Moral Distress and Its Determinants among Nursing Students in an Italian University: A Cross-Sectional Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

I appreciate the opportunity to review the manuscript "Moral distress among nursing students in an Italian university: a cross-sectional study from an Italian University."

Abstract: Accurate, the article type is indicated in the study. 

Background: Please provide a more comprehensive introduction to the background.

Methods: Please briefly indicate if any inclusion/exclusion criteria were applied.

Results: Specify that n=344. Briefly specify the limitations of the abstract and what was found.

Manuscript: The background/rationale is well presented.

Objectives: It is recommended to state not only specific objectives but also general and specific ones.

Study design and methods: Well done, but it is necessary to provide deeper insight into all outcomes (specify why those scales), predictors, and potential bias (can be added in limitations).

Results: Correct tab 1 for table 1 and construct/ give the correct format.

Statistics: Okay, avoid using green or other colors. If used, explain why (significance). Green, yellow, or orange color can have different meanings worldwide.

Bias and limitations: I suggest changing "strengths" to "NURSING CLINICAL IMPLICATIONS" and explaining possible bias (I recommend dividing this paragraph to explain how the text is helpful for nursing science).

Overall recommendation: The manuscript is a good research paper with strong evidence, and precise statistical methods, and can be accepted after minor changes.

Author Response

Comment 1:  Accurate, the article type is indicated in the study.

Response 1: Thank you for the positive comment.

Comment 2: Please provide a more comprehensive introduction to the background.

Response 2: Thank you for the suggestion. We have expanded on introduction section in the abstract.

Comment 3: Methods: Please briefly indicate if any inclusion/exclusion criteria were applied.

Response 3: We reported the inclusion criteria in the abstract.

Comment 4: Results: Specify that n=344. Briefly specify the limitations of the abstract and what was found.

Response 4: Thanks for the suggestion. We expanded the abstract, also as per rev.2 and rev.3 suggestions.

Comment 5: Manuscript: The background/rationale is well presented.

Response 5: Thank you for the positive comment.

Comment 6: Objectives: It is recommended to state not only specific objectives but also general and specific ones.

Response 6: As per rev.2 and rev.3 suggestions, we put "Study Objectives" as a separate section in Introduction, with a more detailed explanation.

Comment 7: Study design and methods: Well done, but it is necessary to provide deeper insight into all outcomes (specify why those scales), predictors, and potential bias (can be added in limitations).

Response 7: Thank you for the suggestion. We have expanded the Methods section to explain the rationale for choosing the ESMEE-It scale and to clarify the meaning of its dimensions. The limitations of the study are discussed in the final part of the Discussion section.

Comment 8: Results: Correct tab 1 for table 1 and construct/ give the correct format.

Response 8: Thanks for the heads up. We corrected table 1 and tried to better the layout of all tables (likely, MDPI post-production will further make HTML changes for the final version).

Comment 9: Statistics: Okay, avoid using green or other colors. If used, explain why (significance). Green, yellow, or orange color can have different meanings worldwide.

Response 9: We changed the results to plain color to avoid misunderstandings.

Comment 10: Bias and limitations: I suggest changing "strengths" to "NURSING CLINICAL IMPLICATIONS" and explaining possible bias (I recommend dividing this paragraph to explain how the text is helpful for nursing science).

Response 10: In order to accommodate Rev.2 and Rev.3 suggestion, the entire Discussion section has been reworked. A "NURSING CLINICAL IMPLICATIONS" paragraph has been added as suggested.

 

Comment 11: Overall recommendation: The manuscript is a good research paper with strong evidence, and precise statistical methods, and can be accepted after minor changes.

Response 11: Thank you for the timely and accurate review of our manuscript. We took great care in its preparation, and we believe the tone and content of the comments reflect the underlying quality of the work. Hereby, we provide a point-by point response to the reviewer's suggestions, all of which have been taken into account.

Reviewer 2 Report

Comments and Suggestions for Authors

In detail, I read and analysed the manuscript Moral Distress among Nursing Students in an Italian University: a cross-sectional study.

Topic and Relevance

The manuscript addresses a highly relevant issue due to the significant moral distress experienced by nursing students. However, several areas need improvement to enhance the manuscript’s overall quality.

Abstract

The abstract is concise and well-written, effectively summarising the main points of the study.

Introduction

The introduction thoroughly overviews moral distress and its implications. It is well-structured, employing a funnel approach and culminating in clearly articulating the study’s objectives. However, the aims presented in the introduction should be consistently aligned with those outlined in the methodology and abstract.

Materials and Methods

The study aims should not be repeated in the methodology section.

The reference [13] cited in the description of participants appears unnecessary.

The instrument is well represented—no need for reference 16.

Results:

Results are effectively presented across four tables, one figure, and text, with appropriate interpretation. However, Table 2 lacks comprehensiveness. It would be beneficial to divide this data into two separate tables for clarity. The figure currently includes duplicates of information already presented in the tables. Consider removing the figure to avoid redundancy.

Discussion and Conclusions

The discussion and conclusions effectively summarise the study’s results and aims.

Limitations

The manuscript acknowledges a limitation, but reference [27] appears unnecessary.

References

The reference list includes outdated sources and some that may be irrelevant. I recommend updating and refining it to include current and pertinent sources.

Final Comments

Congratulations to the authors on their manuscript. I believe these revisions will strengthen the manuscript and improve its overall quality.

 

 

Comments for author File: Comments.pdf

Author Response

Comment 1: The abstract is concise and well-written, effectively summarizing the main points of the study.

Response 1: Thank you for the positive comment.

Comment 2: The introduction thoroughly overviews moral distress and its implications. It is well-structured, employing a funnel approach and culminating in clearly articulating the study’s objectives. However, the aims presented in the introduction should be consistently aligned with those outlined in the methodology and abstract.

