Posttraumatic Stress Disorder among Registered Nurses and Nursing Students in Italy during the COVID-19 Pandemic: A Cross-Sectional Study
Round 1
Reviewer 1 Report
The article presented for review contains interesting reflections on the very difficult psychological phenomenon of PTSD in the group of nurses and nursing students.
However, I have a few comments as to the methodology of the conducted research.
The test group is burdened with sex-bias. Unfortunately, both in the case of nurses and students, the percentage of males is low. Similar problems concern the differentiation of the service experience (by far the most numerous are nurses with 0-10 years of work experience), but in the case of students, the 3rd year students dominate.
This is a serious limitation of this study and the reliability of analyzes and results.
I have not found any information on the analysis of data distribution and the selection of appropriate statistical methods.
It seems that it is necessary to analyze the differences in all scales and the overall score between nurses with different professional experience and students from different years of study. The last paragraph of table 1.
Due to the fairly simple analysis of the results, it may be necessary to perform an additional correlation analysis of the results. Perhaps such an analysis would provide more material for discussion?
It seems that it is also necessary to formulate hypotheses in the Materials and Methods section.
Author Response
Rebuttal letter
Post-Traumatic Stress Disorder among Registered Nurses and Nursing Students in Italy during the Covid-19 pandemic: a cross-sectional study
We thank the Referee for the valuables comments.
Reviewer 1
The article presented for review contains interesting reflections on the very difficult psychological phenomenon of PTSD in the group of nurses and nursing students.
However, I have a few comments as to the methodology of the conducted research.
Q1: The test group is burdened with sex-bias. Unfortunately, both in the case of nurses and students, the percentage of males is low. Similar problems concern the differentiation of the service experience (by far the most numerous are nurses with 0-10 years of work experience), but in the case of students, the 3rd year students dominate.
This is a serious limitation of this study and the reliability of analyzes and results.
R1: All limitations of the present study were up dated in the “Strengths and Limitations” sub section.
Q2: I have not found any information on the analysis of data distribution and the selection of appropriate statistical methods.
It seems that it is necessary to analyze the differences in all scales and the overall score between nurses with different professional experience and students from different years of study. The last paragraph of table 1.
Due to the fairly simple analysis of the results, it may be necessary to perform an additional correlation analysis of the results. Perhaps such an analysis would provide more material for discussion?
It seems that it is also necessary to formulate hypotheses in the Materials and Methods section.
R2: All the Methodology section, also the statistical analysis, were also improved according to the Reviewer’s suggestions.
Reviewer 2
Q1: Title: The title is somewhat ambiguous and should be reworded. Suggestion: PTSD among registered nurses and nursing students in Italy during the Covid-19 pandemic: a cross-sectional study
R1: The title was modified according to the reviewer’s suggestion.
Q2: Although the author discusses PTSD and its symptoms, there is no reference to the situation in Italy at the beginning of the pandemic and the possible consequences of overwork in hospitals and nursing facilities with consequences for nurses. I also miss literature on the prevalence of PTSD among nurses in Italy as a whole. Please explain the scientific background and rationale for the investigation being reported in more detail, and state specific objectives, including prespecified hypotheses.
R2: The Introduction section was improved according to all the Reviewer’s suggestion.
Q3: The study design is not sufficiently described. It is reported that the survey was conducted via Google, Facebook, and Instagram, but exactly how and when is not described yet. Please provide more information on the setting, locations, and relevant dates, including the period of recruitment, exposure, and data collection. Information on eligibility criteria and sources and methods for selecting participants is missing entirely. The questionnaire contains some information on individual variables, but it is not complete. Please clearly define all outcomes, exposures, potential confounders, and effect modifiers. Further, please provide for each variable of interest the source of data and details of the methods if there is more than one group.The statistical methods are not sufficiently described. It is also not clear which statistical tests were applied. The author reports that multivariate analyses were performed, but exactly which one is not mentioned. In addition, there are no results of the multivariate analysis in the results section, only p-values of a statistical test (of a bivariate analysis?), which is also not mentioned here. Furthermore, only mean values (SD) are reported. The two subchapters “Validity and Reliability” and “Ethical considerations” seem to me to be out of place at the end of the methods section.
