Determining Factors in the Implementation of Biosecurity Measures by Hospital Nurses in Piura, Peru

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors,

I think this is an interesting piece of work that is relevant in terms of factors that influence compliance to biosafety risk mitigation strategies for infection prevention and control in hospitals. I think the document could do with some revision to make it clear whether the biosafety measures relate to hospital laboratory staff, nursing staff, or patient protection and should include the questions used in the form.  I do have some other suggestions and comments for your consideration, but please note these are meant to be helpful and are as follows:

-         I think this is simply a translation issue, but the terms biosecurity and biosafety seem to be being used interchangeably. These terms mean different things in English and I’ll refer to the WHO Laboratory Biosafety Manual for differentiation of definitions of these terms, which whilst are laboratory specific, should be of help here (9789240011311-eng.pdf (who.int)). “Biosafety: Containment principles, technologies and practices that are implemented to prevent unintentional exposure to biological agents or their inadvertent release.” “Biosecurity: Principles, technologies and practices that are implemented for the protection, control and accountability of biological materials and/or the equipment, skills and data related to their handling. Biosecurity aims to prevent their unauthorized access, loss, theft, misuse, diversion or release.” Based on the topic of this article, I would suggest you are referring to biosafety and as such suggest replacing “biosecurity” with “biosafety” throughout.

-          The article seems to cover nosocomial associated infections related to hospital laboratory staff initially before moving to nosocomial infections of staff and then patients. Whilst there will be some crossover between how these infections are contracted e.g. lack of following correct procedures etc. the risk of infection and some control measures will be different between these groups.

-          Introduction, Lines 74-76: “ Despite this, challenges related to the availability of personal protective equipment (PPE) and gaps in knowledge about the properties of alcohol and occupational risks have been identified as obstacles to full compliance with biosecurity guidelines [17].” Are you referring to alcohol-based hand rubs here?

-          Introduction, Line 99: “…targeted training programs and improvements in institutional policies, with the…” change “programs” to “programmes”. This has been noted in other areas of the article as well. For ease, programs refers to computer programs, all others are programmes.

-          Literature review, Line 104: “hospital-acquired Infections” – consistency required here, either use “hospital-acquired infections” or “nosocomial infections”, but not both.

-          Literature review, Lines 108-111: seem to have referred back to laboratory biosafety precautions rather than biosafety precautions for nurses.

-          Hypotheses 1 and 2: Hypothesis 1 refers to extrinsic factors, but the notes generally refer to intrinsic factors. Similarly, hypothesis 2 refers to intrinsic factors, but the notes generally refer to extrinsic factors. Have notes here been included correctly? Suggest review of these sections.

-          Figures 1 and 2. States +ORD in the circles, should this be in here? If so please explain the acronym.

-          Results, Line 287: “According to (Hair, 2009)…” as all other references are in the Vancouver style, therefore it might be worth including this reference in the same style for consistency.

-          The questions from the form don’t appear to be in the article. I think it would be useful for the audience to have a table or an annex containing the questions and whether they are considered to relate to intrinsic or extrinsic factors.

-          Discussion: You have mentioned hypotheses 2 and 3 in the discussion, but not hypothesis 1?

-          Every study has limitations and it’s really good to see a limitations section without the need to request one.

I do appreciate the effort that goes into writing articles for publication as well as the research behind them. I would like to see this article published but feel it needs some revision first. In the interim, I wish you all the best with your ongoing and future research.

Comments on the Quality of English Language

General quality of English is good, with just a few minor revisions required (noted in the comments and suggestions section).  

Author Response

Dear Editor,

Thank you for managing our manuscript through the peer review process. We also extend our gratitude to the reviewers; their comments have significantly improved our study.

Reviewer 1

Dear Authors,

I think this is an interesting piece of work that is relevant in terms of factors that influence compliance to biosecurity risk mitigation strategies for infection prevention and control in hospitals. I think the document could do with some revision to make it clear whether the biosecurity measures relate to hospital laboratory staff, nursing staff, or patient protection and should include the questions used in the form. I do have some other suggestions and comments for your consideration, but please note these are meant to be helpful and are as follows:

• I think this is simply a translation issue, but the terms biosecurity and biosafety seem to be being used interchangeably. These terms mean different things in English, and I will refer to the WHO Laboratory Biosecurity Manual for the differentiation of definitions of these terms, which, while laboratory specific, should be of help here (9789240011311-eng.pdf (who.int)). “Biosafety: Containment principles, technologies and practices that are implemented to prevent unintentional exposure to biological agents or their inadvertent release.” “Biosecurity: Principles, technologies and practices that are implemented for the protection, control and accountability of biological materials and/or the equipment, skills and data related to their handling. Biosecurity aims to prevent their unauthorized access, loss, theft, misuse, diversion or release.” On the basis of the topic of this article, I would suggest that you refer to biosecurity and, as such, suggest replacing “biosafety” with “biosecurity” throughout.
  Response: Thank you for your observation; the corresponding changes have been made.
• The article seems to cover nosocomial associated infections related to hospital laboratory staff initially before moving to nosocomial infections of staff and then patients. While there will be some crossover between how these infections are contracted, e.g., lack of following correct procedures, etc., the risk of infection and some control measures will differ between these groups.
  Response: Thank you for your important comment.
• Introduction, Lines 74--76: “Despite this, challenges related to the availability of personal protective equipment (PPE) and gaps in knowledge about the properties of alcohol and occupational risks have been identified as obstacles to full compliance with biosecurity guidelines [17].” Are you referring to alcohol-based hand rubs here?
  Response: According to your comment. This refers to an alcohol-based hand sanitizer.
• Introduction, Line 99: “…targeted training programs and improvements in institutional policies, with the…” change “programs” to “programmes”. This has also been noted in other areas of the article. For ease, programs refer to computer programs; all others are programs.
  Response: Thank you for your observation; the corresponding changes have been made.
• Literature review, Line 104: “hospital-acquired Infections” – consistency required here, either use “hospital-acquired infections” or “nosocomial infections”, but not both.
  Response: Thank you for your observation; the corresponding changes have been made.
• Literature review, Lines 108-111: seem to have referred back to laboratory biosafety precautions rather than biosafety precautions for nurses.
  Response: Thank you for your observation; the corresponding changes have been made.
• Hypotheses 1 and 2: Hypothesis 1 refers to extrinsic factors, but the notes generally refer to intrinsic factors. Similarly, Hypothesis 2 refers to intrinsic factors, but the notes generally refer to extrinsic factors. Have notes here been included correctly? Suggest review of these sections.
  Response: Thank you for your observation; the corresponding changes have been made.
• Figures 1 and 2. States +ORD in the circles, should this be in here? If so please explain the acronym.
  Response: Thank you for your observation. The circles in the proposed model represent the study variables, and +ORD indicates that they are composed of items with ordinal scales.
• Results, Line 287: “According to (Hair, 2009)…” as all other references are in the Vancouver style, therefore it might be worth including this reference in the same style for consistency.
  Response: Thank you for your observation; the corresponding changes have been made.
• The questions from the form don’t appear to be in the article. I think it would be useful for the audience to have a table or an annex containing the questions and whether they are considered to relate to intrinsic or extrinsic factors.
  Response: Thank you for your observation. The survey items have been added to Table 2.
• Discussion: You have mentioned hypotheses 2 and 3 in the discussion, but not hypothesis 1?
  Response: Thank you for the observation. Hypothesis 1 has been considered in the discussion, it just was not explicitly labeled as "Hypothesis 1".
• Every study has limitations and it’s truly good to see a limitations section without the need to request one.
  Response: Thank you for valuing our work.

I do appreciate the effort that goes into writing articles for publication as well as the research behind them. I would like to see this article published but feel it needs some revision first. In the interim, I wish you all the best with your ongoing and future research.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Abstract clearly states the aim, key findings and the conclusion as a take away statement for the reader. Well done.

Introduction - Not sure why the (line 33) the hospital lab personnel are important here. This is an article about nurses and the focus seemed too broad here.

Line 54 seems misplaced. In the same paragraph you speak of China and Canada, both developed countries. The only underdeveloped country you mention in Iran (not very underdeveloped but I am not an expert on the developed vs undersdeveloped.) I think you need to expand your examples if you want to keep this statement. Otherwise, I suggest removing the sentence. 

Lit Review - Hypothesis 1: Extrinsic factors.... (but the narrative starts with Intrinsic factors). Hypothesis 2: Intrinsic factors ( the narrative is about extrinsic factors) Very confusing and needs a close read to clarify for the reader. This section needs fixed prior to publication. 

Results

Table 2 - the reader has no idea what these notations are. See suggestion below of making the tool available. 

line 315 - Table 4 provides the stats for Figure 2. Clarify were the 0.851 (0.0000) comes from for the reader. 

Missing here is mention in the discussion/conclusions about your self developed tool. You took a lot of the article space to confirm the reliability and validity of the tool for your research. This tool now can be used by other researchers to replicate your study or expand your study. Additions of reliable and valid tools is important work of research teams. I suggest you make the tool available in a supplemental pages or however the journal allows.   

Author Response

Dear Editor,

Thank you for managing our manuscript through the peer review process. We also extend our gratitude to the reviewers; their comments have significantly improved our study.

Reviewer 2

Abstract clearly states the aim, key findings, and the conclusion as a takeaway statement for the reader. Well done. Response: Thank you for valuing our work.

Introduction - Not sure why (line 33) the hospital lab personnel are important here. This is an article about nurses, and the focus seemed too broad here.
Response: Thank you for your suggestion. The relevant changes were made.

Line 54 seems misplaced. In the same paragraph you speak of China and Canada, both developed countries. The only underdeveloped country you mention is Iran (not very underdeveloped, but I am not an expert on the developed vs. underdeveloped.) I think you need to expand your examples if you want to keep this statement. Otherwise, I suggest removing the sentence.
Response: Thank you for the observation. The sentence was removed.

Lit Review - Hypothesis 1: Extrinsic factors.... (but the narrative starts with intrinsic factors). Hypothesis 2: Intrinsic factors (the narrative is about extrinsic factors) Very confusing and needs a close read to clarify for the reader. This section needs to be fixed prior to publication.
Response: Thank you for your important observation. The pertinent changes have been made in this section.

Results

Table 2 - the reader has no idea what these notations are. See the suggestion below of making the tool available.
Response: Thank you for your observation. The notations represent each of the items of the data collection instrument, which have now been added to this table.

Lines 315 - Table 4 provide the statistics for Figure 2. Clarify where the 0.851 (0.0000) comes from for the reader.
Response: Thank you for your observation. However, the note for the figure clarifies, “Note: At the intersections of the relationship lines are the path coefficients on the left and the p values on the right (inside the parentheses).” These are the path coefficients and p values.

Missing here is mention in the discussion/conclusions about your self-developed tool. You took a lot of the article space to confirm the reliability and validity of the tool for your research. This tool can now be used by other researchers to replicate their studies or expand their studies. Additions of reliable and valid tools are important for research teams. I suggest you make the tool available in supplemental pages or however the journal allows.

Response: Thank you for the observation. The conclusion now includes that a contribution of the study is a valid and reliable instrument for the scientific community. The items with their respective notations were added to Table 2.

Author Response File: Author Response.pdf