Current Nursing Education Considering Southern Europe’s Reality and Legal Framework: A Two-Phased Research Approach

Round 1

Reviewer 1 Report

Reviewer report:  Current nursing education, Europe reality and legal framework: A two-phased research approach

The strength of the study is twofold. First, it identifies some gaps in the nursing education system in Europe and intends to fill some of these gaps. Second, it surveys not only studies in English but also studies in other European languages. However, I am concerned about the limited geographical coverage of the study—only four countries were included. The study could make a bigger contribution if studies done in more countries were included.

Specific comments

1.     Your title mentions “European reality,” but actually, your study only looks at 4 southern European countries.

2.     Some key information is missing in the Introduction: 1) What type of study is this? 2) Why focus on four southern Europe countries (Portugal, Spain, Italy, and Greece)? 3) A brief description of your approach.

3.     The Results section reports NO real results. All that was reported is the results of the literature search, not the results of the literature ANALYSIS.

  4.     The section titles are a bit misleading. I think most of the materials in the Discussion section should be moved to the Results section.

5.     The “publication bias” issue should be addressed.

6.     In response to the problems you identified from the literature, what’s your proposal to tackle these problems? Is there anything that you can “borrow” from nursing education systems in non-European countries? Any policy implications?

7. The writing should be greatly improved to meet publication standards.

1) Many grammatical errors can be found in the text. Examples:

Line 30: “Thusly” should be “Thus.”

Line 37: “accumulation” should be “Accumulation.”

Line 43: “Regarding to” should be “Regarding.”

Line 49: “state” should be “states.”

Line 51: I think “uniformity” should be “heterogeneity.” Please check.

Line 73: The word “whereas” seems to be misused.

Line 102: “Study” should be “study.”

Line 226: “lasts”?? What do you mean?

2) Font size is not consistent throughout.

3) The authors have a tendency to abuse comma “,”.

Author Response

Thank you very much for taking time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.

Comment 1: Your title mentions “European reality,” but actually, your study only looks at 4 southern European countries.

Response 1: Thank you for pointing this out. I have, accordingly, changed the tittle to be more accurate:
“Current nursing education, Southern Europe reality and legal framework: A two-phased research approach”

Comment 2: Some key information is missing in the Introduction: 1) What type of study is this? 2) Why focus on four southern Europe countries (Portugal, Spain, Italy, and Greece)? 3) A brief description of your approach.

Response 2:
In relation to your second comment, I have revised the information and I have expanded it. I present below the response to your specific questions. Moreover, you could find the changes made in the new submitted manuscript.

1-3) The present study follows a two-phased research approach. In first place a scoping review was done aiming to revise and to get an up-to-date overview of the current nursing education status. By including studies from other continents, it was expected to confirm nursing education heterogeneity over the world and to determinate other education challenges. Then, with the content evaluation of legal public framework, it was intended to make a comparison between the scoping review results and the specific legal framework applied is the countries
selected.

2) The selection of these countries was made aiming to evaluate the situation in South-ern Europe and focusing the analysis and comparison within a specific region. Addition-ally, these destinations are the most popular and frequently chosen by students for their international Erasmus mobility. Consequently, addressing the main distinctions between these countries would be advantageous in promoting student mobility, as it can help reduce and resolve many of the difficulties often encountered due to variations in curricula and ECTS validation.

Comment 3: The Results section reports NO real results. All that was reported is the results of the literature search, not the results of the literature ANALYSIS.

Response 3: To address this comment, a possible solution would be moving this part of the discussion (lines 201-209) to the results.

The results showed considerable amount of research regarding nursing education curriculum, framework and uniformity. The scoping review resulted in the generation of three main themes to assess and the legal framework evaluation identified the core legal bases about nursing curriculum among the
countries selected. The three principal topics extracted from the results were the following ones:

• Nursing education heterogeneity
• Nursing clinical framework and competence areas poorly defined
• Nursing education evolution, quality improvement and guidelines and standards requirement

Comment 4: The section titles are a bit misleading. I think most of the materials in theDiscussion section should be moved to the Results section.

Response 4: In addition to the change mentioned in the question above we could also consider to move another paragraph such as the following one:

In relation to European higher education legislation, The Directive 2013/55EU exposed the legal framework meant to be applied among all European countries within their higher education [6]. The European Union reported that nursing degree must comprehend at least three years of study measured with ECTS representing not less than 4600 hours of theorical and clinical training. The minimum duration of theorical component has to be at least one-third of workload and at least one-half of curriculum ECTS has to be destinated to clinical training. (From Lines 254-260 to 176-180)

Comment 5: The “publication bias” issue should be addressed.

Response 5: We agree with you and the authors introduce on the document , that they work on this region.

Comment 6: In response to the problems, you identified from the literature, what’s your proposal to tackle these problems? Is there anything that you can “borrow” from nursing education systems in non-European countries? Any policy implications?

Response 6: Regarding the conclusion, I agree that the aspects mentioned above lacked. Consequently, the two main proposals planned to tackle the problems presented in the study results would be the following ones:

• The establishment of a comprehensive framework for elementary nursing education with a more precise delineation of nursing competencies
• Global uniformity of nursing degree curriculum and ECTS distribution

You can find the conclusion updated in page 10, lines 304-321.

