Factors associated with the job satisfaction of certified nurses and nurse specialists in cancer care in Japan: Analysis based on the Basic Plan to Promote Cancer Control Programs

Masaki Kitajima; Chiharu Miyata; Keiko Tamura; Ayae Kinoshita; Hidenori Arai

doi:10.1371/journal.pone.0232336

. 2020 May 18;15(5):e0232336. doi: 10.1371/journal.pone.0232336

Factors associated with the job satisfaction of certified nurses and nurse specialists in cancer care in Japan: Analysis based on the Basic Plan to Promote Cancer Control Programs

Masaki Kitajima ¹, Chiharu Miyata ², Keiko Tamura ¹, Ayae Kinoshita ¹, Hidenori Arai ^3,^*

Editor: Janhavi Ajit Vaingankar⁴

PMCID: PMC7233545 PMID: 32421704

Abstract

Background

As the Japanese population ages, the number of cancer patients will likely increase. Therefore, qualified cancer health care providers should be recruited and retained. Nurse job satisfaction is influenced by numerous factors and may affect staff turnover and patient outcomes.

Objectives

To evaluate the job satisfaction of certified nurses and nurse specialists in Japanese cancer care and elucidate factors associated with job satisfaction.

Methods

Participants in this cross-sectional study comprised 200 certified nurse specialists and 1,472 certified nurses working in Japanese cancer care. A chi-square test and logistic regression analysis were conducted to identify job satisfaction factors.

Results

Job satisfaction was present in 38.45% and 49.00% of certified nurses and nurse specialists, respectively. Certified nurses associated job satisfaction with cross-departmental activities (OR 2.24, p<0.001), positive evaluation from senior stuff (OR 4.58, p<0.001), appropriate staff allocation (OR 1.75, p<0.001), more than five years certified nurse experience (OR 1.91, p<0.001), and positive evaluation of the development of certified nurses (OR 2.13, p<0.01) and nurse specialists (OR 1.37, p<0.05). Low job satisfaction was associated with working on a ward (OR 0.51, p<0.001) and a capacity of more than 200 beds (OR 0.33, p = 0.00). Certified nurse specialists associated job satisfaction with palliative care team participation (OR 2.64, p<0.05), cross–sectional activities (OR 7.06, p<0.01), positive evaluation from senior stuff (OR 13.15, p<0.001), presence of certified nurses in radiation therapy (OR 2.91, p<0.05), positive certified nurse specialist development evaluation (OR 7.35, p<0.001), medical service fees (OR 3.78, p<0.01), and independent activities (OR 11.34, p<0.01).

Conclusions

We identified factors related to activities, facilities, and the cancer care team associated with job satisfaction of certified nurses and nurse specialists in Japanese cancer care. Suggestions are provided to enhance job satisfaction through Japan’s Basic Plan to Promote Cancer Control, which may help hospital administrators retain nursing staff.

Introduction

With the aging of the global population, the number of cancer patients and cancer-related deaths in Japan is expected to increase [1]. To provide high-quality medical services and optimally support cancer patients and their families, the Basic Plan to Promote Cancer Control Programs was adopted by the Japanese national health care system. It suggests a collaborative approach involving multiple healthcare professionals.

It is important to ensure a sufficient staff of specialized care providers including nursing professionals with qualifications awarded by the Japan Nursing Association [1]. A certified nurse specialist (CNS) is a nurse who participates in clinical practice, consultation, coordination of activities, ethical management, education, and research; has at least five years of nursing experience; and has obtained certification after completing a master’s degree at a graduate school. Through their job activities, CNSs aim to improve the quality of medical care, propose policies, and work to maintain and improve patient health [2]. Therefore, they are often assigned to nursing administration offices and frequently involved in activities to improve the entire facility, such as staff education, research, and patient discharge.

A certified nurse (CN) is a nurse who participates in clinical practice, teaching, and consultation; has more than five years of nursing experience; and has obtained certification after graduating from a special vocational school approved by the Japan Nursing Association. CNs are generally assigned as staff nurses in a single department such as an outpatient clinic or a ward [3].

In accordance with the stipulations of the Basic Plan to Promote Cancer Control, CNSs and CNs are recruited to hospitals authorized to treat cancer to alleviate the burden on cancer patients and their families and improve the quality of recuperation. Furthermore, CNSs and CNs are assigned to the palliative care team and provide patient counseling. Because of the critical role of oncology CNSs and CNs in patient care, understanding the factors influencing their job satisfaction and performance has important implications for clinical practice. Since the Basic Plan to Promote Cancer Control stipulates the most important measures in the treatment and support of cancer patients, it is important to incorporate it in the evaluation of the job satisfaction of CNs and CNSs [4].

The job satisfaction of nurses has been addressed in other settings [5–10]. A recent integrative review showed that job satisfaction among nurses is a variable and complex phenomenon depending on numerous factors [7]. The factors varied between studies and included adequate staffing and equipment, job security and compensation, opportunities for professional development, supervisor support, autonomy, quality of workplace relationships, and the feeling that one’s job makes a difference.

Many studies evaluated the professional growth, role, support, and recognition of CNSs and CNs [11–21]. However, research on job satisfaction has only been conducted in the fields of psychiatric mental health nursing for CNSs and in dysphagia nursing for CNs [22–25]. CNSs are nursing specialists whose role requires substantial autonomy. Reportedly, the autonomous role of a caregiver improves the job satisfaction and performance of nurses [26–30]. Furthermore, the concept of a specialist implies autonomy including responsibility and expertise [31].

No study has evaluated job satisfaction among CNSs and CNs in the field of oncology in Japan. However, this information is crucial in the retention of nursing stuff and provision of optimal patient care, since job satisfaction presumably affects the expertise of CNSs and CNs and their ability to provide outstanding care. In addition, the specific job profiles and responsibilities of CNSs and CNSs may be associated with distinct job satisfaction factors. Identifying these factors may facilitate the implementation of specific measures to improve job satisfaction. Therefore, we assessed the job satisfaction of CNSs and CNs working in cancer care in Japan and identified factors enabling them to operate productively in their organizations.

Methods

Survey development and testing

Because CNSs and CNs have unique roles, existing scales could not be applied in this study. Previous reports were used to identify possible factors influencing job satisfaction for inclusion in the current investigation [22–25]. Furthermore, the Basic Plan to Promote Cancer Control was utilized to select questions pertaining to personnel deployment requirements for CNSs and CNs, facility types, facility requirements, medical care remuneration, and palliative care team placement requirements.

Items were divided into categories related to activities, facilities, and participation in the cancer care team. To examine the content validity of the questions, university faculty members well acquainted with the Basic Plan to Promote Cancer Control and activities of CNSs and CNs discussed and agreed on the included items. Next, a pretest was administered to four CNSs and four CNs, who were asked whether they faced any difficulties in answering the questions and understanding the terms used. The terminology was revised as necessary. Four researchers extracted the characteristic activities of the CNSs and CNs based on the Basic Plan to Promote Cancer Control. The extracted items and question items on job satisfaction were examined, and the relevance of each was investigated.

Job satisfaction questionnaire: Design and content

The following are examples of questions asked: “Are cross-sectional activities conducted in the hospital?” “Is the personnel placement of the assigned department appropriate?” “Do you feel that you are well evaluated by your boss?” Furthermore, eleven questions concerned factors related to activities (including demographics), seven concerned factors related to facilities, and four concerned factors related to the cancer care team. Table 1 presents the questions. The study participants were asked to respond to the questionnaire survey on a simple three-point scale, which was used because of the difficulty in securing time during working hours in a busy clinical practice. The pretest was measured on a five-point scale, but it required extended time to answer and appeared to cause a significant clinical burden. A confirmatory factor analysis (CFA) was conducted to verify the factor structure of the questionnaire. A three-factor model was analyzed, including factors related to activities, facilities, and the cancer team. The following values were obtained for the model fit: Comparative fit index (CFI) 0.96, Tucker–Lewis index (TLI) 0.90, and root mean-square error of approximation (RMSEA) 0.04. Overall, the findings of the CFA indicated an acceptable fit of the three-factor model. Furthermore, the reliabilities of the three scales were estimated by calculating Cronbach’s alpha, which was 0.79, 0.81, and 0.72 for factors related to activities, facilities, and the cancer team, respectively.

Table 1. Contents of the questionnaire.