R3: All the Methodology section, also the statistical analysis, were also improved according to the Reviewer’s suggestions.
Q4: The authors first describe the sample descriptively, also 2 tables of a bivariate analysis are found. However, it is not comprehensible what exactly has been tested?! Results of multivariate analysis missing.
R4: The statistical analysis was also specified.
Q5: The discussion also shows a few weaknesses. A summary of the key findings in relation to the study objectives is not provided. The strengths and limitations of the study, except the small sample size mentioned in the Conclusion section, are not identified. The generalizability of the results is also not discussed.
Overall, the paper has significant flaws, so I cannot recommend it in its current version for publication in Psych.
R5: The Discussion and the Conclusion sections were also performed.
Changes and modifications have been marked in red color in the text to speed up reviewing.
I hope that the revised version of our manuscript, now, is ready for acceptance.
Sincerely yours,
Elsa Vitale
Bari, 25.02.2022
Rebuttal letter
Post-Traumatic Stress Disorder among Registered Nurses and Nursing Students in Italy during the Covid-19 pandemic: a cross-sectional study
We thank the Referee for the valuables comments.
Reviewer 1
The article presented for review contains interesting reflections on the very difficult psychological phenomenon of PTSD in the group of nurses and nursing students.
However, I have a few comments as to the methodology of the conducted research.
Q1: The test group is burdened with sex-bias. Unfortunately, both in the case of nurses and students, the percentage of males is low. Similar problems concern the differentiation of the service experience (by far the most numerous are nurses with 0-10 years of work experience), but in the case of students, the 3rd year students dominate.
This is a serious limitation of this study and the reliability of analyzes and results.
R1: All limitations of the present study were up dated in the “Strengths and Limitations” sub section.
Q2: I have not found any information on the analysis of data distribution and the selection of appropriate statistical methods.
It seems that it is necessary to analyze the differences in all scales and the overall score between nurses with different professional experience and students from different years of study. The last paragraph of table 1.
Due to the fairly simple analysis of the results, it may be necessary to perform an additional correlation analysis of the results. Perhaps such an analysis would provide more material for discussion?
It seems that it is also necessary to formulate hypotheses in the Materials and Methods section.
R2: All the Methodology section, also the statistical analysis, were also improved according to the Reviewer’s suggestions.
Reviewer 2
Q1: Title: The title is somewhat ambiguous and should be reworded. Suggestion: PTSD among registered nurses and nursing students in Italy during the Covid-19 pandemic: a cross-sectional study
R1: The title was modified according to the reviewer’s suggestion.
Q2: Although the author discusses PTSD and its symptoms, there is no reference to the situation in Italy at the beginning of the pandemic and the possible consequences of overwork in hospitals and nursing facilities with consequences for nurses. I also miss literature on the prevalence of PTSD among nurses in Italy as a whole. Please explain the scientific background and rationale for the investigation being reported in more detail, and state specific objectives, including prespecified hypotheses.
R2: The Introduction section was improved according to all the Reviewer’s suggestion.
Q3: The study design is not sufficiently described. It is reported that the survey was conducted via Google, Facebook, and Instagram, but exactly how and when is not described yet. Please provide more information on the setting, locations, and relevant dates, including the period of recruitment, exposure, and data collection. Information on eligibility criteria and sources and methods for selecting participants is missing entirely. The questionnaire contains some information on individual variables, but it is not complete. Please clearly define all outcomes, exposures, potential confounders, and effect modifiers. Further, please provide for each variable of interest the source of data and details of the methods if there is more than one group.The statistical methods are not sufficiently described. It is also not clear which statistical tests were applied. The author reports that multivariate analyses were performed, but exactly which one is not mentioned. In addition, there are no results of the multivariate analysis in the results section, only p-values of a statistical test (of a bivariate analysis?), which is also not mentioned here. Furthermore, only mean values (SD) are reported. The two subchapters “Validity and Reliability” and “Ethical considerations” seem to me to be out of place at the end of the methods section.
