European Nurses’ Burnout before and during the COVID-19 Pandemic and Its Impact on Patient Safety: A Scoping Review
Round 1
Reviewer 1 Report
Comments and Suggestions for Authors
Dear authors, thank you very much for the opportunity to read your manuscript.
Abstract: Is informative and structured.
Keywords: For burnout there is a more specific descriptor MeSH: "Burnout, Professional"; and for Wellbeing term: "Psychological Well-Being"
Introduction: Is well laid out and introduces the reader to the theoretical framework. They should describe on page 2 (line 73) the use of the acronym for WHO (which is not included), but on page 5 (line 112) WHO is described as an acronym. At the end of the introduction, it is not necessary to identify the objective with the subheading 1.4.
Methods: In the design subheading shoul indicate whether a review protocol exists (or if not). Tables 1 and 2 could be explained in the text (in fact, it is duplicated in the later section 2.3 search strategy). It is irrelevant to include this information in tables. The information (page 5, line 198-199): "Most clinical systematic reviews follow a PICO framework - Patient, Intervention, Comparison, Outcome [32]..." is irrelevant (the PECO structure has already been explained above). The following paragraph: "However, this review aimed to identify the prevalence of burnout among nurses, making a comparison before and during Covid-19, rather than focusing on any specific intervention. The review did not seek to explore the impact of burnout on nurses; rather, the outcome explored was the link between patient safety and burnout, as indicated by the studies conducted." should be moved to the end of the introduction (in the space where the study objectives are described).
Page 6 (line 206) must specify in parentheses the acronym PRISMA-ScR.
Search Strategy: Do not describe the methodological limits in this section. Inclusion criteria are repeated again: time limit for language (English), year of publication (2013-2023); and exclusion: (other reviews and gray literature). They should also not describe that studies retrieved in full text will be included (this information is described in the screening process).
Sudy selection and Quality assessment: Information on the results should not be described in this section (n=17 studies identified); This information must be provided in the results section. Here they should only limit themselves to describing the process.
Results: In results add "n" to the identified records, screened and included studies. They should be referred to in the same terms as Figure 1: For those identified and screened as "records" and not as "papers", For those included as "studies" and not as "papers". (Review this information also in Figure 1, change "reports" to "records"). They should improve the resolution of Figure 1.
The information on the general characteristics of the studies (subsection 3.2) should be shown in a table in the text to make it easier for the reader to read.
Author Response
Thank you very much to the reviewer for their helpful comments. Please see below for responses to individual comments.
Comment 1: For burnout there is a more specific descriptor MeSH: "Burnout, Professional"; and for Wellbeing term: "Psychological Well-Being"
Response 1: We have changed these keywords as indicated.
Comment 2: They should describe on page 2 (line 73) the use of the acronym for WHO (which is not included), but on page 5 (line 112) WHO is described as an acronym.
Response 2: We have included the acronym (WHO) after the first use of World Health Organization.
Comment 3: At the end of the introduction, it is not necessary to identify the objective with the subheading 1.4.
Response 3: We have removed the subheading and slightly moved the objective text.
Comment 4: In the design subheading should indicate whether a review protocol exists (or if not).
Response 4: This scoping literature review was conducted, using an informal study protocol drafted by the first author. We have amended the text (line 196) to indicate this: "To answer this research question, a scoping literature review was conducted, using an informal study protocol drafted by the first author (GM)."
Comment 5: Tables 1 and 2 could be explained in the text (in fact, it is duplicated in the later section 2.3 search strategy). It is irrelevant to include this information in tables.
Response 5: We removed the duplicated text description of search strategy/terms from 2.3 to preserve the table presentation.
Comment 6: The information (page 5, line 198-199): "Most clinical systematic reviews follow a PICO framework - Patient, Intervention, Comparison, Outcome [32]..." is irrelevant (the PECO structure has already been explained above). The following paragraph: "However, this review aimed to identify the prevalence of burnout among nurses, making a comparison before and during Covid-19, rather than focusing on any specific intervention. The review did not seek to explore the impact of burnout on nurses; rather, the outcome explored was the link between patient safety and burnout, as indicated by the studies conducted." should be moved to the end of the introduction (in the space where the study objectives are described).
Response 6: We respectfully submit that this distinction is necessary to answer queries from other reviewers regarding the appropriateness of the scoping review format rather than the systematic review for this particular review study. We have therefore left this unchanged.
Comment 7: Page 6 (line 206) must specify in parentheses the acronym PRISMA-ScR.
Response 7: This has been added to the text in the appropriate place.
Comment 8: Do not describe the methodological limits in this section.
Response 8: These have been removed.
Comment 9:
Inclusion criteria are repeated again: time limit for language (English), year of publication (2013-2023); and exclusion: (other reviews and gray literature). They should also not describe that studies retrieved in full text will be included (this information is described in the screening process)
Response 9: Inclusion criteria have been removed, and changed to “Search limits were added to focus the search for suitable results matching eligibility criteria.” Description of full-text study inclusion has been removed.
Comment 10: Study selection and Quality assessment: Information on the results should not be described in this section (n=17 studies identified); This information must be provided in the results section. Here they should only limit themselves to describing the process.
Response 10: The number of studies has been removed from this section.
Comment 11: Results: In results add "n" to the identified records, screened and included studies.
Response 11: N has been added
Comment 12: They should be referred to in the same terms as Figure 1: For those identified and screened as "records" and not as "papers", For those included as "studies" and not as "papers". (Review this information also in Figure 1, change "reports" to "records"). They should improve the resolution of Figure 1.