1. Factors related to activities (including demographics)

① Years of experience after acquiring nursing license (open-ended)
② Years of experience after acquiring CNS or CN qualifications (open-ended)
③ The presence or absence of other CNSs and CNs working in the same institution (open-ended)

④ Working system (multiple answers)¹ (palliative care team, cancer consultation and support center, outpatient chemotherapy room, radiotherapy room, outpatient department, ward department)

⑤ Position (open-ended)

⑥ Lecturer for study group or training (frequently and regularly; yes, but not that frequently; no)

⑦ Experienced the launch of a department or patient group (yes, no)

⑧ Opportunity for cross-departmental activities¹ (always; not always, but regularly; never)

⑨ Opportunity for exchange with CNSs and CNs in other institutions (regularly; yes, but not regularly; never)

⑩ Positive evaluation from senior staff (yes, sometimes, never)
⑪Appropriate staff allocation

2. Factors related to facilities

① Type of hospital (prefectural cancer center hospital, regional cooperation cancer center hospital, cancer center hospital designated by prefecture, community hospital, other)

② Bed capacity (0 to 199, 200 to 499, ≥ 500, other)

③ Publicize information about the existence of CNSs and CNs among community members and the public (yes, no)

④ Service system in the following four departments pertaining to cancer(chemotherapy room, palliative care team, cancer consultation and support center, radiotherapy room)

⑤ Additional medical service compensation for cancer
(palliative care practice addition, cancer patient counseling charges, outpatient palliative care management charges, cancer pain palliation instruction charges)

⑥ Implementation of cancer care in the institution
(based on the requirements of designated cancer centers and hospitals)

⑦ Positive evaluation of CNS and CN development in the institution (always, sometimes, never)

3. Factors related to the cancer care team

① Coordination among multiple healthcare professionals (always, sometimes, never)

② Independent activities² (always, sometimes, never)

③ Availability of conferences (times per week)
④ Job type (pharmacist, medical social worker, nutritionist, physical therapist, occupational therapist, speech therapist, clinical psychologist)

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Regarding department affiliations, if individuals were involved with two or more affiliations concurrently, they were instructed to choose multiple answers.

Refers to the ability to fulfill one’s role without interference from others.

In addition, we enquired about job satisfaction. We asked the question, “Are you satisfied with your job?” Originally, we used a three-level scale with the following response options: “satisfied,” “somewhat satisfied,” and “dissatisfied.” However, upon review, we combined the first two levels to yield a two-level scale: “satisfied” and “dissatisfied.”

Procedure

This study was cross-sectional and involved the use of self-report questionnaires. A survey request, self-report questionnaire, document explaining the implications of the study, and return envelope were mailed to each participant. The recipients of the survey were asked to return the questionnaire to the researchers within two months. The survey period was between May and July 2014. In addition, a written notification was included informing the participants that their participation was voluntary. Precautions were taken to ensure that the department heads were unaware of whether the CNSs and CNs had mailed the completed questionnaires.

Participants

In February 2014, 3,450 nurses were included on the list of registered CNSs and CNs on the official website of the Japan Nursing Association. Of these, 3,332 nurses (483 CNSs and 2,849 CNs) whose addresses could be confirmed were mailed the questionnaire. In total, 1,696 nurses working in cancer centers or hospitals involved in cancer care responded to the mailed questionnaire. The valid response rate was 98.60% (1,672 respondents).

Ethical considerations

The study protocol was approved by the Institutional Ethics Committee of the Kyoto University Graduate School of Medicine and Faculty of Medicine Hospital with protocol number E2072. The purpose of the study, benefits of participation, confirmation of voluntary participation, and an assurance that all data obtained in the present study would be used only for scientific purposes and anonymously were communicated to all participants in written form. All participants gave their informed consent. To protect confidentiality, personal data were kept separately from the completed questionnaires, which were coded. The study adhered to the STROBE checklist.

Data analysis

Descriptive statistics were computed for each questionnaire item. The three-point scale had the anchors Carried out, Somewhat carried out, and Not carried out. Responses were categorized in a binary format, in which Carried out and Somewhat carried out represented an affirmative Yes response (1), and Not carried out represented a No response (2). In addition, a “bed capacity” of 0–199 was assigned a score of 1, and a capacity ≥ 200 a score of 2. For the type of hospital, a cancer center was assigned a score of 1, and “other hospital” a score of 2. Conferences were scored 1 for “Held/Yes” or 2 for “Not held/No.”

A chi-square test was performed to evaluate the relationship between job satisfaction and other variables. Factors statistically significant in the univariate analysis were included in the subsequent multivariable analysis. To identify factors related to job satisfaction, a logistic regression analysis was conducted with satisfaction or dissatisfaction as the dependent variable, other factors as the explanatory variables, and years of experience after acquiring a nursing license as the control variable. The following explanatory variables were used in the case of categorical variables. A dummy variable was created that was assigned a value of 0 in the case of “Other hospital” for “type of hospital,” “0–199” for “bed capacity,” and “0–4 years” for “years of experience after obtaining CN or CNS qualification.” SPSS Statistics 21 software (IBM-SPSS, Inc., Chicago, IL, USA) was used for all analyses. Two-tailed tests were performed with an alpha level of .05. Because of the exploratory nature of the study, no correction for multiple testing was applied.

Results

Participant characteristics

The participants were 200 CNSs and 1,472 CNs with a mean length of clinical experience of 19.8 years. Job satisfaction was present in 38.45% of CNs and 49.00% of CNSs. In terms of workplace, 71.50% of the participants worked at designated cancer centers or hospitals, and the remaining ones worked at other hospitals (e.g., general hospitals or clinics) also involved in cancer care. Table 2 details the number of nurses working in different types of facilities or having a position title.

Table 2. Demographic characteristics.

			CNS		CN
			N	%	N	%
Job satisfaction		Presence Absence	98 102	49.00 51.00	566 906	38.45 61.55
Clinical nursing experience (years)		5–9	25	12.50	93	6.30
		10–15	48	24.00	354	24.00
		16–20	71	35.50	402	27.30
		21–25	32	16.00	353	24.00
		26–30	20	10.00	194	13.20
		31–35	4	2.00	66	4.50
		36–35	0	0.00	7	0.50
		36–40	0	0.00	2	0.10
		41–45	0	0.00	1	0.10
Clinical experience as a CNS/CN (years)		Less than 5	148	74.00	895	60.80
Clinical experience as a CNS/CN (years)		5 or more	52	26.00	577	39.20
Affiliation		Yes	82	41.00	409	27.80
Palliative care team		No	118	59.00	1064	72.20
	Cancer consultation and support center	Yes	54	27.00	83	5.60
	Cancer consultation and support center	No	146	73.00	1390	94.40
	Chemotherapy room	Yes	26	27.00	402	27.30
	Chemotherapy room	No	174	73.00	1071	72.70
	Radiotherapy room	Yes	4	2.00	65	4.40
	Radiotherapy room	No	196	98.00	1408	95.60
	Outpatient department	Yes	28	14.00	356	24.20
	Outpatient department	No	172	86.00	1117	75.80
	Ward department	Yes	59	29.50	629	42.70
	Ward department	No	141	70.50	1404	57.30
Position		Manager	121	60.50	629	42.70
Position		Staff	79	39.50	843	57.30
Workplace		Cancer centers	175	87.50	1021	69.40
Workplace		Other hospitals	25	12.50	451	30.60
Bed capacity		Less than 200	9	4.50	165	11.20
Bed capacity		200 or more	191	95.50	1307	88.80

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CNS: n = 200, CN: n = 1472

Univariate analysis

The results of the chi-square test showed significant differences in the scores for 21 items for CNSs and 32 items for CNs (Tables 3 and 4). For CNSs, 11 differences were associated with activities, 7 with facilities, and 3 with the cancer care team. For CNs, 15 differences were associated with activities, 12 with facilities, and 5 with the cancer care team.

Table 3. Univariate analyses for CNSs.

