Effectiveness of Integrated Emotional-Self Enhancement (IESE) program among staff nurses: protocol for a quasi-experimental study

Background: Staff nurses face frequent emotional situations in their work environment. The constant contact with suffering patients, and the busy work environment, pose tremendous stress on nurses’ physical and emotional health. The Emotional Intelligence skills of empathy, self-awareness, motivation, self-control, and keeping relationships, can help handle difficult emotions and allow nurses to work in an organized, calm, and professional way. This study aims to implement and assess the effectiveness of a training program developed by the investigator, tailored to the mental and emotional needs of staff nurses who are working in an organization. The study also aims to observe any significant change, correlation, and association in the staff nurses’ level of emotional intelligence, intrinsic motivation, self-compassion, emotional labor, and nurse-in-charges’ and patients’ perception of nursing care after the program. Methods: A quasi-experimental (one-group) study design was used in this study. The study will involve 80 staff nurses working in a selected hospital in India. The staff nurses will be selected from the hospital’s general wards using convenience sampling. For the current study, a quasi-experimental design will be used. The investigator will deliver a training program, divided into four sessions of two hours each. Data will be collected from the participants at baseline and 3-months pre-intervention; and post-test data will be collected immediately after the intervention, at 3-month, and 6-month follow-up, to observe any significant change in the study variables before and after the intervention. Results: The current study primarily focuses on the vital aspect of developing emotional needs, for promoting a better work-life balance. Research findings from the study will significantly contribute to the evidence based Emotional Intelligence programs for staff nurses, and if proven effective, could be delivered extensively in the hospitals. Trial registration: The study is registered in June 2019 under the Central Trial Registry of India ( CTRI/2019/08/020592).


Introduction
Nurses are faced with frequent emotional situations in their work environment which may hinder their decision-making, concentration, and recall, and may lead to an increase in errors.Thus, the skills of emotion regulation may help them in handling difficult emotions, especially in the times of crisis, and allow them to act appropriately.

Background
Emotion is a complex feeling that results in physical and psychological changes which influence thoughts and behaviours (Drigas & Papoutsi, 2018), motivate our decisions (Keltner & Kring, 1998), and guide our interpersonal relationships (Susskind, Lee, Cusi, Feiman, Grabski, & Anderson, 2008).Emotions are fundamental to nursing practice and play a vital role in the interaction with colleagues and patients.It is through the exchange and perception of emotions that nurses and patients initiate, establish, and maintain a therapeutic relationship.Therefore, it is essential that nurses understand and manage their own emotions and are skilled in managing others' emotions.
Nurses face various difficult events and emotions due to the nature of the job itself, which puts them in a vulnerable position (Lee, 2019).Additionally, nurses are expected to control their emotional reactions while calming their patients' distress, show empathy, be always amiable (Ryan & Deci, 2000), express positive emotions, and suppress negative emotions (Glomb & Tews, 2004).Such experiences can be overwhelming, emotionally laborious, and expose nurses to "psychological strain" (Zaghini, Fiorini, Piredda, Fida, & Sili, 2020).When nurses experience such tremendous occupational stress, the motivation to engage in work and serve others lowers, potentially leading to a loss in productivity (Jiang, Jia, Zhang, Li, Song, & Yu, 2021) and ultimately negatively affecting their quality of care (Varghese, George, Kondaguli, Naser, Khakha, & Chatterji, 2021).
In recent years, various emotional well-being components/concepts have garnered the attention of scientists and have been proven to impact a variety of outcomes in healthcare workers such as optimal physical and psychological health, intelligent decision-making, effectively managing workload, burnout and stress (Hotchkiss, 2018), as well as improved ability to care for patients with greater compassion and more sustainably, sensitivity, and empathy and improved interpersonal skills (Søvold, Naslund, Kousoulis, Saxena, Qorondleh, Grobler, & Münter, 2021).One such concept is Emotional Intelligence (EI) which can be defined as an individual's ability to understand others and their own emotions to make intelligent decisions.Previous studies have suggested that individuals with high EI have a set of emotional aptitudes and competencies that enable them to evaluate and regulate their as well as other's emotions (e.g., anger) to reach a variety of adaptive outcomes or emotional states (e.g., motivation) (O'Connor, Hill, Kaya & Martin, 2019).The available literature in Nursing also recognizes EI as a crucial element in providing patient-centred care (Giménez-Espert & Prado-Gascó, 2018), and suggests that nurses with higher EI experiences less professional stress, perform better at work, have better communication skills, are empathetic and solves problems more effectively (Kahraman & Hicdurmaz, 2016).These findings emphasize the importance of EI in nursing.
Intrinsic motivation (IM), self-compassion (SC) and emotional labour (EL) have also been closely linked with EI in the available literature.Nurses with higher emotional regulation skills were found to have high IM (Lelorain, Bachelet, Goncalves, Wortel, Billes, Seillier, Bertin, & Bourgoin, 2018).This suggests that interventions aiming at improving nurses' emotional regulation/EI skills may also improve their IM.