R3: All the Methodology section, also the statistical analysis, were also improved according to the Reviewer’s suggestions.
Q4: The authors first describe the sample descriptively, also 2 tables of a bivariate analysis are found. However, it is not comprehensible what exactly has been tested?! Results of multivariate analysis missing.
R4: The statistical analysis was also specified.
Q5: The discussion also shows a few weaknesses. A summary of the key findings in relation to the study objectives is not provided. The strengths and limitations of the study, except the small sample size mentioned in the Conclusion section, are not identified. The generalizability of the results is also not discussed.
Overall, the paper has significant flaws, so I cannot recommend it in its current version for publication in Psych.
R5: The Discussion and the Conclusion sections were also performed.
Changes and modifications have been marked in red color in the text to speed up reviewing.
I hope that the revised version of our manuscript, now, is ready for acceptance.
Sincerely yours,
Elsa Vitale
Bari, 20.04.2022
Reviewer 2 Report
The aim of the present study was to examine differences in the prevalence of PTSD among registered nurses and nursing students. In addition, stratified analyses were performed by sex and work experience. The author used crossed-sectional data, conducted during the first wave of the Covid-19 pandemic. The author concludes that PTSD could be a serious consequence of the pandemic in both registered nurses and nursing students. How this vaguely formulated conclusion is reached remains unclear.
Title:
_a. The title is somewhat ambiguous and should be reworded. Suggestion: PTSD among registered nurses and nursing students in Italy during the Covid-19 pandemic: a cross-sectional study
Background:
_a. Although the author discusses PTSD and its symptoms, there is no reference to the situation in Italy at the beginning of the pandemic and the possible consequences of overwork in hospitals and nursing facilities with consequences for nurses. I also miss literature on the prevalence of PTSD among nurses in Italy as a whole. Please explain the scientific background and rationale for the investigation being reported in more detail, and state specific objectives, including prespecified hypotheses.
Methods:
_a: The study design is not sufficiently described. It is reported that the survey was conducted via Google, Facebook, and Instagram, but exactly how and when is not described yet. Please provide more information on the setting, locations, and relevant dates, including the period of recruitment, exposure, and data collection.
_b: Information on eligibility criteria and sources and methods for selecting participants is missing entirely.
_c. The questionnaire contains some information on individual variables, but it is not complete. Please clearly define all outcomes, exposures, potential confounders, and effect modifiers. Further, please provide for each variable of interest the source of data and details of the methods if there is more than one group.
_d. The statistical methods are not sufficiently described. It is also not clear which statistical tests were applied. The author reports that multivariate analyses were performed, but exactly which one is not mentioned. In addition, there are no results of the multivariate analysis in the results section, only p-values of a statistical test (of a bivariate analysis?), which is also not mentioned here. Furthermore, only mean values (SD) are reported. The two subchapters “Validity and Reliability” and “Ethical considerations” seem to me to be out of place at the end of the methods section.
Results:
_a. The authors first describe the sample descriptively, also 2 tables of a bivariate analysis are found. However, it is not comprehensible what exactly has been tested?! Results of multivariate analysis missing.
Discussion:
_a. The discussion also shows a few weaknesses. A summary of the key findings in relation to the study objectives is not provided. The strengths and limitations of the study, except the small sample size mentioned in the Conclusion section, are not identified. The generalizability of the results is also not discussed.
Overall, the paper has significant flaws, so I cannot recommend it in its current version for publication in Psych.