			N	Satisfaction n (%)	Dissatisfaction n (%)	P
Factors related to activity
Clinical nursing experience (years)		Less than 19	105	48 (45.70)	57 (54.30)	0.33
Clinical nursing experience (years)		19 or more	95	50 (52.60)	45 (47.40)
Years of experience after acquiring CNS qualification (see Note)		Less than 5	148	62 (47.90)	86 (58.10)	0.00
		5 or more	52	36 (69.20)	16 (30.80)
Presence in the same facility		Yes	115	46 (40.00)	69 (60.00)	0.16
• CNS		No	85	36 (42.40)	79 (57.60)
• CN in palliative care		Yes	150	75 (50.00)	75 (50.00)	0.62
		No	50	23 (46.00)	27 (54.00)
• CN in cancer pain management		Yes	114	55 (48.20)	59 (51.80)	0.81
nursing		No	86	43 (50.00)	43 (50.00)
• CN in cancer		Yes	163	81 (49.70)	82 (50.30)	0.72
chemotherapy nursing		No	37	17 (45.90)	20 (54.10)
• CN in radiation therapy		Yes	66	35 (53.00)	31 (47.00)	0.04
nursing		No	134	63 (47.00)	71 (53.00)	0.04
• CN in breast		Yes	74	35 (47.30)	39 (52.70)	0.71
cancer nursing		No	126	63 (50.00)	63 (50.00)	0.71
Affiliation		Yes	79	47 (59.50)	32 (40.50)	0.02
	• Palliative care team	No	121	51 (42.10)	70 (57.90)	0.02
	• Cancer consultation and support center	Yes	54	35 (64.80)	19 (35.20)	0.01
	• Cancer consultation and support center	No	146	36 (24.70)	83 (75.30)	0.01
	• Chemotherapy clinic	Yes	26	12 (46.20)	14 (53.80)	0.76
	• Chemotherapy clinic	No	174	86 (49.40)	88 (50.60)	0.76
	• Radiotherapy room	Yes	4	3 (75.00)	1 (25.00)	0.29
	• Radiotherapy room	No	196	95 (48.50)	101 (51.50)	0.29
	• Outpatient department	Yes	28	13 (46.40)	15 (53.60)	0.77
	• Outpatient department	No	172	85 (49.40)	87 (50.60)
	• Ward department	Yes	59	13 (22.00)	46 (78.00)	0.00
	• Ward department	No	141	85 (60.30)	56 (39.70)	0.00
Position		Manager	121	73 (60.30)	48 (39.70)	0.00
Position		Staff	79	25 (31.60)	54 (68.40)
Role in educating others		Yes	185	96 (51.90)	89 (48.10)	0.00
Role in educating others		No	15	2 (13.30)	13 (86.70)
Launched a department or patient group		Yes	79	26 (32.90)	53 (67.10)	0.00
Launched a department or patient group		No	121	72 (59.50)	49 (40.50)
Cross-departmental activities		Yes	151	93 (61.60)	58 (38.40)	0.00
Cross-departmental activities		No	49	5 (10.20)	44 (89.80)
Information exchanges or joint workshops etc. with other facilities		Yes	169	89 (52.70)	80 (47.30)	0.02
		No	31	9 (29.00)	22 (71.00)
High ratings from senior staff		Yes	150	95 (63.30)	55 (36.70)	0.00
High ratings from senior staff		No	50	3 (6.00)	47 (94.00)
Appropriate staff allocation		Yes	86	53 (61.63)	33 (38.37)	0.02
Appropriate staff allocation		No	114	45 (39.47)	69 (60.53)
Factors related to facilities
Type of hospital		Cancer centers	175	88 (50.30)	87 (49.70)	0.34
Type of hospital		Other hospitals	25	10 (40.00)	15 (60.00)
Bed capacity		Less than 200	9	3 (33.30)	6 (66.70)	0.40
Bed capacity		200 or more	191	95 (49.70)	96 (50.30)
Advertisements for CNSs and CNs		Yes	185	91 (49.20)	71 (50.80)	0.85
Advertisements for CNSs and CNs		No	15	7 (46.70)	8 (53.30)
Service system in four departments		Yes	152	81 (53.30)	71 (46.70)	0.03
Service system in four departments		No	48	17 (35.40)	31 (64.60)
Additional medical services Palliative care practice		Yes	111	58 (52.30)	53 (47.70)	0.30
Additional medical services Palliative care practice		No	89	40 (44.90)	49 (55.10)
• Cancer patient counseling		Yes	139	75 (54.00)	64 (46.00)	0.45
• Cancer patient counseling		No	61	23 (37.70)	38 (62.30)
• Outpatient palliative care management		Yes	74	42 (56.80)	32 (43.20)	0.09
• Outpatient palliative care management		No	126	56 (44.40)	70 (55.60)
• Cancer pain palliation instructions		Yes	140	80 (57.10)	60 (42.90)	0.00
• Cancer pain palliation instructions		No	60	18 (30.00)	42 (70.00)
Requirements • Second opinion		Received	186	94 (53.40)	82 (46.60)	0.11
Requirements • Second opinion		Not received	14	4 (28.60)	10 (71.40)
• Collaboration team and the primary care physician		Received	99	59 (59.60)	40 (40.40)	0.00
• Collaboration team and the primary care physician		Not received	101	39 (38.60)	62 (61.40)
• Operation of cancer regional alliances path		Received	187	96 (51.30)	91 (48.70)	0.00
• Operation of cancer regional alliances path		Not received	13	2 (15.40)	11 (84.60)	0.00
• Training of local healthcare professionals		Received	171	86 (50.30)	85 (49.70)	0.01
• Training of local healthcare professionals		Not received	29	12 (41.40)	17 (58.60)	0.01
• Hospital cancer registry		Received	167	86 (51.50)	81 (48.50)	0.11
• Hospital cancer registry		Not received	33	12 (36.40)	21 (63.60)	0.11
Education or support in obtaining CNS qualification of the assigned facilities		Yes	99	70 (70.70)	29 (29.30)	0.00
		No	101	28 (27.70)	73 (72.30)	0.00
Education or support in obtaining CN qualification of the assigned facilities		Yes	156	92 (59.00)	64 (41.00)	0.00
		No	44	6 (13.60)	38 (86.40)	0.00
Factors related to the cancer care team
Coordination among healthcare professionals		Yes	194	98 (50.50)	96 (49.50)	0.00
Coordination among healthcare professionals		No	6	0 (0.00)	6 (100.00)	0.00
Independent activities		Yes	98	96 (98.00)	2 (2.00)	0.00
Independent activities		No	102	62 (60.80)	40 (39.20)	0.00
Availability of conferences		Yes	187	96 (51.30)	91 (48.70)	0.01
Availability of conferences		No	13	2 (15.40)	11 (84.60)	0.01
Job type• Pharmacist		Involvement	183	90 (49.20)	93 (50.80)	0.44
Job type• Pharmacist		Non-involvement	17	8 (47.10)	9 (52.90)	0.44
	• Medical social worker	Involvement	175	86 (49.10)	89 (50.90)	0.92
	• Medical social worker	Non-involvement	25	12 (48.00)	13 (52.00)	0.92
	• Nutritionist	Involvement	140	66 (47.10)	74 (52.90)	0.42
	• Nutritionist	Non-involvement	60	32 (53.30)	28 (46.70)	0.42
	• Physical therapist	Involvement	132	61 (46.20)	71 (53.80)	0.27
	• Physical therapist	Non-involvement	68	37 (54.40)	31 (45.60)	0.27
	• Occupational therapist	Involvement	85	38 (44.70)	47 (55.30)	0.30
	• Occupational therapist	Non-involvement	115	60 (52.20)	55 (47.80)	0.30
	• Speech therapist	Involvement	54	21 (38.90)	33 (61.10)	0.08
	• Speech therapist	Non-involvement	146	77 (52.70)	69 (47.30)	0.08
	• Clinical psychologist	Involvement	103	55 (53.40)	48 (46.60)	0.20
	• Clinical psychologist	Non-involvement	97	43 (44.30)	54 (55.70)	0.20

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The threshold for years of experience was set at 5 years, because according to [32], 44.00% of CNs are hesitant to renew their 5-year contracts the first time. Reasons given for their hesitation include: “There is no satisfaction in the work” and they have “not been able to fully refresh.”

Table 4. Univariate analyses for CNs.