REVISED Amendments from Version 1
The new version of the article is modified according to the comments and suggestions received from the reviewers.In the new version, the investigator has modified the 'introduction section' by covering all the study variables and has tried to make the concepts as clear as possible.After performing a thorough literature review, the investigator has identified a few research gaps which have been addressed in the new version.The research gaps that were identified also inform the need for and importance of conducting this study, especially in India, which has also been addressed in the new version.In the methodology section, information about using a conceptual framework to design the study, the steps taken to control the confounding factors, as well as the information on the recruitment of patients and nurse-in-charges were added.The equation showing the sample size calculation is also corrected.New information such as the type of hospital (study setting) is clarified by providing the necessary details.The new version of this article also provides a detailed description of the process of developing the training program, and a table (Table 2) showing the outline of the training program has been added.It is also clarified in the new text that the training program will only be provided to the eligible and consented staff nurses, and not to patients or nurse-in-charges.The strengths and limitations of the study have also been addressed in the new version of the manuscript.The table showing the timeline of the study (Table 3) and study status is updated and the total duration of the study is included in the text.All the revisions made in the new manuscript followed the reviewers' suggestions.A few grammatical errors were also corrected in the text.No changes were made to the abstract and author list.
Any further responses from the reviewers can be found at the end of the article Kristen Neff (2003) defined SC as being open to and moved by one's suffering, experiencing feelings of caring and kindness toward oneself, taking an understanding non-judgmental attitude toward one's inadequacies and failures and recognizing that one's own experience is part of the common human experience.Neff (2003) also suggests that individuals who are capable of self-compassion are kind to themselves and accept reality, and in doing so hold a balanced awareness of their thoughts and feelings by being emotionally intelligent.Within the nursing literature SC is found to be positively associated with higher EI (Heffernan, Griffin, McNulty, & Fitzpatrick, 2010;Kousar, Kousar, Afzal, Waqasr, & Gilani, 2017;Joseph & Elias, 2019), higher IM (Kotera, Taylor, Fido, Williams, & Tsuda-McCaie, 2021), greater wellbeing (Durkin & Beaumont, 2016), lower compassion fatigue and burnout (Beaumont, Irons, Rayner, & Dagnall, 2016;Dev, Fernando, Lim, Consedine, 2018;Durkin & Beaumont, 2016).
As mentioned earlier, nurses are always in direct contact with patients who are suffering.In this interaction, nurses are always expected to keep a check on their as well as patients' emotions.Pam Smith defined this as emotional labour, which is the act or skills that are involved in caring for and recognizing the emotions of others and not only the emotions experienced by nurses (Freitas, Costa, Diogo, & Gaiva, 2021).Available literature indicates that nurses experience mild to moderate EL, which if remains unchecked, leads to emotional dissonance, emotional exhaustion (Badolamenti, Sili, Caruso, & Fida, 2017), stress and burnout (Delgado, Upton, Ranse, Furness, & Foster, 2017).However, EL is also recognized as an essential characteristic of nurse-patient interaction (Delgado, Upton, Ranse, Furness, & Foster, 2017), and the caring process (Tuna & Baykal, 2017) which helps nurses in establishing and maintaining a trusting relationship with patients (Yeh, Chen, Yuan, Chou, & Wan, 2020).