Author Response
Rebuttal letter
Post-Traumatic Stress Disorder among Registered Nurses and Nursing Students in Italy during the Covid-19 pandemic: a cross-sectional study
We thank the Referee for the valuables comments.
Reviewer 1
The article presented for review contains interesting reflections on the very difficult psychological phenomenon of PTSD in the group of nurses and nursing students.
However, I have a few comments as to the methodology of the conducted research.
Q1: The test group is burdened with sex-bias. Unfortunately, both in the case of nurses and students, the percentage of males is low. Similar problems concern the differentiation of the service experience (by far the most numerous are nurses with 0-10 years of work experience), but in the case of students, the 3rd year students dominate.
This is a serious limitation of this study and the reliability of analyzes and results.
R1: All limitations of the present study were up dated in the “Strengths and Limitations” sub section.
Q2: I have not found any information on the analysis of data distribution and the selection of appropriate statistical methods.
It seems that it is necessary to analyze the differences in all scales and the overall score between nurses with different professional experience and students from different years of study. The last paragraph of table 1.
Due to the fairly simple analysis of the results, it may be necessary to perform an additional correlation analysis of the results. Perhaps such an analysis would provide more material for discussion?
It seems that it is also necessary to formulate hypotheses in the Materials and Methods section.
R2: All the Methodology section, also the statistical analysis, were also improved according to the Reviewer’s suggestions.
Reviewer 2
Q1: Title: The title is somewhat ambiguous and should be reworded. Suggestion: PTSD among registered nurses and nursing students in Italy during the Covid-19 pandemic: a cross-sectional study
R1: The title was modified according to the reviewer’s suggestion.
Q2: Although the author discusses PTSD and its symptoms, there is no reference to the situation in Italy at the beginning of the pandemic and the possible consequences of overwork in hospitals and nursing facilities with consequences for nurses. I also miss literature on the prevalence of PTSD among nurses in Italy as a whole. Please explain the scientific background and rationale for the investigation being reported in more detail, and state specific objectives, including prespecified hypotheses.
R2: The Introduction section was improved according to all the Reviewer’s suggestion.
Q3: The study design is not sufficiently described. It is reported that the survey was conducted via Google, Facebook, and Instagram, but exactly how and when is not described yet. Please provide more information on the setting, locations, and relevant dates, including the period of recruitment, exposure, and data collection. Information on eligibility criteria and sources and methods for selecting participants is missing entirely. The questionnaire contains some information on individual variables, but it is not complete. Please clearly define all outcomes, exposures, potential confounders, and effect modifiers. Further, please provide for each variable of interest the source of data and details of the methods if there is more than one group.The statistical methods are not sufficiently described. It is also not clear which statistical tests were applied. The author reports that multivariate analyses were performed, but exactly which one is not mentioned. In addition, there are no results of the multivariate analysis in the results section, only p-values of a statistical test (of a bivariate analysis?), which is also not mentioned here. Furthermore, only mean values (SD) are reported. The two subchapters “Validity and Reliability” and “Ethical considerations” seem to me to be out of place at the end of the methods section.
R3: All the Methodology section, also the statistical analysis, were also improved according to the Reviewer’s suggestions.
Q4: The authors first describe the sample descriptively, also 2 tables of a bivariate analysis are found. However, it is not comprehensible what exactly has been tested?! Results of multivariate analysis missing.
R4: The statistical analysis was also specified.
Q5: The discussion also shows a few weaknesses. A summary of the key findings in relation to the study objectives is not provided. The strengths and limitations of the study, except the small sample size mentioned in the Conclusion section, are not identified. The generalizability of the results is also not discussed.
Overall, the paper has significant flaws, so I cannot recommend it in its current version for publication in Psych.
R5: The Discussion and the Conclusion sections were also performed.
Changes and modifications have been marked in red color in the text to speed up reviewing.
I hope that the revised version of our manuscript, now, is ready for acceptance.