			N	Satisfied n (%)	Not satisfied n (%)	P
Factors related to activity
Clinical nursing experience (years)		Less than 19	849	320 (37.70)	529 (62.30)	0.48
Clinical nursing experience (years)		19 or more	623	246 (39.50)	377 (60.50)
Years of experience after acquiring CN qualification (see Note)		Less than 5	895	270 (30.20)	625 (69.80)	0.00
		5 or more	577	296 (51.30)	281 (48.70)	0.00
Presence in the same facility• CNS		Yes	467	199 (42.60)	268 (57.40)	0.02
Presence in the same facility• CNS		No	1005	367 (36.50)	638 (63.50)	0.02
	• CN in palliative care	Yes	962	390 (40.50)	572 (59.50)	0.02
	• CN in palliative care	No	510	176 (34.50)	334 (65.50)	0.02
	• CN in cancer pain management nursing	Yes	603	233 (38.60)	370 (61.40)	0.74
	• CN in cancer pain management nursing	No	869	333 (38.30)	536 (61.70)	0.74
	• CN in cancer chemotherapy nursing	Yes	911	374 (41.10)	537 (58.90)	0.04
	• CN in cancer chemotherapy nursing	No	561	192 (34.20)	369 (65.80)	0.04
	• CN in radiation therapy nursing	Yes	310	137 (44.20)	173 (55.80)	0.01
	• CN in radiation therapy nursing	No	1162	429 (37.00)	733 (63.00)	0.01
	• CN in breast cancer nursing	Yes	363	158 (43.50)	205 (56.50)	0.03
	• CN in breast cancer nursing	No	1109	408 (36.80)	701 (63.20)	0.03
Affiliation		Yes	409	186 (45.50)	223 (54.50)	0.00
• Palliative care team		No	1063	380 (35.70)	683 (64.30)	0.00
	• Cancer consultation and support center	Yes	83	45 (54.20)	38 (45.80)	0.00
	• Cancer consultation and support center	No	1389	521 (37.50)	868 (62.50)	0.00
	• Chemotherapy room	Yes	402	167 (41.50)	235 (58.50)	0.14
	• Chemotherapy room	No	1070	399 (37.30)	671 (62.70)	0.14
	• Radiotherapy room	Yes	65	19 (29.30)	46 (70.70)	0.12
	• Radiotherapy room	No	1407	547 (38.90)	860 (61.10)	0.12
	• Outpatient department	Yes	356	130 (36.50)	226 (63.50)	0.39
	• Outpatient department	No	1116	436 (39.10)	680 (60.90)	0.39
	• Ward department	Yes	629	177 (28.10)	452 (71.90)	0.00
	• Ward department	No	843	389 (46.10)	454 (53.90)	0.00
Position		Manager	629	177 (28.10)	452 (71.90)	0.00
Position		Staff	843	389 (46.10)	454 (53.90)	0.00
Role in teaching other nurses		Yes	1359	533 (39.20)	826 (60.80)	0.00
Role in teaching other nurses		No	113	33 (29.20)	80 (70.80)	0.00
Launched a department or patient group		Yes	877	305 (34.80)	572 (65.20)	0.00
Launched a department or patient group		No	595	261 (43.90)	334 (56.10)	0.00
Cross-departmental activities		Yes	1053	500 (47.50)	553 (52.50)	0.00
Cross-departmental activities		No	419	66 (15.80)	353 (84.20)	0.00
Information exchanges or joint workshops etc. with other facilities		Yes	1209	505 (41.80)	704 (58.20)	0.00
		No	263	61 (23.20)	202 (76.80)	0.00
High ratings from senior staff		Yes	980	511 (52.10)	469 (47.90)	0.00
High ratings from senior staff		No	492	55 (11.20)	437 (88.80)	0.00
Factors related to facilities
Type of hospital		Cancer centers	1021	412 (40.40)	609 (59.60)	0.02
Type of hospital		Other hospitals	451	154 (34.10)	297 (65.90)	0.02
Bed capacity		Less than 200	165	75 (45.50)	90 (54.50)	0.05
Bed capacity		200 or more	1307	491 (37.60)	816 (62.40)	0.05
Advertisements for CNSs and CNs		Yes	1273	501 (39.40)	772 (60.60)	0.07
Advertisements for CNSs and CNs		No	199	65 (32.70)	134 (67.30)	0.07
Service system in the following four departments		Yes	883	361 (40.90)	522 (59.10)	0.02
Service system in the following four departments		No	589	205 (34.80)	384 (65.20)	0.02
Additional medical services• Palliative care practice		Yes	593	236 (39.80)	357 (60.20)	0.38
Additional medical services• Palliative care practice		No	879	330 (37.50)	579 (62.50)	0.38
	• Cancer patient counseling	Yes	942	394 (41.80)	548 (58.20)	0.00
No	• Cancer patient counseling	530	172 (32.50)	358 (67.50)		0.00
	• Outpatient palliative care management	Yes	340	139 (40.90)	201 (59.10)	0.29
No	• Outpatient palliative care management	1132	427 (37.70)	705 (62.30)		0.29
	• Cancer pain palliation instruction	Yes	830	349 (42.00)	481 (58.00)	0.00
No	• Cancer pain palliation instruction	642	217 (33.80)	425 (66.20)		0.00
Requirements • Second opinion		Received	1021	476 (46.60)	725 (53.40)	0.05
Requirements • Second opinion		Not received	271	90 (33.20)	181 (66.80)	0.05
	• Collaboration team and the primary care physician	Received	605	278 (46.00)	327 (54.00)	0.00
Not received	• Collaboration team and the primary care physician	867	288 (33.20)	579 (66.80)		0.00
	• Operation of cancer regional alliances path	Received	670	291 (43.40)	379 (56.60)	0.00
Not received	• Operation of cancer regional alliances path	802	275 (34.30)	527 (65.70)		0.00
	• Training of local healthcare professionals	Received	996	424 (42.60)	572 (57.40)	0.00
Not received	• Training of local healthcare professionals	476	142 (29.80)	334 (70.20)		0.00
	• Hospital cancer registry	Received	973	404 (41.50)	569 (58.50)	0.00
Not received	• Hospital cancer registry	499	162 (32.50)	337 (67.50)		0.00
Positive evaluation of CNS development		Yes	531	286 (53.90)	245 (46.10)	0.00
Positive evaluation of CNS development		No	941	280 (29.80)	661 (70.20)	0.00
Positive evaluation of CN development		Yes	898	451 (50.20)	447 (49.80)	0.00
Positive evaluation of CN development		No	574	115 (27.00)	459 (73.00)	0.00
Appropriate staff allocation		Yes	604	319 (52.81)	285 (47.19)	0.00
Appropriate staff allocation		No	868	247 (28.46)	621 (71.54)	0.00
Factors related to the cancer care team
Coordination among healthcare professionals		Yes	1384	548 (39.60)	836 (60.40)	0.00
Coordination among healthcare professionals		No	88	18 (20.50)	70 (79.50)	0.00
Independent activities		Yes	1090	542 (49.70)	548 (50.30)	0.00
Independent activities		No	382	24 (6.30)	358 (93.70)	0.00
Availability of conferences		Yes	1235	515 (41.70)	720 (58.30)	0.00
Availability of conferences		No	237	51 (21.50)	186 (78.50)	0.00
Job Type• Pharmacist		Involvement	1350	528 (39.10)	822 (60.90)	0.44
Job Type• Pharmacist		Non-involvement	122	38 (31.10)	84 (68.90)	0.44
	• Medical social worker	Involvement	1137	461 (40.50)	676 (59.50)	0.00
	• Medical social worker	Non-involvement	335	105 (31.30)	230 (68.70)	0.00
	• Nutritionist	Involvement	987	398 (40.30)	589 (59.70)	0.35
	• Nutritionist	Non-involvement	485	168 (34.60)	317 (65.40)	0.35
	• Physical therapist	Involvement	831	325 (39.10)	506 (60.90)	0.55
	• Physical therapist	Non-involvement	641	241 (37.60)	400 (62.40)	0.55
	• Occupational therapist	Involvement	547	217 (39.70)	330 (60.30)	0.46
	• Occupational therapist	Non-involvement	925	349 (37.70)	576 (62.30)	0.46
	• Speech therapist	Involvement	307	119 (38.80)	188 (61.20)	0.90
	• Speech therapist	Non-involvement	1165	447 (38.40)	718 (61.60)	0.90
	• Clinical psychologist	Involvement	537	233 (43.40)	304 (56.60)	0.00
	• Clinical psychologist	Non-involvement	935	333 (35.60)	602 (64.40)	0.00

Open in a new tab

The threshold for years of experience was set at 5 years, because according to [32], 44.00% of CNs are hesitant to renew their initial 5-year contracts. Reasons given for their hesitation Include: “There is no satisfaction in the work” and they have “not been able to fully refresh.”

Multivariable analysis

The results of the chi-square test were used in a logistic regression analysis to identify variables particularly important to the job satisfaction of CNSs and CNs. Table 5 presents the results of this analysis.

Table 5. Logistic regression analysis.

			OR	95% CI			p
CNS
Factors related to
	Activities	Belongs to palliative care team	2.64	1.08	–	6.45	0.04
		Presence of cross-departmental activities	7.06	1.95	–	25.54	0.00
		Positive evaluation from senior staff	13.15	3.19	–	54.19	0.00
		Presence of CN in radiation therapy nursing in the same institution	2.91	1.08	–	7.84	0.03
	Facilities	Positive evaluation of CNS development	7.35	2.96	–	18.29	0.00
	Facilities	Medical service fees: Cancer pain palliation instruction charges	3.78	1.45	–	9.85	0.01
Team	Opportunity for independent activities	11.34	2.04	–	62.99	0.01
CN
Factors related to
	Activities	Belongs to ward department	0.49	0.38	–	0.66	0.00
		Opportunities for cross-departmental activities	2.24	1.57	–	3.19	0.00
		Positive evaluation from senior staff	4.88	3.46	–	6.46	0.00
		Appropriate staff allocation	1.75	1.35	–	2.27	0.00
		CN experience of more than 5 years	1.91	1.44	–	2.54	0.00
	Facilities	Bed capacity	0.33	0.20	–	0.54	0.04
		Positive evaluation of CNS development	1.37	1.01	–	1.86	0.04
		Positive evaluation of CN development	2.13	1.55	–	2.93	0.00
Team	Opportunity for independent activities	6.83	4.28	–	10.91	0.00

Open in a new tab

Adjusted for years of experience after acquiring a nursing license. Only variables that remained significant in the regression models are shown in this table.

Multivariable analysis of job satisfaction in CNSs

In terms of the factors related to activities, job satisfaction was present when the participant belonged to the palliative care team [odds ratio (OR) = 2.64], cross-departmental activities could be performed (OR = 7.06), the participant received a favorable rating from senior staff (OR = 13.15), and a CN was involved in radiation therapy nursing in the same institution (OR = 2.91). Of the factors related to facilities, job satisfaction was found when there was a high rating for CNS development in the institution (OR = 7.35) and the participant belonged to an institution where an additional pain relief management fee was charged (OR = 3.78). Of the factors related to the cancer care team, job satisfaction was found when independent activities could be performed (OR = 11.3) (Cox-Snell R² = 0.49; Nagelkerke R² = 0.65).