Despite the obvious emotional element of nurses' work, there remains a dearth of professional acknowledgement and literature on emotional work in nursing practice (Williams, 2013).After performing a thorough literature search, the investigator identified a few research gaps.First, very few studies in the available literature have implemented and tested interventions designed to enhance nurses' emotional intelligence, intrinsic motivation, self-compassion, and emotional labour.Second, studies that have assessed the effectiveness of an intervention to improve nurses' EI, IM, SC and EL for a longer follow-up are very minimal.Third, limited studies have explored the relationship between nurses' EI, IM, SC, and EL.Fourth, although there is enough evidence indicating that nurses' ability to regulate emotions influences the quality of care (Khademi, Abdi, Saeidi, Piri, & Mohammadian, 2021), no previous studies have assessed the perception of nursing care after the nurses underwent emotional-wellbeing training.It was also observed that studies on patients' perception of nursing care are inadequately explored in low-income countries (Gishu, Weldersadik, & Tekleab, 2019;Kewi, Tasema, & Negussie, 2018;Dikmen & Yilmaz, 2017), as well as no studies were found that assessed nurse-in-charges'/ supervisors' perception of nursing care.
Recent studies suggest that more than 87.6% of nurses in India experience stress in their workplace (Bai & Ravindran, 2020).Factors such as work overload, poor staffing, long shift hours, dealing with death and suffering, and rapidly changing technology, lead to increased fatigue, low motivation, increased error (Wu, Zhu, Wang, Wang, & Lan, 2007), excessive anger and worry (Kane, 2009), anxiety and depression (Chaudhury, Mazumdar, & Mehta, 2018).In 2015, the United Nations (UN) Sustainable Development Goals (SDG) defined mental health as a priority for global development for the next 15 years.As the patient population is increasing, with ever-increasing stressors for nurses, it is a need of the moment that mental health and emotional wellness are paid due consideration and are strengthened (WHO, 2022) by using both general and targeted evidenced-based interventions, and by creating and promoting strength-based intervention and preventative programs.Remarkably, studies that focus on improving positive emotions, motivation and behaviors of healthcare workers are rare (vanDorssen-Boog, vanVuuren, DeJong, & Veld, 2021).As EI, IM, SC (Fabio & Saklofske, 2021) and EL are among the many identified primary prevention resources, linked with psychological health and well-being in previous research, interventions aimed at supporting and strengthening nurses' personal and psychological resources would not only aid in enhancing their emotional regulation, emotional well-being, and coping mechanisms, but they may also improve patient care.The investigator of this study has weaved these components of emotional well-being together with the purpose to strengthen them through a training program for promoting a better work-life balance.