Response 2: Thank you for the positive feedback. In accordance with also REV.1 suggestions, we have updated the "objectives" section of the paper. We hope you will find the changes satisfactory.

Comment 3: The study aims should not be repeated in the methodology section.

Response 3: As per previous response, we have better organized the study aims section of the document.

Comment 4: The reference [13] cited in the description of participants appears unnecessary.

Coment 4: We removed the unnecessary reference as suggested.

Comment 5: The instrument is well represented—no need for reference 16.

Coment 5: We removed the unnecessary reference as suggested.

Comment 6: Results are effectively presented across four tables, one figure, and text, with appropriate interpretation. However, Table 2 lacks comprehensiveness. It would be beneficial to divide this data into two separate tables for clarity. The figure currently includes duplicates of information already presented in the tables. Consider removing the figure to avoid redundancy.

Response 6: Given Rev.3 comments, we decided to keep the figure as it is of more immediate reading, and to remove the table instead, placing it as supplementary material. We hope you will find the change satisfactory.

Comment 7: The discussion and conclusions effectively summarise the study’s results and aims.

Response 7: Thank you for the positive comment.

Comment 8: The manuscript acknowledges a limitation, but reference [27] appears unnecessary.

Response 8: We removed the unnecessary reference as suggested.

Comment 9: The reference list includes outdated sources and some that may be irrelevant. I recommend updating and refining it to include current and pertinent sources.

Response 9: Thank you for the suggestion. We have added some more accurate and recent references across the document where appropriate.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

file Annex.

Best

Comments for author File: Comments.pdf

Author Response

Comment 1: Title and Abstract: In general, the title and abstract are well-structured, but adding a few more details could make them even more useful and clear for the reader. For instance, include specific details about the results, such as descriptive statistics or significant associations found in the study. Additionally, consider starting the abstract with the acronym Moral Distress (MD) for consistency.

Response 1: Thanks for the suggestion, shared by the other reviewers. We have slightly expanded the introduction, results, and limitations sections. Also, we started the abstract as suggested.

Comment 2: The section could benefit from a clearer structure by dividing the text into distinct paragraphs (possibly expanding them) for general context, definitions, specific issues, and study objectives. This would improve readability and strengthen the rationale for the study. It would also be helpful to present a clear and concise definition of MD at the beginning, then explore different interpretations and complexities, reinforcing the connection between existing literature and the specific research. For example, briefly explain how your research addresses gaps identified in the existing literature and emphasize the practical and theoretical importance of the study.

Response 2: Thank you for your suggestions. Coherently with the other reviewers' suggestions, we have divided the Introduction in two sections (Background & Rationale, Study Objectives), and also expanded some concepts with more up-to-date references. We hope you will find the changes satisfactory.

Comment 3: Methods: Overall, the "Materials and Methods" section is well-structured and provides a clear description of the procedures and techniques used in the study. However, some adjustments could make it even clearer. There is an editorial error (aim) that makes the second objective of the study unclear. I suggest providing more details on sampling, such as the exact number of participants and the response rate obtained. The STROBE checklist reference is missing, including in the supplementary files, and a section dedicated to managing selection bias and data analysis should be added. Also, the description of the interview management tool is too generic, such as “telematic meeting.”

Response 3: Thank you for your suggestions. Unfortunately, while preparing the manuscript for the journal template, a part of the "Aims" section went lost; we have updated and moved in the new "1.2 Study objectives" section. We have also added the STROBE checklist (as Non-published Material). In the last part of the discussion there are the limitations of the study.

Comment 4: Results: I apologize, but Tables 2 and 3 are too cumbersome and nearly unreadable; I suggest including them in a supplementary file and elaborating more descriptively on the results in the text. The results for other tables are also underdeveloped.

Response 4: We are sorry for this. We tried to adjust the table formatting to the Journal style, as online version will likely use a MDPI Html format. In the meantime, also in accordance with Rev.2 suggestions, we removed Table 2 and placed its contents as supplementary material.

              

Comment 5: Providing a more detailed comparison with previous studies on MD among nursing students to better contextualize the results. Discuss in greater depth how the findings fit into the existing research landscape, perhaps by expanding the existing bibliography.

Response 5: We expanded on existing literature, and discussed and compared our findings in current panorama.

Comment 6: Delving deeper into why specific socio-demographic and academic variables influence MD intensity, and strengthening the discussion on the practical implications of the results for practice, possibly including concrete suggestions for educators and institutions based on the study’s findings.

Response 6: Thanks for the suggestion. We expanded on the topic in the "Conclusions" section.

Comment 7: Limits: In summary, the "Limitations" section provides a useful overview of the study’s limitations but could benefit from a more in-depth discussion of the underlying mechanisms and concrete suggestions for future research. I suggest adding a more thorough analysis of how career choice and socio-demographic factors influence MD, supported by psychological theories and previous studies. Consider proposing future studies that address the identified limitations, such as conducting longitudinal or comparative studies to explore how MD might evolve over time and in different contexts. Also, consider discussing the reasons for using convenience sampling and the associated limitations. Missing potential negative effect of Covid-19.

Response 7: Thanks for your comments. We have expanded this part with 4.3 section implications for practice and research.

Comment 8: Punctuation should follow the bibliographic reference […], not the other way around.

Response 8: Thanks for the heads up. We checked, and punctuation should now be fine.

Comment 9: The bibliography is relevant, but following the previous suggestions, it should be broader and more updated.

Response 9: This aspect is highlighted by all three reviewers, and we have added further updated references where appropriate.

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

thanks for humbly appreciating the suggestions provided. The manuscript is already for publication. Editor will best assist you for dissertation.

Best