Multivariable analysis of job satisfaction in CNs

Of the factors related to activities, working on a ward was associated with the absence of job satisfaction (OR = 0.49). In contrast, job satisfaction was present when cross-departmental activities could be performed (OR = 2.24), a high rating was received from senior staff (OR = 4.88), there was appropriate staff allocation in each ward or department (OR = 1.75), and the participant had at least five years of experience after acquiring a CN qualification (OR = 1.91). Of the factors related to facilities, job satisfaction was present when the capacity was less than 200 beds (OR = 0.33) and there was a high rating of CNS and CN development in the institution (OR = 1.37 and 2.13, respectively). Of the factors related to the cancer team, job satisfaction was present when independent activities could be performed (OR = 6.83) (Cox-Snell R² = 0.33; Nagelkerke R² = 0.45).

Discussion

In this study on CNs and CNSs working in cancer care in Japan, we identified numerous factors related to activities, facilities, or the cancer team that influenced job satisfaction.

Of the factors related to activities, opportunities for cross-departmental activities and positive evaluation from senior stuff were common to CNs and CNSs.

In our study, CNSs were often affiliated with departments engaged in cross-departmental activities throughout the entire facility (Fig 1).

Cross-departmental activities increased the job satisfaction of CNSs and CNs. However, these mainly involved activities by the palliative care team and the counseling and support center. In this study, only 409 members of palliative care teams and 83 members of the counseling and support centers were surveyed, and a high number of respondents (1,404) were affiliated with a single department (Fig 2). In facilities without CNSs, consultations in other wards and care for patients during radiotherapy require specialized abilities and offer CNs an opportunity to demonstrate their professional skills, which is thought to increase job satisfaction [33, 34].

Our findings are consistent with those of a previous study that showed that consciously conducting professional activities as a specialist increases work engagement, which influences job satisfaction [35]. Furthermore, the feeling that a job is worthwhile and that one’s performance in the role has been noticed have been correlated with increased job satisfaction [36]. Affective commitment is associated with increased job satisfaction and attachment to the organization [37, 38]. The results here suggest that it would be beneficial to provide CNSs and CNs with opportunities to maximize their abilities, which would enhance their affective commitment and job satisfaction.

CNs reported the presence of job satisfaction when staffing was appropriate in the department and when opportunities were available to perform cross-departmental and independent activities. However, job satisfaction was lower among CNs working on a ward, because doing so is associated with a higher level of exhaustion, which reduces job efficacy. Consistent with our findings, the appropriate staff allocation in wards or departments has been associated with a higher level of job satisfaction among CNs [17]. Therefore, flexible staffing is considered a guarantee that CNs will complete their activities. Job satisfaction increased at least five years after obtaining a CN qualification and when the individual received good evaluations from superiors. In addition, length of experience has been cited as a factor influencing the career development of CNs, and specialty careers with greater autonomy are associated with higher job satisfaction [39, 40]. For CNs, job satisfaction increased after the fifth year, when they can be fully active and solve problems independently.

In addition, job satisfaction was higher when the development of CNSs and CNs was conducted more proactively. Those who received positive evaluations from their senior staff tended to report the presence of job satisfaction. Because work engagement is increased by the availability of resources such as support from senior staff and colleagues [41], and lack of social support from senior staff is associated with the intention to quit a job [42], a high rating and support from senior staff is thought to increase the job satisfaction of CNSs and CNs. Thus, for CNSs and CNs to develop their professional abilities [43], receiving a favorable evaluation from a supervisor is essential.

Although previous studies found the presence of job satisfaction among CNSs and CNs who are more active in teaching, the absence of supportive colleagues reportedly influence job satisfaction as well [41–43]. Moreover, affective commitment, which involves equating one’s personal values with those of the organization, is strongly associated with job motivation in nurses [44] and enhances job satisfaction. Importantly, the perception of support from colleagues is related to this affective commitment [45, 46]. For example, perceptions of mutual support between CNSs and CNs seemed to enhance job satisfaction.

Of the factors related to facilities, a positive evaluation of the development of CNs and CNSs was associated with job satisfaction in both CNs and CNSs.

CNSs’ job satisfaction was significantly higher when institutions charged additional fees for pain relief management. The fee for opioid use in Japan is approximately 5.00% of that in Western countries [47]. However, it is difficult to determine whether appropriate pain care is provided in Japan. In this context, there is often misunderstanding due to the lack of knowledge about opioids of both patients and healthcare professionals [48]. Therefore, the reevaluated and newly established system for medical service fees that provides instructions on pain palliation in cancer treatment may offer a sense of fulfillment and satisfaction to CNSs, because they are able to provide care that alleviates pain and improves their patients’ quality of life.

Moreover, job satisfaction was higher among CNs who worked at an institution with a capacity of less than 200 beds. Reportedly, professional autonomy is affected by the size and management system of the organization, not by individual traits [40]. The opinions of nurses are addressed by administrators more readily in smaller institutions than in larger ones, and they can demonstrate their competency more easily, which may explain the association between bed capacity and job satisfaction. Of the factors related to the cancer care team, opportunity for independent activities was associated with the job satisfaction of both CNs and CNSs. To experience job satisfaction, individuals with an internal locus of control need an environment in which they can effectively use their roles to determine the outcomes of their actions [35]. Hence, for CNSs and CNs to provide care as intended, an environment is required in which they can fully use their cultivated knowledge, skills, and designated roles. This tendency toward an internal locus of control might have increased job satisfaction in the current study.

Certified nursing was an outcome of the notion that nurses should collaborate and engage in cross-sectional activities beyond their wards. Engaging in such activities likely increases collaboration and the job satisfaction of CNSs. It is important that organizations adopt practices based on the findings of this study. Moreover, the working conditions and job satisfaction of CNSs and CNs reported in this study are closely connected with policy. Therefore, our findings should be used to guide policy in Japan in the future.

Several previous studies have been conducted on the job satisfaction of nurses in Japanese institutions. They highlight the complex nature of factors influencing job satisfaction and importance thereof in staff retention [49–55].

Our study has several limitations. Because fewer responses were obtained from CNSs (only 200 of the total 483 CNSs) than CNs (1,472 responses), the 95% confidence interval of the logistic regression was rather large. In addition, the effects of age and sex were not considered. The group sizes of participants working in radiotherapy or wards with lower bed capacity were skewed. Finally, because of the explorative character of our study, we did not correct for multiple testing. Therefore, these results must be generalized with caution.

Conclusion

Our study identified the factors related to activities, facilities, and the cancer care team associated with the job satisfaction of CNSs and CNs, and highlighted potential avenues through which to enhance job satisfaction through the Basic Plan to Promote Cancer Control in Japan. Whereas the majority of the factors identified were shared by CNs and CNSs, several were unique to one of the groups. Moreover, the findings have implications for hospital administrators aiming to retain staff who might otherwise be hesitant to stay because of job dissatisfaction. Finally, changes regarding the CN certification may be beneficial.

Supporting information

S1 Data

(XLSX)

Click here for additional data file.^{(42KB, xlsx)}

S2 Data

(XLSX)

Click here for additional data file.^{(256.3KB, xlsx)}

Acknowledgments

Editorial support in the form of medical writing, assembling tables, creating high-resolution images based on authors’ detailed directions, collating author comments, copyediting, fact-checking, and referencing was provided by Editage, Cactus Communications.

Data Availability

The minimal anonymized dataset necessary to replicate our study is available within the Supporting Information files.

Funding Statement

This study was supported by research grants from The Japan Geriatrics Society (H.A.), JSPS KAKENHI (JP17K18202) (M.K.) and Yasuda Memorial Medical Foundation (M.K.). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

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PLoS One. doi: 10.1371/journal.pone.0232336.r001

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18 Dec 2019

PONE-D-19-28473

Job satisfaction of certified nurse specialists and certified nurses in cancer care centers in Japan: A large cross-sectional study

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Kind regards,

Janhavi Ajit Vaingankar

Academic Editor

PLOS ONE

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: No

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: No

Reviewer #2: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

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PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The manuscript touches an important topic by trying to assess Job satisfaction of certified nurse specialists and certified nurses in cancer care centers in Japan. However, I have some doubts how this study was conducted:

Title:

- Your title of this study is “to assess Job satisfaction of certified nurse specialists and certified nurses in cancer care centers in Japan”. However; there is no finding in your study which shows the level of job satisfaction among these two group of nurses. Therefore, you have to either present this finding or modify your title.

Abstract:

- In the background part of abstract, information about nurses’ job satisfaction such as level of job satisfaction and burden of job dissatisfaction on patients should be presented from the available literature.