Comments on the Quality of English Language
7. The writing should be greatly improved to meet publication standards.
1) Many grammatical errors can be found in the text. Examples:

• Line 30: “Thusly” should be “Thus.”
• Line 37: “accumulation” should be “Accumulation.”
• Line 43: “Regarding to” should be “Regarding.”
• Line 49: “state” should be “states.”
• Line 51: I think “uniformity” should be “heterogeneity.” Please check.
• Line 73: The word “whereas” seems to be misused.
• Line 102: “Study” should be “study.”
• Line 226: “lasts”?? What do you mean?

2) Font size is not consistent throughout.
3) The authors have a tendency to abuse comma “,”.

Checked

Reviewer 2 Report

The study is properly carried out from a  methodological point of view. It would be necessary to discuss why the term "quality" has been chosen instead of "legislative framework".  I do not see the record in OSF. It should have been consulted and done. if it has been done and not indicated, it would be appropriate. 

On the other hand, the discussion should be a bit more enriching. The conclusions should express advantages in a more concrete way, not in such an abstract and/or general way

Author Response

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.

Comment: 

The study is properly carried out from a  methodological point of view. It would be necessary to discuss why the term "quality" has been chosen instead of "legislative framework".  I do not see the record in OSF. It should have been consulted and done. if it has been done and not indicated, it would be appropriate. 

On the other hand, the discussion should be a bit more enriching. The conclusions should express advantages in a more concrete way, not in such an abstract and/or general way

Response:

We agree with you that the legislative framework would have been more appropriate.

In relation to the OSF registration, we did not it. 

According to the conclusion review, we agree with your point of view. The changes carried out after checking our analysis could be found in the new submitted manuscript below.

Reviewer 3 Report

Dear Authors,

I have read your manuscript with interest. It raises an important issue of undergraduate training of nursing staff. It seems that this is an important topic, especially in the context of international mobility of nursing students and professional nurses. I am an Erasmus student coordinator and I often encounter difficulties in matching the education program because, despite the existing arrangements made as part of the Bologna process, education varies greatly from country to country. 

Despite the value of the work, I have a few doubts and comments:

1- Why focus on Portugal, Spain, Italy and Greece. Were these countries chosen as a guide?

2- Why, despite the fact that the topic includes European countries, the results of research from countries from the USA, Brazil, Hong Kong, Canada were analyzed?

3- Perhaps in the conclusions it would be good to mention Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients' rights in cross-border healthcare, which, among others, says that the patient has the right to health care at a qualitatively similar level. Without uniformity in the educational process, this is difficult to achieve. I think this argument will reinforce the legitimacy of your study.

Author Response

Thank you very much for taking the time to review this manuscript. Please find the detailed responses below and the corresponding revisions/corrections highlighted/in track changes in the re-submitted files.

Comment 1: Why focus on Portugal, Spain, Italy and Greece. Were these countries chosen as a guide?

Response 1: The selection of these countries was made aiming to evaluate the situation in South-ern Europe and focusing the analysis and comparison within a specific region. Additionally, these destinations are the most popular and frequently chosen by students for their international Erasmus mobility. Consequently, addressing the main distinctions between these countries would be advantageous in promoting student mobility, as it can help reduce and resolve many of the difficulties often encountered due to variations in curricula and ECTS validation.

Comment 2: Why, despite the fact that the topic includes European countries, the results of research from countries from the USA, Brazil, Hong Kong, Canada were analysed?

Response 2: By including studies from other continents, it was expected to confirm nursing education heterogeneity over the world and to determinate other education challenges. Then, with the content evaluation of legal public framework, it was intended to make a comparison between the scoping review results and the specific legal framework applied is the countries
selected.

Comment 3: Perhaps in the conclusions it would be good to mention Directive 2011/24/EU of the European Parliament and of the Council of 9 March 2011 on the application of patients'; rights in cross-border healthcare, which, among others, says that the patient has the right to health care at a qualitatively similar level. Without uniformity in the educational process, this is difficult to achieve. I think this argument will reinforce the legitimacy of your study.

Response 3: Thank you for pointing this out, we have positively considered your argument and added it to the new submitted manuscript.

Round 2

Reviewer 1 Report

The paper has been improved. However, the very small number of studies reviewed remains a concern. I suggest that the authors expand the "limitations" section to better inform the reader. For example, what caution should be kept in mind when interpreting the results of your paper? Are there any fundamental limitations associated with the chosen review methods? And so on.

The English is fine.

Author Response

Thank you very much again for your content revision. Please find the detailed responses below and the corresponding corrections highlighted in the re-submitted files.

Comment: The paper has been improved. However, the very small number of studies reviewed remains a concern. I suggest that the authors expand the "limitations" section to better inform the reader. For example, what caution should be kept in mind when interpreting the results of your paper? Are there any fundamental limitations associated with the chosen review methods? And so on.

Response: Thank you for pointing this out, we have expanded the limitations section in the new submitted manuscript.

Author Response File: Author Response.pdf