Sincerely yours,
Elsa Vitale
Bari, 20.04.2022
Reviewer 3 Report
Thank you for the opportunity to review this interesting manuscript. I have a few comments for the authors to consider:
· Introduction:
o Line 87: “…also to sex and nursing experience”. Please replace ‘sex’ with ‘gender’, and also throughout the whole manuscript.
· Materials and Methods:
o Line 120-121: Please state the values of their validity and reliability scores, e.g. internal consistency (Cronbach alpha’s = XXX); test-retest reliability (kappa = xxx).
o Line 147-148: The sentence “As the distributions of the variables analyzed were conform to Gaussian distribution, intra-group comparisons were assessed using bivariate analysis.” is too generic. Please specify the statistical tests performed. For instance, “Independent samples t-tests were applied to assess the differences in the IER-S score between registered nurses and nursing students” or “One-way ANOVAs were performed to assess the differences in the IER-S score between registered nurses (male/female) and nursing students (male/female); and between registered nurses (1-10/11-20/>21 years of experience) and nursing students (first/second/third or more year).”. Alternatively, a multiple linear regression model could be performed with gender and years of experience as covariates.
o Line 148-150: The sentence “The threshold for probability of erroneous rejection of the null hypothesis H0 which was in fact not equal was assessed at 0.05” could be rephrased to just “The alpha level was set at 0.05.”.
· Results:
o Tables 2 and 3: Instead of reporting the F-values, please report the 95% CI of mean difference instead.
o Footnotes: please clarify the statistical tests performed, e.g. p-values were derived from independent samples t-tests, or p-values were derived from one-way ANOVA.
· Discussion:
o Line 241: The authors noted the ‘small sample size’ as a reason that limited the generalizability of the study results, however, the authors should have noted the choice of using incomprehensive sampling frames and the convenience sampling as a potential issue of selection bias, and hence the limited generalisability.
o Lines 242-247: These ‘limitations’ could be overcome by performing a multiple linear regression (MLR) model with the IES-R score as the outcome variable (y), the group (nurses vs nursing students) as the main independent variable (x1), whilst controlling for the effect of gender (x2) and experience (x3) as covariates in the MLR. Please do perform this and update add a table, or even replace Tables 2 and 3 with the new table.
o The authors may also add the implication of this finding (if any) in a last paragraph.
Author Response
I thank the Referee for the valuables comments.
Reviewer 3
Thank you for the opportunity to review this interesting manuscript. I have a few comments for the authors to consider:
R1: Introduction:
- Line 87: “…also to sex and nursing experience”. Please replace ‘sex’ with ‘gender’, and also throughout the whole manuscript.
A1: Sex was replaced with gender in all the revised manuscript.
R2: Materials and Methods:
- Line 120-121: Please state the values of their validity and reliability scores, e.g. internal consistency (Cronbach alpha’s = XXX); test-retest reliability (kappa = xxx).
A2: Both internal consistency and test re-test were added in the manuscript and references were also up dated.
R3: Line 147-148: The sentence “As the distributions of the variables analyzed were conform to Gaussian distribution, intra-group comparisons were assessed using bivariate analysis.” is too generic. Please specify the statistical tests performed. For instance, “Independent samples t-tests were applied to assess the differences in the IER-S score between registered nurses and nursing students” or “One-way ANOVAs were performed to assess the differences in the IER-S score between registered nurses (male/female) and nursing students (male/female); and between registered nurses (1-10/11-20/>21 years of experience) and nursing students (first/second/third or more year).”. Alternatively, a multiple linear regression model could be performed with gender and years of experience as covariates.
- Line 148-150: The sentence “The threshold for probability of erroneous rejection of the null hypothesis H0 which was in fact not equal was assessed at 0.05” could be rephrased to just “The alpha level was set at 0.05.”.
A2: The Methodology section was improved according to all changes required.
R3: Results:
o Tables 2 and 3: Instead of reporting the F-values, please report the 95% CI of mean difference instead.