AIM
This study's primary aim was to develop, validate, and implement a structured Integrated Emotional-Self Enhancement (IESE) Program among staff nurses and examine the program's impact on the staff nurses' EI, IM, SC and EL, as well as on the patients' and nurse-in-charges' perception of nursing care.

Trial registration
The study is registered in June 2019 under the Central Trial Registry of India (CTRI/2019/08/020592).

Design
The current study has a quasi-experimental (one-group) design, which involves staff nurses working in the general wards of a selected hospital.The present study's design is well suited, keeping in mind the work shifts of staff nurses and the number of staff nurses in the selected hospital.To derive a better understanding of whether intervention on emotional well-being components would affect staff nurses and the perception of patients and nurse-in-charges, the current study has based its concept on Neuman's System Model and King's Interacting Systems Theory to design the conceptual framework.Both of these theories have been proven effective in providing guidance for applying the theoretical understanding to practical clinical nursing situations to improve practice (Montano, 2021;Shanta & Connoly, 2013).

Study site
The study will be conducted in a selected tertiary care hospital in Mangalore, India.This multispecialty hospital has outpatient and inpatient facilities that cater to patient care, teaching, and scientific research.The hospital has approximately a total of 450 staff nurses.The staff nurses have three shift duty hours viz.morning, evening, and night shifts.To maintain the confidentiality of the study participants, the hospital name is not disclosed.

Study participants
The staff nurses working in the selected hospital's general wards, who match the inclusion and exclusion criteria, will be considered as a potential study participant.All the nurses who provide their consent to participate will be considered for recruitment in the study.However, only those who fulfill the inclusion criteria will be included for the final sample.The IESE program will be delivered to all the recruited staff nurses.Also, data about the perception of nursing care will be collected from the patients who are under the direct care of the recruited nurse participants, and from the nurse-in-charges who are supervising the recruited nurses.The program will not be provided to the patients and nurse-in-charges.Table 1 shows the summary of the inclusion and exclusion criteria of study participants.The confounding factors will be controlled by applying an appropriate research design, communicating clearly with the participants and stakeholders, and by making the duty roster of staff nurses well in advance.

Sample size and selection
For the current study, all staff nurses working in the general wards will have the probability of being selected.At a 20% dropout rate, 80% power, SD of 12.3 (taken after feasibility study), and clinically significant difference of 5, it was calculated that approximately 63 staff nurses should be recruited for the current study.However, to reduce the chances of higher attrition due to the unpredictable nature of the hospital environment, the researchers decided to recruite 80 staff nurses.
Table 1.Summary of inclusion and exclusion criteria.

Nurse Nurse-in-charge Patient Inclusion criteria
Staff nurses working in a selected hospital at Mangalore, Karnataka, India.
Nurse-in-charge working in a selected hospital at Mangalore, Karnataka, India.
Patients who are willing to participate.
Staff nurses who are willing to participate in the study.
Nurse-in-charge who are willing to participate in the study.
Patients in the age group of 18-60-years.
Patients who can read Kannada and English.
Patients who are conscious.

Exclusion criteria
Staff nurses with earlier exposure to similar programs.
Nurse-in-charge working in psychiatric units, Outpatient-department, and Intensive Care Units.
Patients with current diagnosis of mental illness.
Patients who are critically ill.
Staff nurses working in psychiatric units, Intensive Care Units, and Out-patient Departments.
Patients who are admitted for less than 3 days.
n = minimum sample size required With 20% drop out rate As nurse-in-charges of all the general wards of the selected hospital will be approached for their consent to participate using complete enumeration, a sample size calculation was not performed.Similarly, a sample calculation was not performed for patients, because only those in-patients who will be receiving care from the recruited staff nurses will be approached for their consent to participate in the study.

Recruitment
For recruiting the participants, first, informed written consent to participate in the study will be collected from the staff nurses working in the selected hospital's general wards.Then, to choose a sample of the consented staff nurses from each general ward, the sample will be matched against the inclusion and exclusion criteria.The nurses who do not fulfil the inclusion criteria will be excluded from the study.
Nurse-in-charges from each general ward will be taken conveniently using complete enumeration.The nurse-in-charges who are supervising the participating staff nurses at the time of data collection will only be considered for recruitment.
If there is a ward from where no staff nurses are taking part, the researcher will exclude the nurse-in-charge and patients from that ward.A written informed consent for participation will be taken before recruiting.
Patients will also be selected conveniently.Only the patients who are receiving care from the staff nurses participating in the study, during the time of data collection, will be selected from each general ward.One patient (who provides their consent) for each nurse will be selected for the study (1:1).As the study is longitudinal, collecting data from the same patient in the in-patient department is very unlikely.Therefore, data from 80 patients will be collected at each (five) contact point, i.e., at baseline, 3-months pre-intervention, and immediately after the intervention, at 3-month, and 6-month follow-up.

