Possible Health Benefits and Risks of DeepFake Videos: A Qualitative Study in Nursing Students

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors. I appreciate the opportunity to review your manuscript. I found it to be an interesting study. AI has fully entered our lives and developing studies focused on this new reality and adapted to students is fascinating to me.

I would like to make some comments that I believe may improve/clarify your manuscript.

- Review lines 59-62. The quote is interesting but the opinion of 60 nurses and 61 university students is not representative of the population. I think you should use a reference that more broadly encompasses this statement.

- The bibliographic reference is missing when you talk about INCIBE.

- In the introduction you could include valuable information without including questions. Answering these questions is more interesting than the question itself.

- Were all the students familiar with the term DeepFakes to be able to discuss it with a solid knowledge base?

- Were the students familiar with Microsoft's Flipgrid tool? Were they previously trained in the use of that tool?

- The methodology and results are well described.

- In the discussion, my advice is to review it since there are paragraphs that could be unified to facilitate reading and understanding.

Best regards

Author Response

Comments 1: Review lines 59-62. The quote is interesting but the opinion of 60 nurses and 61 university students is not representative of the population. I think you should use a reference that more broadly encompasses this statement.

Response 1: We fully agree with your suggestion. The information is complemented with two recently published quotes that reinforce the main idea of ​​the paragraph.

Comments 2: the bibliographic reference is missing when you talk about INCIBE.

Response 2: Added this reference. Thanks for detecting the lapse.

Comments 3: in the introduction you could include valuable information without including questions. Answering these questions is more interesting than the question itself.

Response 3: Thank you for this suggestion. The questions are eliminated based on the reviewer's recommendations and modifications are made to the theoretical framework in this regard in order to clarify some concepts that would have been unclear in the previous submission.

Comments 4: Were all the students familiar with the term DeepFakes to be able to discuss it with a solid knowledge base? Were the students familiar with Microsoft's Flipgrid tool? Were they previously trained in the use of that tool?

Response 4: An advertisement using this technology became popular in Spain. That is why it is part of the proposed exercise to watch the video explaining how this spot was made. The material given to them to carry out the activity was designed to give them a first approach to this concept. Of course, they could also consult the internet for more information.

Many had already heard of this theme, not only from the aforementioned advertising but also from films such as Star Wars. We cannot say that they had a solid knowledge base on this topic, in fact, it was the first time it was mentioned in the classroom. However, we felt it was important to work on the subject from their point of view as users of the Internet and as future health professionals. It was not really looking for ‘right’ answers or evidence-based debates, it was looking for the student's opinion on the subject.

In relation to the use of the Flipgrid tool, a brief explanation has been included in the methodology section.

Comments 5: the methodology and results are well described. The discussion, my advice is to review it since there are paragraphs that could be unified to facilitate reading and understanding.

Response 5: thank you for this very good suggestion. The unification of content that could be repetitive in this section is carried out. We hope that now it is clearer and more synthetic.

Reviewer 2 Report

Comments and Suggestions for Authors

The study reports a pedagogical experience.

Given that the participants are not experts, the content analysis of their projections provides material for teachers to promote critical reflection in the classes. Still, it does not add knowledge to what is already known about the subject. 

Replicating this study with other types of students, not experts in the field, will probably have similar results, as it is a subject that is very present in the lives of young people, regardless of whether they are nursing students or not.

Author Response

Comments 1: 

The study reports a pedagogical experience.

Given that the participants are not experts, the content analysis of their projections provides material for teachers to promote critical reflection in the classes. Still, it does not add knowledge to what is already known about the subject. 

Replicating this study with other types of students, not experts in the field, will probably have similar results, as it is a subject that is very present in the lives of young people, regardless of whether they are nursing students or not.

Response 1:

We appreciate these suggestions, however, we wish to be able to justify the objective of our study. Given the topicality of the issue raised in this study, we consider it necessary to analyze the use of AI from the prism of DeepFakes based on the opinions of the nursing students interviewed, especially considering that the nursing professional profile is far from that of other disciplines. Furthermore, it should be noted that no previous research on this topic has been carried out in Spain with students. Therefore, it seems pertinent to us to delve into how young nursing students perceive DeepFakes technology, whether they consider its use ethical and whether they believe it could be beneficial in the field of nursing and care. We are interested in identifying and learning about the positive and negative aspects of the use of DeepFakes in the healthcare setting. We are aware that artificial intelligence has multiple variants and uses, however, in this work we focus only on technology based on DeepFakes. In any case, we believe that this study leaves the door open to other new studies, so it would be the starting point for further research in other environments.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear authors,

In my opinion, the subject of your study is of great value. However, I see some areas where there is room for improvement. I have outlined my comments below.

Background

I recommend restructuring this article to separate the general description of AI from the more specific analyses related to nursing care. Overall, this section could be more concise. Additionally, you could strengthen your argumentation regarding AI applications in nursing care. Furthermore, it would be beneficial to include more country-specific information, especially concerning AI implementation in health and nursing care. Please provide more information on why you have chosen Deepfake technology as the primary focus of your research. Additionally, you should clearly describe its relevance and applications in healthcare.

Methods

You should include a description and justification of your study design. Please ensure that you differentiate between the study design and the data analytical approach (“qualitative thematic content analysis study”). Why did you decide that the students needed to prepare a video? Did you utilize the visual video data in your research? Could you please explain what types of different data sets you have and how you performed the triangulation? In information about your analytical approach is very limited.