- I am not clear with your sample size calculation and sampling procedure. How 200 certified nurse specialist and 1,472 certified nurses were recruited and participated in the study?

- The authors should indicate the level of job satisfaction of both certified nurse specialist and certified nurses

- Indicate all variables associated with job satisfaction separately for certified nurse specialist and certified nurses, and mention their respective AOR with CI.

- The authors should present the conclusion of their finding in the conclusion section of the abstract

Introduction:

- Based on the available literature, the authors should present the level of job satisfaction among nurses in global, regional and local perspectives

- The authors should also show what the literature says about the burden/impact of nurses’ job dissatisfaction on cancer patients. The authors should also mention important factors influencing job satisfaction based on the available literature on this particular topic

- I recommend the authors to remove table 1 from introductory part of this manuscript, because information in the table are already mentioned in narration

- The statement “No study in the study area” don’t justify the need of your study. The authors should show gap of previous studies (global perspectives) and justify the need of your studies

Methods:

- I am not sure whether the level job satisfaction of nurses was measured in this study. If so, which tool was used to measure this job satisfaction? Was this tools validity and reliability checked?

- Why you conducted pre-test on only 4 nurses? As a rule, on how much percentage of sample size pre-test should be conducted?

- How you determined the sample size? What was your sampling procedure? The authors should describe the mechanism how participants were recruited and participated in the study

- Since the data were collected through mail, I doubt how the informed consent was obtained.

- My major issue with this research is how job satisfaction was assessed/measured and categorized as “satisfaction” and “dissatisfaction”. Therefore, the authors should clearly explain this in the methods

- Your method of analysis is not clear. Please, explain your method of analysis in detail

Results:

- Your objective is to assess Job satisfaction of certified nurse specialists and certified nurses in cancer care centers in Japan. Where is the result which indicate level of job satisfaction for certified nurse specialist and certified nurses? What percentages of certified nurse specialists and certified nurses were satisfied and dissatisfied with their job?

Discussion:

- The authors should re-write the discussion. The authors only stated and discussed their finding and didn’t compare their finding with other study findings. The authors should discuss only the key finding of their study with previous study findings.

Conclusion:

- The authors should write the conclusion of the study finding separately

Reviewer #2: Thank you for the opportunity to review this paper. This paper is novel in that it is the first to evaluate the factors associated with job satisfaction among nurses involved in cancer care in Japan, which is an important group of healthcare professionals.

Introduction

1) In Table 1, years of clinical experience to qualify for CNSs for university graduates is stated as “0” years. Please confirm this is correct.

2) Reference 22 appears to be out of context w.r.t addressing job satisfaction among nurses. Please confirm if the reference is appropriate. (line 91)

Methods

1) The interviews conducted (line 111) needs to be further clarified. E.g., with who?

2) “a logistic regression analysis was conducted with satisfaction or dissatisfaction as the dependent variable” (line 183)- please provide more information to explain how the dependent variable is being determined. Given the proposed title of the manuscript, it is also important to report on job satisfaction status as descriptive statistics in Table 3.

3) “years of experience as the control variable” (line 185) refers to years of experience after acquiring nursing license or after acquiring CN qualification?

Results:

Overall: The regression analysis for CNSs (n=200) is under-powered given the large no. of independent variables involved (which i suppose to be 20 of them).

1) “remaining participants worked at other hospitals (e.g., general hospitals or clinics)” (line 196-197). It is unclear if these participants were also involved in cancer care? This appears to contradicts the statement under section-Participants which stated that “A total of 1,696 nurses working in cancer centers and hospitals responded to the mailed questionnaire. (line 160-161)”. Please clarify.

2) “51.6% of the nurses had a position title (e.g., head or chief nurse), whereas the others were staff nurses” (line 203), is this established based on “position” in Table 3 where managers are “head or chief nurse”? If so, the reported % does not seem to be correct.

3) I noticed significant differences in 5 (not 3) items with cancer team care for Table 5. Please correct text under results accordingly (line 208 and line 211).

Was it that only items with p<0.05 at univariate analysis were selected as explanatory variables in the logistic regressions? If so, why is “presence of CN in radiation therapy nursing” included and remained significant in the regression analysis for CNS (Table 6) when it was reported as “n.s” in the univariate analysis for CNS. Please clarify. I have concern on the over-loading of the model, particularly given the small sample in CNS analysis. Is correction for multiple testing considered?

5) Table 6 shows only variables that remain significant in regression models? If so, please state this as legend in the Table.

6) “when a CN was involved in radiation therapy nursing within the same institution” (line 242-243); please clarify if this is a factor related to activity or facilities? It is reported as a factor for facilities.

7) Suggest to use the terms “presence” or “absence” of job satisfaction instead of “higher” or “lower” level of job satisfaction when reporting the results.

Discussion

1) “a high number of respondents (1,404) were affiliated with a single ward” (line 294). Figure 2 shows that less than 700 (based on bar height) were involved in ward department. Please clarify.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files to be viewed.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at figures@plos.org. Please note that Supporting Information files do not need this step.

PLoS One. 2020 May 18;15(5):e0232336. doi: 10.1371/journal.pone.0232336.r002

Author response to Decision Letter 0

27 Jan 2020

Response to the Editor and Reviewers

Editor:

When submitting your revision, we need you to address these additional requirements. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming.

Response: We have renamed the files in accordance with the journal requirements and rechecked the text for compliance with the formatting requirements.

We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

Response: We confirm that we will make the manuscript data publicly available upon acceptance of the article and agree with the outlined procedure.

Please amend your current ethics statement to include the full name of the ethics committee/institutional review board(s) that approved your specific study. Once you have amended this/these statement(s) in the Methods section of the manuscript, please add the same text to the “Ethics Statement” field of the submission form (via “Edit Submission”). For additional information about PLOS ONE ethical requirements for human subjects research, please refer to http://journals.plos.org/plosone/s/submission-guidelines#loc-human-subjects-research.

Response: We have specified the name of the Ethics Committee (“Institutional Ethics Committee of the Kyoto University Graduate School of Medicine and Faculty of Medicine Hospital”) in the Methods section and the ethical statement.

PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ.

Response: We have provided the ORCiD ID for the corresponding author as requested.

Reviewer #1:

The manuscript touches an important topic by trying to assess Job satisfaction of certified nurse specialists and certified nurses in cancer care centers in Japan. However, I have some doubts how this study was conducted:

Title:

Response: We thank the reviewer for this helpful comment. Job satisfaction was present in 38.45% of CNs and 49% of CNSs, but absent in 61.55% of CNs and 51% of CNSs. We have added this information to the revised manuscript (page 12, lines 202-203 and Table 2). Furthermore, to more exactly convey the topic and findings of the paper, we have modified the title to: “Factors affecting the job satisfaction of certified nurse specialists and certified nurses in cancer care in Japan: Analysis based on the Basic Plan to Promote Cancer Control Programs.”

Abstract:

Response: We have added a statement on the level of job satisfaction and its consequences to the background part of the abstract. Due to the 300 words limit for the abstract, we had to keep the statement concise (page 2, lines 21-23).

-I am not clear with your sample size calculation and sampling procedure. How 200 certified nurse specialist and 1,472 certified nurses were recruited and participated in the study?

Response: The sample size was restricted by the number of eligible qualified and recruited CNs and CNSs. Overall, 2,378 eligible CNs were identified and contacted; 1,486 replied, and 1,472 among them provided valid answers. Overall, 514 eligible CNSs were identified and contacted; 210 replied, and 200 among them provided valid answers.

-The authors should indicate the level of job satisfaction of both certified nurse specialist and certified nurses

Response: Job satisfaction was present in 38.45% of CNs and 49% of CNSs but was absent in 61.55% of CNs and 51% of CNSs. We have added this information to the manuscript (page 12, lines 202-203 and Table 2).

-Indicate all variables associated with job satisfaction separately for certified nurse specialist and certified nurses, and mention their respective AOR with CI.

Response: All variables associated with job satisfaction were listed separately, and their odds ratios and p-values were specified. Unfortunately, the word limit for the abstract (300 words) did not allow listing also the 95% CI in the abstract; however, this information is described in the main text.

-The authors should present the conclusion of their finding in the conclusion section of the abstract

Response: We have stated the conclusion of the study in the conclusion section of the abstract (page 3, lines 45-48).

Introduction:

- Based on the available literature, the authors should present the level of job satisfaction among nurses in global, regional and local perspectives

Response: The introduction has been modified (page 5, lines 86-91).

Response: We have mentioned important factors affecting job satisfaction in the introduction (page 5, lines 86-91). Unfortunately, the effect of nurse job dissatisfaction on cancer patient outcomes has not been investigated well. We have added that as a future research direction in the discussion.

- I recommend the authors to remove table 1 from introductory part of this manuscript, because information in the table are already mentioned in narration

Response: We have removed Table 1 from the revised version of the manuscript.