Study intervention
The IESE Program was developed by the investigator with the help and collaboration of experts from the field of EI, Human Resource Development, Nursing, and Psychology.The investigators' personal experience working as a mental health nurse and a thorough literature search served as the foundation for need analysis and base for intervention development.Also, before developing the training program, the investigator interacted with a group of nurses from the study setting as well as other hospitals to do a need assessment.The investigator asked them about the factors that induces stress, their emotional experiences and emotional requirements at work, and the ways they handle stressful situations.The investigator also interacted with patients and nurse-in-charges and nursing supervisors of two hospitals to understand what their expectations are from nursing services.This allowed the investigator to identify and understand practices and gaps in real world.By combining the findings from the need assessment, and critical observation the framework of the training program was developed.Drafts of the IESE program was shared among the above mentioned experts several times for their suggestions and modifications were made as suggested before finalizing the content of the program.
The program was also pilot tested among 12 staff nurses in a different setting to establish its credibility and assess its effectiveness.The investigator has also taken a hands-on certificate training course on Emotional Intelligence to gain an understanding of Emotional Intelligence techniques under the supervision of experts in the field of Emotional Intelligence from EquiPoise, Maharashtra, which is a certified Emotional Intelligence training institute in India.
The IESE program does not instruct the nurses on how to feel; rather, it encourages the nurses to reflect on their mental and emotional health.The investigator will deliver the program through lectures, Power Point presentations, group activities, situation analysis, videos, worksheets, and workbooks.A booklet will be given to the participants for future reference.These materials will be applied for a copyright by the authors.Hence, they have not been uploaded to an approved repository yet.
The IESE program components are divided into four sessions.An outline of the sessions is provided in Table 2.
To provide the IESE program without disrupting the work environment of the hospital, the consented nurses will be divided into smaller groups of 5-10, so that the participants engage in the activities of the training program with more efficiency.Each group will be given the same IESE program in similar setting and using similar techniques.Nurses in each group will complete a total of eight hours of training (two hours each day for four days) at the end of the intervention program.If a participant misses any session, he/she will be accommodated in another group to complete the missed session.The sessions will be made flexible and accommodating.The investigator will make sure that the IESE program does not overlap with the staff nurses' daily work schedule and hamper the hospital activities or disturb the patients.The nurse-in-charges, staff nurses, and the nurse-supervisors will be informed many weeks prior to starting the program to effectively make the duty roster.The investigator will collect the e-mail address and phone numbers of the participants, for sending reminders about the sessions, and follow-up.Table 3 shows an overview of the time plan.The project will be implemented from approximately January 2021 to May 2022, with a total duration of 17 months (which includes data collection and intervention implementation).

Study outcomes
Table 4 shows the primary and secondary outcomes, including the measurement.The secondary objectives/outcomes will be measured using the validated questionnaires at five time-points.

Data collection
Data from the staff nurses, patients, and nurse-in-charges will be collected at baseline and 3-month pre-intervention, and immediately after the intervention, at 3-month, and 6-month follow-up by the investigator.Multiple baselines enable an assessment of whether changes occur after or during an intervention, rather than before or as a result of any extraneous  factor (Dundas, Binder, Hansen, & Stige, 2017).The questionnaires will be completed by the participants on the same day.The investigator will always be present with the participants when they fill in the questionnaire and will provide help to understand the questionnaire's statements if needed.All the participants will be given a unique code to maintain confidentiality and to make sure that only the participants who have consented to participate complete the questionnaires.The investigator will collect the questionnaires on completion and store them safely in a folder.The investigator has considered an attrition rate of 20% while calculating the sample size, to account for participants who discontinue the intervention or follow-ups.Also, the investigator will maintain an attendance sheet of the participants.Reminders will be sent, and calls will be made to the study participants about upcoming and missed sessions.