Results

Please ensure, that there is sufficient transparency regarding how the categories were constructed. You should explain 1) how you identified data saturation and 2) how you selected the data to be analyzed. Why did you reorganize your findings according to the questions? It would be interesting to know how specific the videos are to nursing care. I recommend providing information about the contents of the videos. Additionally, you should clearly specify whether the categories cover general information or are specific to nursing care. If the information is general, you should point out the relevance for the health care sector. I believe it is essential for your revision to include a description of the participants' thoughts about Deepfake technology. This could lead to false assumptions by summarizing the findings, as the respondents may be referring to completely different digital technologies. Based on my comments, I recommend restructuring the results section.

Discussion/conclusions

I believe you are missing opportunities to critically discuss your findings. Several relevant aspects have already been mentioned in my critique to data analysis and results presentation. Additionally, your discussion is somewhat repetitive, so I recommend shortening the text. Instead, you should adress relevant questions, such as: What are the participants' subjective perception of Deepfake? How do they contextualise Deepfake in nursing care? How do they connect this technology to their nursing care practice?

Author Response

Comments 1: In my opinion, the subject of your study is of great value. However, I see some areas where there is room for improvement. I have outlined my comments below.

Response 1: Thank you for all the comments made, as in this way, we hope to have improved the text. 

 Comments 2: Background. I recommend restructuring this article to separate the general description of AI from the more specific analyses related to nursing care. Overall, this section could be more concise. Additionally, you could strengthen your argumentation regarding AI applications in nursing care. Furthermore, it would be beneficial to include more country-specific information, especially concerning AI implementation in health and nursing care. Please provide more information on why you have chosen Deepfake technology as the primary focus of your research. Additionally, you should clearly describe its relevance and applications in healthcare. 

Response 2: The recommendations have been followed in an attempt to make it more concise and concrete.

The applicability of AI and DeepFakes has been deepened, specifying their use in healthcare. In addition, some citations have been updated and the information has been reorganised following the corrections. The introduction concludes by indicating the purpose of the study and the importance in the area of nursing.

Comments 3: Methods. You should include a description and justification of your study design. Please ensure that you differentiate between the study design and the data analytical approach (“qualitative thematic content analysis study”). Why did you decide that the students needed to prepare a video? Did you utilize the visual video data in your research? Could you please explain what types of different data sets you have and how you performed the triangulation? In information about your analytical approach is very limited. 

Response 3: The study design and how to analyse the data has been better explained. Thank you for your suggestions. 

In this subject, students are required to generate videos as part of the competences to be acquired. In addition, it was considered a good way to work on the subject, not so much because it was a video but because Flipgrid allows students to view other students' contributions and add comments. This tool has already been used by other authors for reflection in the classroom. We add an explanation in the text to clarify this part and a bibliography.   

In this research, visual data were not used and only the transcripts of the audio clips included in the videos were used. The researchers only worked with the text transcription data set, which was the material analysed in Atlas ti, relying on audio verification when there was an error or inconsistency in the transcribed text. We have added this explanation in the methodology section. We understand that there could be confusion with the word triangulation, which in this case did not refer to triangulating data but to triangulating between authors. It has been modified and corrected to avoid confusion. Here it refers to verification between authors in order to be rigorous and reach agreement.  

Comments 4: Results. Please ensure, that there is sufficient transparency regarding how the categories were constructed. You should explain 1) how you identified data saturation and 2) how you selected the data to be analyzed. Why did you reorganize your findings according to the questions? It would be interesting to know how specific the videos are to nursing care. I recommend providing information about the contents of the videos.  

Additionally, you should clearly specify whether the categories cover general information or are specific to nursing care. If the information is general, you should point out the relevance for the health care sector. I believe it is essential for your revision to include a description of the participants' thoughts about Deepfake technology. This could lead to false assumptions by summarizing the findings, as the respondents may be referring to completely different digital technologies. Based on my comments, I recommend restructuring the results section. 

Response 4: An explanation of the data analysis process and saturation has been included. We thank you for pointing this out, which has helped us to explain it better. The categories that emerged clearly referred to the questions asked to the students who mainly tried to answer what we had asked them. 

The material provided to the students for the activity was not specific to nursing or health except for the Microsoft chatbot that could be directly related to bereavement after the loss of a family member or loved one. All the material used in the activity is available in Appendix A.   

There has indeed been an error when copying and pasting the text into the article template and all the students' literal comments, which should have been in italics, appear in normal font. I believe that this may have caused confusion and eliminated the possibility of reading these literal comments. All student comments have been reinstated in italics. We hope that their thoughts on this technology can be seen in this way. 

Comments 5: Discussion/conclusions. I believe you are missing opportunities to critically discuss your findings. Several relevant aspects have already been mentioned in my critique to data analysis and results presentation. Additionally, your discussion is somewhat repetitive, so I recommend shortening the text. Instead, you should adress relevant questions, such as: What are the participants' subjective perception of Deepfake? How do they contextualise Deepfake in nursing care? How do they connect this technology to their nursing care practice? 

Response 5: We appreciate the reflections on the structure of the discussion and the recommendations to make it more solid and synthetic.  
Information that could be repetitive or less relevant has been eliminated. In addition, it has been structured, firstly, in the opinions of the students on the use of DeepFake in areas not related to nursing care. The main risks and benefits indicated by the participants have been described. Next, Deepfakes in nursing care and their applicability of said technology in healthcare practice have been contextualized following the previous scheme (advantages and disadvantages perceived by the students in the use of DeepFake in nursing). And, taking into account the design of the activity, the opinions of the students on the applicability of DeepFake in grief, after the loss of a loved one, have been captured.  
Finally, emphasis has been placed on the importance of reviewing ethical approaches from the classrooms in university environments and in professional practice to avoid risks and misuse of DeepFake technology. We hope that the information is now clearer and more concise.