Head Nurse Leadership: Facilitators and Barriers to Adherence to Infection Prevention and Control Programs—A Qualitative Study Protocol^†

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Unfortunately, this paper does not confirm the role of head nurses in HAI prevention and management that emerged from the interviews and FGIs. Key findings statements are missing. 

Author Response

Thank you very much for taking the time to review this manuscript.

 This paper does not confirm the role of head nurses in HAI prevention and management because it is a research protocol and the data are not collected yet.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

This study examines how the actions and actions of senior nurses influence healthcare professionals' compliance with infection prevention and control (IPC) programs. Utilizing a multicenter qualitative approach, this study provides insight into nurses' perceptions of leadership influence and suggests strategies to improve IPC compliance, thereby mitigating negative patient outcomes associated with HAIs.

I offer the following suggestions to improve the quality of this research:

Materials and Methods

Healthcare facility managers from various cultures are expected to participate. Researchers must take into account differences in managers' cultural backgrounds and perceptions.

Researchers emphasize the importance of the actions and actions of nurses, nurses, nursing assistants, and clinicians. Therefore, it is recommended that they present a simple table showing how the educational programs or leadership training they carry out affect IPC.

Data Analysis

How many experts participate in the analysis? Interdisciplinary analysis can help improve the quality of research.

Author Response

Thank you very much for taking the time to review this manuscript.

Thank you for your suggestion. We have inserted in the introduction the definition of head nurses and their role inside the organization.

To consider differences in the cultural background and perceptions of the head nurses, data on education, and work experience as a nurse and as a head nurse in the observed ward have been added to Table 1.

In the light of the results obtained, a leadership programme on IPC programmes could be structured. To avoid also possible confusion among the readers and focus on our aim, we think that a table on training should be proposed in a different manuscript, such as an experimental or quasi-experimental study.

 Three experts will participate in the analysis to ensure the interdisciplinarity of the analysis.

“The interdisciplinary analysis will be conducted by an occupational psychologist, a qualitative research expert, and a university professor specialising in Grounded Theory”.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The role of head nurse is vital in providing leadership across the department in which they work, and this includes the important topic of IPC. Not only does this ensure patient safety but that of HCW, and reduces the possibility of antibiotic resistance. As well as the safety aspects, the wider context is the economic burden of HAIs and the public reputation of the hospital. Robust methods to implement and audit IPC programmes therefore are valuable, including identifying barriers to their facilitation.

This paper provides a useful framework / template with which the above can be explored. The combination of interviews and Focus Group activities is well established and known to achieve the proposed aims.  One question I had was about potential bias brought about by peer pressure that might limit open and frank discussion within focus groups, depending on who was chosen. However, I believe the limitations section (lines 278 - 283) acknowledges this.   My only other question is about the topic list in section 2.6. In point 6 management of environmental sanitation is referenced, and cleaners are referred to. Does this include clinical waste management? It is not clear so I suggest you add this as a further example as this is an area that is important to IPC but where controls may break down.

Author Response

Thank you very much for taking the time to review this manuscript.

Although the topic of waste in IPC programmes plays a key role, our study will not assess this aspect but will try to observe how cleaners personnel work near the patients, the routine cleaning of rooms and what strategies are used and suggested by the head nurse.

To improve the section, we have specified near the bullet point of the cleaners’ personnel some examples. (e. g. priority of cleaning order, from non-infected to infected patient)”.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

Many thanks for sending me this paper for review.  

Overall comments:

Can you provide a definition of a ‘head nurse’?  Different countries have different interpretations.  For example, Clinical Nurse Manager 1, Clinical Nurse Manager 2, Clinical Nurse Manager 3, Director of Nursing, Assistant Director of Nursing, Staff Nurse, Ward Sister are just some variations of ‘head nurse’.

Line 49: consider ‘the head nurse has a responsibility’ rather than ‘the head nurse must be responsible’

Line 78: having read refs 24/5, should read ‘are positively related to’ rather than ‘can effectively reduce’.  (studies used SEM regression which does not measure cause and effect)

Line 81: language is too strong.  This relates to my previous point.  Consider ‘ these findings may have been achieved because of.....’

Line 92: having read ref 28, this should read ‘work enviroment’ rather than ‘internal environment’

Line 140: if the purpose of the study is to understand the internal 140 organizational dynamics and leadership style of the head nurse and how it affects the 141 nursing team [19].can you explain (using references) why you propose to include non-nurses in the sample?

Line 118:

•                    describe the thought processes that motivate healthcare professionals in the care 118 provided for reducing HAIs;  is at odds to the purpose of the study in line 140

Line 127: The study will use a purposive sampling method.  Is it really purposive sampling or is it convenience sampling if the inclusion criteria is that the participant is simply to be involved in direct patient care rather than a specific IPC activity or knowledge base.