Data collection measures/instruments
The tools will be administered to participants at each time point.The investigator has taken permission from the respective authors for using the standardized tools.All the tools/instruments were chosen for their usefulness and appropriateness to fulfil the current study's objectives.All the standardized instruments have been previously used in health and occupational research.The tools developed by the investigator have been validated by subject experts.Also, feasibility and pilot tests were done to measure the reliability of all the instruments which are to be used in the study.
Demographic variables to be collected are age, gender, education qualification, marital status, type of family, personal annual income, type of job (full time/part-time), and ward/unit.
GENOS EI Inventory (concise version) will be used to assess the staff nurses' EI.The tool focuses upon the measurement of the frequency of typicality with which an individual exhibits EI, and has 31 items across seven dimensions of emotional awareness of self and others, emotional management of self and others, emotional expression, and emotional self-control.
The items are scored on a five-point Likert scale, from 'almost never' to 'almost always'.The test-re-test reliability score of the tool is 0.9 (Palmer, Stough, Harmer, & Gignac, 2009).
The Emotional Labour Scale consists of 15 items with the subscales like duration (1 item), frequency (3 items), intensity (2 items), variety (3 items), surface acting (3 items) and deep acting (3 items).The reliability of the tool is 0.83.Respondents are asked to rate "on an average day at work how frequently" they performed interpersonal behaviours on a 5-point Likert-type response scale (1 = never, 5 = always).The higher the score, the higher the emotional labour (Brotheridge & Lee, 2002).The Perception of nursing care tool is developed by the investigator to assess the patients' and nurse-in-charges' perception of nursing care before and after the intervention program.The tool has ten items that are scored on a Likert scale from "strongly agree" to "strongly disagree".The tool has been validated by experts and translated into Kannada (Local language).The Cronbach's alpha reliability score and Content Validity Index of the tool is 0.93 and 0.87 respectively.

Data management
All the questionnaires are paper-and-pen based.So, the data obtained will be entered manually into Microsoft Excel (version 2306) sheets and SPSS (version 20) and will be stored under a folder with a password.The investigator will rectify the mistake if a participant signs their name or any other identifying information on the questionnaire at the time of data collection.The data will all be stored safely on a secure server for further analysis and reference, and the paper copies will be stored safely for five years after the study's completion.

Statistical analysis
Mean and standard deviation will be used to describe measurement data.Frequencies and percentages will be used to represent count data.Repeated measures ANOVA will be used to analyze the effect of the training program.Chi-square will be used to see if an association between the variables before is after the training program.

Risk monitoring and referral
The current study is safe, considering there are no invasive procedures for the intervention.There are no direct risks associated with taking part in the current study.However, participants may feel uncomfortable or stressed while attending the program or while answering the questionnaires, of which the investigator will be very observant about.Also, in the current pandemic state, the investigator will be very vigilant and cautious of all the norms and regulations to be followed to eliminate the risk of participants getting COVID-19 infection.In any crisis, the participant will be flagged and at once referred for counselling or any other support as needed.During the study, the participants (staff nurses) are needed to attend sessions on IESE program and provide responses in the questionnaires given to them.Before recruiting the study participants, the investigator will provide them with the study's details, including the purpose, details of the program, potential risks, and benefits of being a participant.Similarly, the patients and nurse-in-charges will also be given information in detail about the program and their role in the study.