- Footnotes: please clarify the statistical tests performed, e.g. p-values were derived from independent samples t-tests, or p-values were derived from one-way ANOVA.
A3: Tables were performed according to the Reviewer’s comments.
R4: Discussion:
- Line 241: The authors noted the ‘small sample size’ as a reason that limited the generalizability of the study results, however, the authors should have noted the choice of using incomprehensive sampling frames and the convenience sampling as a potential issue of selection bias, and hence the limited generalisability.
A4: The limitations section was improved thanks all your precious comments.
R5: Lines 242-247: These ‘limitations’ could be overcome by performing a multiple linear regression (MLR) model with the IES-R score as the outcome variable (y), the group (nurses vs nursing students) as the main independent variable (x1), whilst controlling for the effect of gender (x2) and experience (x3) as covariates in the MLR. Please do perform this and update add a table, or even replace Tables 2 and 3 with the new table.
The authors may also add the implication of this finding (if any) in a last paragraph.
A5: Multiple linear regression was also assessed (Table 4 was added), which confirmed all the above mentioned results obtained.
Changes and modifications have been marked in red color in the text to speed up reviewing.
I hope that the revised version of our manuscript, now, is ready for acceptance.
Sincerely yours,
Elsa Vitale
Bari, 24.06.2022
Author Response File: 
Author Response.docx
Round 2
Reviewer 1 Report
I am happy with the corrections. Paper is ready to publish.
Author Response
Dear Reviwer,
thank you for your positive comment.
Warm regards
EV
Author Response File: Author Response.doc
Reviewer 2 Report
The manuscript was resubmitted to me after revision. However, my comments were only partially implemented. The methods section and the results section still have significant flaws. The recruiting process is still not explained in a comprehensible way. How was the questionnaire brought to the included participants? Was a Facebook advertising campaign created? How were the inclusion criteria checked? Please take a look at how other researchers have described access and recruitment via Facebook, e.g., here: https://doi.org/10.1016/j.invent.2016.02.001. Furthermore, the instruments (e.g., IES-R) used are not yet sufficiently described. I don't want to look at the original questionnaire first and then compare it with the item numbers provided here to find out which item covers which aspect? The statistical analysis cannot be replicated as described here. It was tested for normal distribution, but why? The associated test for the p-values in the results section is still missing. It seems to me that there is a lack of statistical knowledge here, so I would strongly advise getting a statistician's advice. My evaluation of the discussion section is omitted because the results are probably not based on a statistical basis.
Author Response
c
I thank the Referee for the valuables comments.
Reviewer 2
The manuscript was resubmitted to me after revision. However, my comments were only partially implemented. The methods section and the results section still have significant flaws.
R1: The recruiting process is still not explained in a comprehensible way. How was the questionnaire brought to the included participants? Was a Facebook advertising campaign created? How were the inclusion criteria checked? Please take a look at how other researchers have described access and recruitment via Facebook, e.g., here: https://doi.org/10.1016/j.invent.2016.02.001.
A1: The recruited procedure was better explained and also the checked criteria were improved (lines: 93-96).
R2: Furthermore, the instruments (e.g., IES-R) used are not yet sufficiently described. I don't want to look at the original questionnaire first and then compare it with the item numbers provided here to find out which item covers which aspect? The statistical analysis cannot be replicated as described here. It was tested for normal distribution, but why? The associated test for the p-values in the results section is still missing. It seems to me that there is a lack of statistical knowledge here, so I would strongly advise getting a statistician's advice. My evaluation of the discussion section is omitted because the results are probably not based on a statistical basis.
R2: All the statistical procedure was improved thanks to your precious answers. Please, note that the Methodology and the results sections were also implemented of all your requests.
Changes and modifications have been marked in red color in the text to speed up reviewing.
I hope that the revised version of our manuscript, now, is ready for acceptance.
Sincerely yours,
Elsa Vitale
Bari, 24.06.2022
Author Response File: Author Response.docx