Line 153: can you define ‘care co-ordinator’

Section 2.6: this needs to be developed.  Observational data collection methods should address how you propose how to address observer effect, hawthorne effect, inter-observer effect,

How will informed consent be addressed?

What does ‘experienced observer’ mean?

Going in and observing for a period of 3 hours without addressing the point above will generate biased data

The paper should include a section on reflexivity (of the authors).

Author Response

Thank you very much for taking the time to review this manuscript

Can you provide a definition of a ‘head nurse’?  Different countries have different interpretations.  For example, Clinical Nurse Manager 1, Clinical Nurse Manager 2, Clinical Nurse Manager 3, Director of Nursing, Assistant Director of Nursing, Staff Nurse, Ward Sister are just some variations of ‘head nurse’.

Thank you for your suggestion. Following your suggestion and reviewer 1, we have inserted in the introduction the definition of head nurses and their role inside the organization.

Line 49: consider ‘the head nurse has a responsibility’ rather than ‘the head nurse must be responsible’

We modified and added the sentences as suggested

Line 78: having read refs 24/5, should read ‘are positively related to’ rather than ‘can effectively reduce’.  (studies used SEM regression which does not measure cause and effect)

Thank you for your suggestion. We modified and added the sentences as suggested

Line 81: language is too strong.  This relates to my previous point.  Consider ‘ these findings may have been achieved because of.....’

Thank you for your suggestion. We modified and added the sentences as suggested

Line 92: having read ref 28, this should read ‘work environment’ rather than ‘internal environment’

Thank you for your suggestion. We modified and added the sentences as suggested

Line 140: if the purpose of the study is to understand the internal 140 organizational dynamics and leadership style of the head nurse and how it affects the 141 nursing team [19].

Thank you for your suggestion. We have revised the aim because we will focus on the “clinical-care team”

can you explain (using references) why you propose to include non-nurses in the sample?

Thank you. We will consider a clinical care team because the head nurse inspires and motivates healthcare professionals to work together to ensure optimal patient care. For example, a good head nurse promotes collaboration and communication between team members. In the manuscript, we have added a sentence and a reference to sustain our choice

Line 118: describe the thought processes that motivate healthcare professionals in the care 118 provided for reducing HAIs; is at odds to the purpose of the study in line 140

We modified the sentences as suggested:

The purpose is to understand the work organizational dynamics and leadership style of the head nurse and how it affects the thought processes of the clinical-care team

Line 127: The study will use a purposive sampling method.  Is it purposive sampling or is it convenience sampling if the inclusion criteria is that the participant is simply to be involved in direct patient care rather than a specific IPC activity or knowledge base.

Thank you for your suggestion. We modified the sentences as suggested.

Line 153: can you define ‘care co-ordinator’

Section 2.6: this needs to be developed.  

Observational data collection methods should address how you propose how to address observer effect, Hawthorne effect, inter-observer effect,

We modified the sentences as suggested

“To contain the Hawthorne effect [43] and potential biases of healthcare professionals, the observations will be conducted by experienced observers (professionals who have already participated in five hand hygiene audits) from the ward involved in the study.  Furthermore, all observed activities will be recorded in a logbook to reduce the researcher's subjectivity”

How will informed consent be addressed?

Thank you for your suggestion. We have specified how participants will sign the informed consent

What does ‘experienced observer’ mean?

Thank you. We have specified the experiences of the observer.

Going in and observing for a period of 3 hours without addressing the point above will generate biased data

Thanks for your suggestion. To avoid possible behavioural change in the work of the clinical care team (inter-observation biases) we will use experienced professionals belonging to the ward setting of the study and the healthcare organization. We have added a sentence to justify and sustain our choice: “Each ward will be observed for approximately three hours because the observers are inside the observed ward and this allows the dynamics and behaviors of the observed operators to be captured”.

The paper should include a section on reflexivity (of the authors).

Thank you for your suggestion. Typically, a qualitative research manuscript reports the reflexivity in the section of the methodological rigor paragraph. We have not created a section in the manuscript but we have added in the rigor paragraph sentences about the reflexivity. 

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I think this protocol is a good research proposal that applies observation, individual interviews, and focus group interviews to determine how decision-making processes influence healthcare professionals' behavior in managing HAIs. 

Please correct the omission of observation #2 in the Tools section due to an editing error.

I wish you all the best in your revision work and hope to see this manuscript as a published research article.

Sincerely, your reviewer

Author Response

Please correct the omission of observation #2 in the Tools section due to an editing error.

Thank you for the wish and the note. 
We have added the suggested additions