The Frontline Nurse’s Experience of Nursing Outlier Patients

Round 1

Reviewer 1 Report

The introduction raises paragraphs of difficult understanding for the non-health public. Contextualization should be improved.
Clearly explained methods and designs.
Also, it results in present images that help to understand.
Robust discussion, nevertheless it is hindered by the number of references with more than five years (only 60% from 2015 to 2020).

Author Response

Thank you for considering my submission the revised manuscript of ijerph-852471, titled “The frontline nurse’s experience of caring the outlier patients”. I sincerely appreciate your constructive comments and suggestions, which helped to improve the manuscript. We have gone through all comments and suggestions, and revised the Manuscript accordingly. Revisions have been highlighted using Track-changes function in Microsoft word.

I am committed to have my first research paper published and any further comments and suggestions will be gratefully received. Please see attached my responses to the review report.  Thanks.

Title: The frontline nurse’s experience of nursing the outlier patients

Author’s reply to the Review Report from Reviewer 1

Reviewer 2 Report

Thank you for the opportunity to review this paper.  This paper sought to report findings from a study that explored nurses' perceptions of care provided to "outlier" patients using hermeneutic phenomenological methods. Outlier patients, per the implied definition in the paper, are patients who are placed in a nursing unit due to bed availability and perhaps not consistent with the patient type typically seen on that unit.  The following could strengthen the paper.  The title of the paper doesn't read very clearly.  The first part is the best title with modification "The frontline nurses' experience of caring for the outlier patient". 

The concept of the outlier patient isn't a new phenomenon.  I can recall being assigned patients who were outside my population expertise.  As the paper states, we as nurses dive in and provide care without question.  One could argue that the outlier patient could also be one that requires skills or knowledge that the nurse has either not before experienced, such as the rare disease process or applied equipment.  Which then brings into the argument of novice to expert as developed by Brenner.  I am surprised that this didn't not appear as background in the paper to help set up the argument and then let the reader know the focus is the outlier patient on the unit that does not fit the typical patient population. 

The inclusion and exclusion criteria appears to be very broad, capturing those who worked in a hospital within two years.  Years of experience, degree obtained, license, full time/part time, float elements are unclear.  The participants were all well experienced nurses, seven years the least and >30 to 38 the highest.  The implication from the inclusion criteria and recruitment is that this was a coincidence.  I think having captured inexperienced nurses and their perspectives would have been much richer data.  For this reason, this should be explained and acknowledged that the sample was overwhelmingly well experienced. 

Results-If I understand this correctly, one participant mentioned a ladder and that led to the model?  Here I was looking for the collection of categories and supported exemplars to support the conclusions.  The presentation of the ladder model and analogies with the rungs is nice, however, it is unclear how this fits with the respondents.  Reading onward, and reading the categories such as 3.1 with synchronizing and so forth, I didn't understand the link to the ladder.  3.1 onward provided great insights into the responses and understanding of caring for a patient that is an outlier for expert nurses as defined by a patient who doesn't fit the unit specialization. 

What was the process for achieving agreement with the interpretation of the data? Was the transcription verified for accuracy? Interviews varied in length and some were very long, questioning participant fatigue.  What were the limitations of this study?  These are unclear in the paper. 

If the ladder model came from the interviews in total, then it could be moved to the end of the results section.  Otherwise, this remains unclear.

The discussion presents the 5 categories and these are clear and make sense with the type of data. 

Author Response

Thank you for considering my submission the revised manuscript of ijerph-852471, titled “The frontline nurse’s experience of caring the outlier patients”. I sincerely appreciate your constructive comments and suggestions, which helped to improve the manuscript. We have gone through all comments and suggestions, and revised the Manuscript accordingly. Revisions have been highlighted using Track-changes function in Microsoft word.

I am committed to have my first research paper published and any further comments and suggestions will be gratefully received. Please see attached my responses to the review report.  Thanks.

Title: The frontline nurse’s experience of nursing the outlier patients

Author’s reply to the Review Report from Reviewer 2

Author Response File: Author Response.docx

Reviewer 3 Report

Dear authors,

The work is of great interest in the field of nursing practice and the consequences of treating atypical patient cases. It has great virtues but also some weaknesses. These are the detected ones:
- Section 1 should divide it into 2: Introduction and another that encompasses the theoretical background that you propose.
- The question or problem that you have detected to carry out the investigation does not appear well formulated.
- It would be good if you graphically present the steps of the applied methodology.
- The data collected is from 2009 to 2011. May there be any bias over time? If you believe that this is not the case, they should clarify it, and point out that they do not have current data. Past data may give inconsistent results at a later time.
- The figures have poor quality, they are blurred. Improve them.
- The discussion section is very long to read. Divide it in relation to the results you discuss in section 3.
- What limitations have you found when carrying out the study? Express them in the text.
- The references are not expressed as indicated by the journal. Take care of those details.

Author Response

Thank you for considering my submission the revised manuscript of ijerph-852471, titled “The frontline nurse’s experience of caring the outlier patients”. I sincerely appreciate your constructive comments and suggestions, which helped to improve the manuscript. We have gone through all comments and suggestions, and revised the Manuscript accordingly. Revisions have been highlighted using Track-changes function in Microsoft word.

I am committed to have my first research paper published and any further comments and suggestions will be gratefully received. Please see attached my responses to the review report.  Thanks.

Title: The frontline nurse’s experience of nursing the outlier patients

Author’s reply to the Review Report from Reviewer 3

Round 2

Reviewer 2 Report

Thank you for the opportunity to review this revised manuscript.  The suggestions recommended and comments put forth have been addressed. The paper reads better and the logic is more in sync.  Thanks.

Author Response

Thank you again for your positive comments for our manuscript of ijerph-852471, titled “The frontline nurse’s experience of caring the outlier patients”.  Your comments have improved and strengthened our manuscript.

Reviewer 3 Report

Dear authors,
I gratefully check the improvement of the manuscript, although there are still details to correct:
- Figures 1 to 4: too blurry
- You need to read the authors' guideline to avoid submitting a manuscript as requested by the journal (tables, words in bold ...).
- They used the word "study" 43 times. Too many. Maybe some synonym?

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Dear authors,

I congratulate you on your work. This presents great advantages and opportunities, although I also observe some doubts that I let you know to improve it:

- The title is confusing, even more so the subtitle. It should be more concise.
- Write more keywords. Think of these as a search tool.
- Line 39: “unsaid” should be in quotation marks and in italics?
- The first paragraph only has a reference? Is everything written from your previous knowledge?
- The Introduction should be a separate section from the subsections they do. These should go in another section.
- The objective of the study is not clearly defined, nor how they would define it.
 - Why is this study important in the area of ​​health? Why is it necessary to do it?
- The conclusions are too short. If they are not going to extend them, join them to the previous section.
- Anyway, the conclusion should be more rigorous and more extensive, after approaching this work. It is not a phrase that you say to a friend in an elevator, but to define what they have extracted from this work and why it is interesting.

Reviewer 2 Report

Dear authors

The conclusion is too short and biased by the author's personal interpretation. It is recommended to strengthen their interpretation of results with some quantitative method that evaluates the professional performance of specialized nurses in this type of high-demand work environment.