- The statement “No study in the study area” don’t justify the need of your study. The authors should show gap of previous studies (global perspectives) and justify the need of your studies

Response: We have modified the justification for the study (page 6, lines 98-102).

Methods:

- I am not sure whether the level job satisfaction of nurses was measured in this study. If so, which tool was used to measure this job satisfaction? Was this tools validity and reliability checked?

Response: To measure job satisfaction, we asked the question, "Are you satisfied with your job?” Originally, we used a scale with three levels, “satisfied,” “somewhat satisfied,” and “dissatisfied.” However, upon review, we combined the first two levels to yield a two-level scale, “satisfied” and ”dissatisfied.” We have added this information to the text of the manuscript (page 8, lines 142-145).

- Why you conducted pre-test on only 4 nurses? As a rule, on how much percentage of sample size pre-test should be conducted?

Response: Only 4 nurses were included in the pre-test due to organizational and technical reasons despite our intention to conduct a more extensive pre-test. Since the pre-test was conducted in person and was time-consuming, it was difficult to recruit nurses willing to commit the time for the pre-test. Furthermore, the nurses we managed to recruit were at a geographical distance from us, which necessitated travel to their institutions, further increasing the time load.

- How you determined the sample size? What was your sampling procedure? The authors should describe the mechanism how participants were recruited and participated in the study

Response: As mentioned earlier in our response, we contacted all eligible qualified CNs and CNSs. Overall, there were 2,378 eligible CNs; 1,486 replied, and 1,472 among them provided valid answers. Overall, there were also 514 eligible CNSs; 210 replied, and 200 among them provided valid answers.

- Since the data were collected through mail, I doubt how the informed consent was obtained.

Response: The contacted CNs and CNSs had the opportunity to select also the item “I do not agree to participate.” in the questionnaire we sent them.

- Your method of analysis is not clear. Please, explain your method of analysis in detail

Response: The description of the data analysis has been revised in the text.

Results:

Response: Job satisfaction was present in 38.45% of CNs and 49% of CNSs, and absent in 61.55% of CNs and 51% of CNSs (page 12, lines 202-203 and Table 2).

Discussion:

Response: We have modified the discussion to focus more on the comparison of our findings with the results of previous investigations.

Conclusion:

- The authors should write the conclusion of the study finding separately

Response: The Conclusion has been separated into an individual section (page 27, lines 390-396).

Introduction

1) In Table 1, years of clinical experience to qualify for CNSs for university graduates is stated as “0” years. Please confirm this is correct.

Response: We thank the Reviewer for this comment. The second Reviewer of the manuscript requested that we remove Table 1 due to the presentation of the data in the text. Therefore, Table 1 has been removed from the revised version of the manuscript.

2) Reference 22 appears to be out of context w.r.t addressing job satisfaction among nurses. Please confirm if the reference is appropriate. (line 91)

Response: We thank the Reviewer for pointing out this inconsistency. We have removed reference 22 from the revised manuscript.

Methods

1) The interviews conducted (line 111) needs to be further clarified. E.g., with who?

Response: We meant the pre-test interviews with CNs. To avoid confusion, this phrase was removed from the revised version of the manuscript.

Response: We have reported on job satisfaction in the descriptive statistics Table, which is currently Table 2 in the revised manuscript. To measure job satisfaction, we asked the question, "Are you satisfied with your job?” Originally, we used a scale with three levels, “satisfied,” “somewhat satisfied,” and “dissatisfied.” However, upon review, we combined the first two levels to yield a two-level scale, “satisfied” and ”dissatisfied.” (page 12, lines 202-203 and Table 2).

3) “years of experience as the control variable” (line 185) refers to years of experience after acquiring nursing license or after acquiring CN qualification?

Response: "Years of experience after acquiring nursing license" was used as a control variable, whereas "years of experience after acquiring CNS or CN qualification" was utilized as an independent variable. We have clarified this information in the text.

Results:

Overall: The regression analysis for CNSs (n=200) is under-powered given the large no. of independent variables involved (which i suppose to be 20 of them)

Response: We contacted all eligible qualified CNs and CNSs. Overall, there were 514 eligible CNSs; 210 replied, and 200 among them provided valid answers. Thus, the CNS sample size was limited by the number of individuals eligible and willing to participate. We have stated this fact as a limitation of our study.

Response: We apologize for this unclarity. These participants worked in general hospitals or clinics, but they were also involved in cancer care. We have modified both statements, to which the Reviewer referred, to clarify this point (page 12, lines 204-206).

Response: We apologize for this inconsistency and have changed the value to the correct value of 60.5%.

3) I noticed significant differences in 5 (not 3) items with cancer team care for Table 5. Please correct text under results accordingly (line 208 and line 211).

Response: We thank the Reviewer for pointing out this inconsistency; we have corrected it (page 14, lines 219-220).

4) “The results of the χ2 test were used in a logistic regression analysis to identify variables particularly important to job satisfaction among CNSs and CNs.” (line 228-229). This needs to be highlighted in the methodology and it is unclear how results from chi square tests were used to identify variables for inclusion in logistic regressions? Was it that only items with p<0.05 at univariate analysis were selected as explanatory variables in the logistic regressions? If so, why is “presence of CN in radiation therapy nursing” included and remained significant in the regression analysis for CNS (Table 6) when it was reported as “n.s” in the univariate analysis for CNS. Please clarify. I have concern on the over-loading of the model, particularly given the small sample in CNS analysis. Is correction for multiple testing considered?

Response: We thank the Reviewer for pointing out this unclarity. We have specified in the revised manuscript that only items with p < 0.05 in the univariate analysis were selected as explanatory variables in the logistic regressions (page 11, lines 186-188). The presence of CN in radiation therapy nursing “n.s” report in the univariate analysis for CNS was a mistake that we have corrected. Due to the exploratory character of our study, we did not correct for multiple testing. We have stated this fact as a limitation in the revised version of the manuscript (page 27, lines 387-388).

5) Table 6 shows only variables that remain significant in regression models? If so, please state this as legend in the Table.

Response: We have stated in the note to the table in the revised manuscript that only variables that remain significant in regression models are shown in Table 6.

Response: We thank the Reviewer for pointing out this inconsistency and apologize for it. “When a CN was involved in radiation therapy nursing within the same institution” was a factor associated with facilities. We have corrected the text accordingly.

7) Suggest to use the terms “presence” or “absence” of job satisfaction instead of “higher” or “lower” level of job satisfaction when reporting the results.

Response: We have replaced the phrases “higher” or “lower” level of job satisfaction with “presence” or “absence” of job satisfaction.

Discussion

1) “a high number of respondents (1,404) were affiliated with a single ward” (line 294). Figure 2 shows that less than 700 (based on bar height) were involved in ward department. Please clarify.

Response: We thank the reviewer for pointing out this inconsistency. By “affiliated with a single ward” we meant “affiliated with a single department,” including a ward or outpatient department, as well as a chemotherapy or radiotherapy room. We have modified the phrase in the text correspondingly (page 23, lines 305-306).

Attachment

Submitted filename: Response to Reviewers.docx

Click here for additional data file.^{(31.2KB, docx)}

PLoS One. doi: 10.1371/journal.pone.0232336.r003

Decision Letter 1

Janhavi Ajit Vaingankar

25 Feb 2020

PONE-D-19-28473R1

Factors affecting job satisfaction of certified nurse specialists and certified nurses in cancer care in Japan: Analysis based on the Basic Plan to Promote Cancer Control Programs

PLOS ONE

Dear Professor Arai,

==============================

ACADEMIC EDITOR:

Please consider the comments by the third reviewer pertaining to data analysis. You may wish to revise your analysis or justify your analytical approach in the light of these comments.

=============================

We would appreciate receiving your revised manuscript by Apr 10 2020 11:59PM. When you are ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled 'Response to Reviewers'.
A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled 'Revised Manuscript with Track Changes'.
An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled 'Manuscript'.

We look forward to receiving your revised manuscript.

Kind regards,

Janhavi Ajit Vaingankar

Academic Editor

PLOS ONE

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #2: Yes

Reviewer #3: No

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #2: Yes

Reviewer #3: No

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #2: Yes

Reviewer #3: No

**********

6. Review Comments to the Author

Reviewer #2: The authors have adequately addressed most of comments except one:

1) "when a CN was involved in radiation therapy nursing within the same institution” (line 248-252 in the clean version);

please clarify if this is a factor related to activity or facilities? The author replied in his/her comment that this is a factor related to facilities which is confusing and it does not tally with information presented in the tables. I did not also see any change in the text.

Others:

1) Line 217 to 218. All reported numbers should be updated. 20->21, 30->32, 10->11

Reviewer #3: The use of the abbreviations is not consistent. For example, CN or CNs, CNSs. I would suggest to remove all acronyms from the abstract in the least and standardize their use throughout the manuscript. The use of the acronyms has to be grammatically correct i.e. used in singular or plural forms. Consider using ‘certified nurse or nurse specialists’ in the sentences. Please spell chi-square in full.