Response 12: The PRISMA Flow Diagram generator (Haddaway et al, 2022, https://doi.org/10.1002/cl2.1230) was used to generate Figure 1, and changing of Figure 1 terminology is not allowed. We have amended the text to match the terminology in the figure, and generated a new higher-resolution version which is added as a separate file in the resubmission.
Comment 13: The information on the general characteristics of the studies (subsection 3.2) should be shown in a table in the text to make it easier for the reader to read.
Response 13: Thank you for this suggestion; detailed information on included studies is shown as Appendix A, as it would be impractical to provide it in the body of the text.
Reviewer 2 Report
Comments and Suggestions for Authors
Thank you for having the chance to review this interesting manuscript.
I hope the following recommendation will help advance the manuscript.
Introduction
The text of the introduction is too long. The authors had better avoid the repetitive writing and focus on the purpose of the study.
line 133-137. I think the authors had better add the references.
2. Materials and Methods
The authors specified how this study was done.
3. Results
I think that these have to be classified as studies conducted before COVID-19. Please consider it.
line 277-279. I can’t understand that data collection for 3 studies was done before Covid-19, but only published during the pandemic; these have been classified as studies conducted during Covid-19, because of the publication year.
line 302. The authors wrote ‘all the 17 studies...’ Is it right? 16? Please check it out.
I think that the authors had better present the difference between European nurses’ burnout before COVID-19 and those during COVID-19 and compare that according to the title and purpose of this study.
I think the authors should highlight ‘3.5 Burnout and Patient Safety Relationship’.
Author Response
Thank you very much to the reviewer for their helpful comments. Please see individual points below:
Comment 1: The text of the introduction is too long. The authors had better avoid the repetitive writing and focus on the purpose of the study.
Response 1: We have reduced the length of the introduction to avoid some repetition.
Comment 2: line 133-137. I think the authors had better add the references.
Response 2: We have added references here.
Comment 3: 3 I think that these have to be classified as studies conducted before COVID-19. Please consider it. Line 277-279. I can’t understand that data collection for 3 studies was done before Covid-19, but only published during the pandemic; these have been classified as studies conducted during Covid-19, because of the publication year.
Response 3: While the data collection of these 3 studies predates the pandemic, the insights provided by the authors and their discussion reflects pandemic realities and therefore these studies have been counted as during COVID-19. We have edited the text accordingly: "Data collection for 3 studies was done before Covid-19, but only published during the pandemic; these have been classified as studies conducted during Covid-19, because of the publication year due to the insights provided by the authors and their discussions reflecting pandemic realities."
Comment 4: line 302. The authors wrote ‘all the 17 studies...’ Is it right? 16? Please check it out.
Response 4: We have corrected to 16, thank you for picking up on this typo.
Comment 5: I think that the authors had better present the difference between European nurses’ burnout before COVID-19 and those during COVID-19 and compare that according to the title and purpose of this study.
Response 5: Unfortunately due to the methods of presentation of data, it was not possible to effectively compare burnout before and during the pandemic; we have described this limitation in 4.4. Hence our title does not include “comparison” and our objective/purpose is to “examine the impact that the pandemic had made on nurses’ burnout” (we have amended the text to clarify this)
Comment 6: I think the authors should highlight ‘3.5 Burnout and Patient Safety Relationship’.
Response 6: Unfortunately the studies scoped did not comprehensively explore the direct relationship between burnout and patient safety; where this did take place we have documented this thoroughly.
Reviewer 3 Report
Comments and Suggestions for Authors
Thank you very much for your article. I would like to provide some suggestions to improve your contribution.
In the abstract, you mentioned searching only in Medline, but in the methodology section, you indicated data from Medline, Scopus, and CINAHL. Please review this discrepancy and adjust the abstract accordingly.
Regarding section 3.3 Quality of the Study, could you specify further and expand on the quality criteria, and clarify more about the scores and their significance?
The literature review was peer-reviewed; however, this was not mentioned.
A combination of systematic review and meta-analysis would have provided a deeper insight and a more rigorous verification of the results, given the abundance of studies on the topic.
I would try to condense the discussion; it is quite lengthy.
Author Response
Thank you very much to the reviewer for their helpful comments to revise this work. Please see individual comment responses below:
Comment 1: In the abstract, you mentioned searching only in Medline, but in the methodology section, you indicated data from Medline, Scopus, and CINAHL. Please review this discrepancy and adjust the abstract accordingly.
Response 1: Thankyou for flagging this oversight, we have corrected.
Comment 2: Regarding section 3.3 Quality of the Study, could you specify further and expand on the quality criteria, and clarify more about the scores and their significance?
Response 2: We have clarified and expanded this section, and added our scorecard as Appendix B.
Comment 3: The literature review was peer-reviewed; however, this was not mentioned.
Response 3: GM conducted all the initial study selection and quality assessment, while JC reviewed selection and assessment at each stage, and both authors discussed studies where eligibility or ineligibility was unclear to reach consensus. We have clarified this in the text (section 2.4)
Comment 4: A combination of systematic review and meta-analysis would have provided a deeper insight and a more rigorous verification of the results, given the abundance of studies on the topic.
Response 4: We agree that this approach would have provided deeper insight and verification, though our purpose in this scoping review was to understand major trends and contributing factors only. As we state in our Study limitations (section 4.4) “A systematic review combined with meta-analysis would have been more ideal as it would allow researchers to look more deeply into the data, analyze to verify results identified by the studies, not only relying on what is stated.”
Comment 5: I would try to condense the discussion; it is quite lengthy.
Response 5: We have reduced the length of the discussion somewhat, while striving to remain robust in our exploration of this complex issue.
Round 2
Reviewer 2 Report
Comments and Suggestions for Authors
Thank you for having the chance to review this interesting manuscript.
I am sure that the manuscript was corrected according to the reviewer's comments.