Ethics and consent
The investigator has received approval from the university ethics committee (Kasturba Medical College and Kasturba Hospital Institutional Ethics Committee, approval number 427/2019; Institutional Ethics Committee Kasturba Medical College, Mangalore, approval number-IEC KMC MLR 08-19/331) in 2019 and has received written permission from the selected hospital authorities to conduct the study.The investigator will provide all the staff nurses, patients, and nursein-charges with a participant information sheet and a written consent form will be collected from the study participants.
The participant information sheet will hold all the details of the study, including the aims, objectives, details about the intervention or absence of it, and the risks and benefits of participating.No one will be forced or compelled to participate in the study.The participants can withdraw from the study at any time during the study without penalty.

Dissemination
The investigator intends to disseminate the study results by publishing in peer-reviewed Scopus indexed journals and present papers at scientific conferences.

Confidentiality and access to data
The study data will be safely stored in a digital format on a secure server for five years after completion of the study.
The raw data will be accessible to only the research team members and will be kept in a password-protected file.However, de-identified data can be made accessible on request.

Discussion
Nurses work in an environment that is always emotionally charged.They work with patients and their families who are most often dealing with demanding situations, emotionally and physically.Being self-aware of one's own emotions, empathizing, having meaningful relationships, and being compassionate are important aspects of professional nursing.
Understanding EI and emotion regulation skills are incredibly significant to the nursing profession because of its nature and the complexities and challenges it brings with it.Many researchers have recommended conducting studies by developing and providing a structured program to enhance nurses' EI, IM, SC and EL.The investigator believes that the intervention program in the study would help enhance the nurses' EI, which would influence their intrinsic motivation and self-compassion, thereby reducing their emotional labor, which would eventually positively impact their professional and personal life, as well as in the patient outcome.

Strengths and Limitations
One of the major strength of this study is that it has used established theories and models to design the conceptual framework that would guide the study.The investigator has also used established theories and models to design the intervention program which improves the credibility of the study.Another strength of this study is using multiple pre-tests and longitudinal post-test data collection method.This would be helpful in indicating the true impact of the IESE Program.However, a major limitation of the study is that there is no control arm in this quasi-experimental study.
The unavailability of similar hospitals in terms of infrastructure, workforce and working schedule did not allow the investigator to select another setting that could work as a control arm.Another limitation could be a higher attrition rate due to the unpredictable nature of any hospital setting.Appropriate measures were taken to control this limitation during the sample size calculation.The investigator will also send reminder e-mails and messages to participants before every follow-up.All limitations can veil the true effect of the program.However, considering the current state of COVID-19 pandemic, where staff nurses and healthcare professionals are scarce in general, and to avoid large gatherings that can put the participants' health at risk, the investigator believes that the current study design and sample size will suffice the study objectives.

Conclusion
The IESE program can have a significant impact on staff nurses' personal and professional lives, which can have a positive effect on the patient care outcome.Such programs on EI and emotional well-being are a need of the hour, as healthcare workers and nurses are facing great stress in the face of COVID-19 pandemic.The findings of the current study will add to the research and development of emotional intelligence training programs among nursing and healthcare professionals.

Study status
The study intervention has been delivered to the study participants.The follow-up data collection was completed in May 2022.
ii.Institutional Ethics Committee: ○ Monitoring study ○ Audit of 6 monthly feedback from the principal investigator ○ Data verification

Protocol amendments
Any modifications to the protocol which may impact on the conduct of the study will be informed and amended by the Institutional Ethics Committee of the current study setting.
The project contains the following extended data: • English PIS (nurses).doc(Participant Information Sheet for nurses) • English PIS (nurse-in-charge).doc(participant information sheet for nurse-in-charge) • English PIS (patients).doc(Participant information sheet for patients) • Socio-demographic proforma (Staff nurses).docx(demographic proforma for staff nurses) • Demographic proforma (nurse-in-charge).docx(demographic proforma for nurse-in-charges) • Demographic proforma (patients).docx(demographic proforma for patients) • Intrinsic Motivation.docx (Intrinsic motivation scale, developed by the investigator) • Nurse Incharge's Perception.docx (nurse-in-charges' perception of nursing care scale, developed by the investigator) • Patients Perception.docx (patients' perception of nursing care scale, developed by the investigator) Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).
Copyright will be applied for the booklet, workbook, and teaching material which will be developed by the investigators, and hence these materials have not been uploaded to the repository yet.

