

d)     References:  Abbreviate the journal name in those references with the complete journal name.

Author Response

Thank you for the additional feedback and the opportunity to revise as suggested. Please see attached for detailed responses to feedback.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

I congratulate the authors on the improvements made to this revised manuscript, which address my previous comments and suggestions. 

However, I still have two comments:

Abstract - Please remove the sentence "This study was not registered on a publicly accessible registry." I believe this information is unnecessary. 

Some typos throughout the paper can be easily fixed with a new attentive read. For instance, "COVI-19" must be "COVID-19". In addition, some spaces between words were added more than necessary. 

Author Response

Thank you for the additional feedback and the opportunity to revise as suggested. Please see attached for detailed responses to feedback.

Author Response File: Author Response.pdf