Since this is a cross-sectional study, refrain from using terms such as ‘predictive’. Change these to ‘association’ instead.

State all proportions with upto one decimal points and other estimates upto 2 or 3 (keep it consistent).

Please state full p values instead of asterisks in the tables.

I am unable to understand the significant of having the analysis based on the Basic Plan to Promote Cancer Control Programs. Perhaps in the introduction this should be described and its relevance to this study should be highlighted. It may also be necessary to state why it was of interest to study CN and CNS groups separately. Just stating there were no previous studies may not be enough.

The discussion is not informative and needs to be clearly focused on the main findings of the study and the distinctions between the two groups and their practice implications.

In terms of analysis, some of the groups are highly skewed eg. Proportions working in radiotherapy, wards with lower bed capacity. Years of clinical nurse experience also needs to be carefully looked at since this has been used as control variable in the logistic regression. Although authors justify using 5 year cut off, I believe this again would be very skewed population given the mean duration was 19 years in the sample. The univariate analysis need to relooked at carefully before presenting multivariable findings. On that note, the correct term would be ‘multivariable’ instead of ‘multivariate’

Overall, I found this article quite difficult to follow. Given that it is currently quite long, authors need to edit the content carefully after considering the above comments. This could be achieved by shortening the introduction, avoiding repetitions between the tables and text in the results and trimming the discussion. Parts of the manuscript also need better flow and focus. For example, why is the statement ‘The study adheres to the STROBE checklist’ included in the job satisfaction questionnaire section? The intent of mentioning ‘Basic Plan to Promote Cancer Control Programs’ is not clear. Analysis needs to be reviewed thoroughly and reanalyzed as necessary to be eligible for publication.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

Reviewer #3: No

PLoS One. 2020 May 18;15(5):e0232336. doi: 10.1371/journal.pone.0232336.r004

Author response to Decision Letter 1

31 Mar 2020

Response to the Editor and Reviewers

Academic Editor:

Please consider the comments by the third reviewer pertaining to data analysis. You may wish to revise your analysis or justify your analytical approach in the light of these comments.

Response: Thank you for the opportunity to revise our manuscript. We have conducted additional statistical analysis in accordance with the comments of Reviewer 3.

Reviewer #2:

The authors have adequately addressed most of comments except one:

1) "when a CN was involved in radiation therapy nursing within the same institution” (line 248-252 in the clean version); please clarify if this is a factor related to activity or facilities? The author replied in his/her comment that this is a factor related to facilities which is confusing and it does not tally with information presented in the tables. I did not also see any change in the text.

Response: We apologize for this mistake. In the revised manuscript, we changed this to “when a CN was involved in radiation therapy nursing within the same institution” as a factor related to activity (page 21, lines 234-235).

Others:

1) Line 217 to 218. All reported numbers should be updated. 20->21, 30->32, 10->11

Response: Thank you for pointing out this inconsistency. We have updated the reported numbers accordingly (page 14, lines 205-208).

Reviewer #3:

The use of the abbreviations is not consistent. For example, CN or CNs, CNSs. I would suggest to remove all acronyms from the abstract in the least and standardize their use throughout the manuscript. The use of the acronyms has to be grammatically correct i.e. used in singular or plural forms. Consider using ‘certified nurse or nurse specialists’ in the sentences. Please spell chi-square in full.

Response: Thank you for this comment. We have ensured that the use of abbreviations in the revised version of the manuscript is consistent by introducing the following modifications: (1) We have removed all acronyms from the abstract. (2) In the main text, we have used CN and CNS in singular form and CNs and CNSs in plural form. (3) In the abstract, we have used the expression “certified nurses or nurse specialists” as suggested. (4) We have spelled out “chi-square” in full.

Since this is a cross-sectional study, refrain from using terms such as ‘predictive’. Change these to ‘association’ instead.

Response: We deleted all terms indicating a causative effect such as “predictive” and changed them to terms indicating an “association” as requested.

State all proportions with upto one decimal points and other estimates upto 2 or 3 (keep it consistent).

Response: We have modified the text to consistently present estimates up to 2 decimal points.

Please state full p values instead of asterisks in the tables.

Response: We have provided the full p-values instead of asterisks in the tables.

Response: In the introduction, we now elaborate why we chose to base the analysis on the Basic Plan to Promote Cancer Control Programs (page 5, lines 75-77 of the clean copy). The roles of certified nurses and nurse specialists are regulated by the Basic Plan to Promote Cancer Control Programs. Therefore, it is important to consider this plan when assessing nurses’ job satisfaction. Furthermore, considering the plan would help us make more relevant suggestions for measures from the Japanese Ministry of Health, Labour and Welfare to improve job satisfaction. The roles of certified nurses and nurse specialists partially overlap, but also differ in several aspects. Therefore, it is important to analyze the factors influencing job satisfaction in these groups separately to identify overlapping and distinct factors. This also facilitates the identification of measures that can improve the job satisfaction of certified nurses and nurse specialists.

The discussion is not informative and needs to be clearly focused on the main findings of the study and the distinctions between the two groups and their practice implications.

Response: We have extensively revised the discussion accordingly.

Response: Thank you for your comment. In the revised manuscript, we conducted an univariate analysis on the association of job experience of “less than 19 years”/“19 years and above” with “job satisfaction” (page 14, Table 3). No significant association was found for both certified nurses and nurse specialists. In addition, we replaced the term “multivariate” with “multivariable.” We have stated in the limitations statement that some groups such as participants working in radiotherapy or wards with lower bed capacity were skewed.

Response: We edited the introduction for conciseness and shortened it. We also checked the text for repetition between the tables and text and removed any such cases. Finally, we modified the discussion and edited it for conciseness.

Parts of the manuscript also need better flow and focus. For example, why is the statement ‘The study adheres to the STROBE checklist’ included in the job satisfaction questionnaire section? The intent of mentioning ‘Basic Plan to Promote Cancer Control Programs’ is not clear. Analysis needs to be reviewed thoroughly and reanalyzed as necessary to be eligible for publication.

Response: We moved the statement regarding the STROBE checklist (page 10, lines 170-171). Furthermore, we clarified the intent of mentioning the Basic Plan to Promote Cancer Control Programs in the introduction (page 5, lines 75-77). We also reviewed the statistical analysis and conducted additional statistical analysis.

Additional comment:

Reviewer #2: Yes

Reviewer #3: No

Response: If the manuscript is accepted for publication, we will make the data fully available in a public repository.

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PLoS One. doi: 10.1371/journal.pone.0232336.r005

Decision Letter 2

Janhavi Ajit Vaingankar

14 Apr 2020

Factors associated with the job satisfaction of certified nurses and nurse specialists in cancer care in Japan: Analysis based on the Basic Plan to Promote Cancer Control Programs

PONE-D-19-28473R2

Dear Dr. Arai,

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Reviewer #3: All comments have been addressed

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Reviewer #2: (No Response)

Reviewer #3: Yes

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Reviewer #3: Yes

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Reviewer #3: Yes

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PLoS One. doi: 10.1371/journal.pone.0232336.r006

Acceptance letter

Janhavi Ajit Vaingankar

1 May 2020

PONE-D-19-28473R2

Factors associated with the job satisfaction of certified nurses and nurse specialists in cancer care in Japan: Analysis based on the Basic Plan to Promote Cancer Control Programs

Dear Dr. Arai:

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Data Availability Statement

The minimal anonymized dataset necessary to replicate our study is available within the Supporting Information files.

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PERMALINK

Factors associated with the job satisfaction of certified nurses and nurse specialists in cancer care in Japan: Analysis based on the Basic Plan to Promote Cancer Control Programs

Masaki Kitajima

Chiharu Miyata

Keiko Tamura

Ayae Kinoshita

Hidenori Arai

Roles

Abstract

Background

Objectives

Methods

Results

Conclusions

Introduction

Methods

Survey development and testing

Job satisfaction questionnaire: Design and content

Table 1. Contents of the questionnaire.

Procedure

Participants

Ethical considerations

Data analysis

Results

Participant characteristics

Table 2. Demographic characteristics.

Univariate analysis

Table 3. Univariate analyses for CNSs.

Table 4. Univariate analyses for CNs.

Multivariable analysis

Table 5. Logistic regression analysis.

Multivariable analysis of job satisfaction in CNSs

Multivariable analysis of job satisfaction in CNs

Discussion

Fig 1. Total number of CNSs in each affiliation.

Fig 2. Total number of CNs in each affiliation.

Conclusion

Supporting information

Acknowledgments

Data Availability

Funding Statement

References

Decision Letter 0

Janhavi Ajit Vaingankar

Roles

Author response to Decision Letter 0

Decision Letter 1

Janhavi Ajit Vaingankar

Roles

Author response to Decision Letter 1

Decision Letter 2

Janhavi Ajit Vaingankar

Roles

Acceptance letter

Janhavi Ajit Vaingankar

Roles

Associated Data

Supplementary Materials

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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