Rafi Alnjadat
Irbid University College, Al-Balqa Applied University, Irbid, Jordan The introduction has a good start, but it loses its logical structure as it progresses.Please rewrite The introduction to cover all study variables. 1.
Identify research gaps by reviewing existing literature.2.
Explain the importance and necessity of doing this study in India.

3.
Method: Although this section is well written, it needs more detailed information.4.
Write the time of project implementation (month/year), the duration of project implementation, and the type of the hospital.

5.
Add more details about the training sessions' development, the title and content of each training session, and the time of each session in a table to this section.In addition, add the content and title of educational programs provided to patients in another table and incharge nurse if so? 6.
Add more on how to control the confounding factors?7.
Explain the sample size for the patients and in-charge nurse.8.
Please highlight the limitations and strengths.9.
In the data collection section: the authors stated that "will be collected at baseline and 3month pre-intervention, and immediately after the intervention".what is the difference between baseline and 3-months pre-intervention?kindly clarify.Reviewer Expertise: Clinical education, neurocognitive science I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
1.The investigator has modified the introduction section and have included all the study variables to make it clearer.
2. Research gaps were found after doing a thorough literature search.This has been added to the background section.
3. After performing a thorough literature search, the investigator found few gaps.One of them was that the author has not found many studies that have weaved emotional wellbeing components of Emotional intelligence, intrinsic motivation, self-compassion and emotional labour to develop and implement a training program for nurses in India.Also, assessing perception of nursing care received by the patients and observed by the nursing in-charges/ supervisors provide a feedback and indication of the quality of care delivered by the nurses.Very few studies are available in the literature which has examined the perception of nursing care from patients and nursing supervisors after administering a training program to staff nurses.The investigator assumes that staff nurses EI, IM, SC & EL will improve after the training program which would reflect on the patients' as well as nursing supervisors' perception of nursing care and would eventually help in improving the staff nurses' emotional well-being as well as patient satisfaction.As the hospital environment is stressful, especially in India where there is a shortage of nursing staff, such training programs may positively impact the staff nurses' emotional wellbeing.
4. The investigator has added a few points to make this section more transparent.5.The selected hospital is a tertiary care hospital in Mangalore, India.This multispecialty hospital has outpatient and inpatient facilities that cater to patient care, teaching, and scientific research.The hospital has approximately a total of 450 staff nurses.To maintain the confidentiality of the study participants, the hospital name is not disclosed.The project was implemented from January 2021 to May 2022, with a total duration of 17 months (this period includes data collection and intervention implementation).(Table 2) is added to the new version which shows the outline of the training program (the content and time of each session).The investigator would like to bring this to the notice that no training program/ intervention will be provided to the patients and/or nurse-in-charges.Data about their perception of nursing care will only be collected before and after staff nurses undergo the IESE Program.

A table
7. The confounding factors were controlled by applying an appropriate research design, communicating clearly with the participants and stakeholders, and by making the duty roster of staff nurses well in advance so that there are lesser chances of overlap and attrition.
8. As nurse-in-charges of all the general wards of the selected hospital will be approached for their consent to participate using complete enumeration, a sample size calculation was not performed.Similarly, a sample calculation was not performed for patients, because only those in-patients who will be receiving care from the recruited staff nurses will be approached for their consent to participate in the study.The details of the recruitment process are provided in the section 2.6-Recruitment.9. the strengths and limitations of this study are highlighted in Section 7 of the new version.10.Multiple baselines enable an assessment of whether changes occur after or during an intervention, rather than before or as a result of any extraneous factor.In the current study, the investigator assumes that at baseline, participants (staff nurses) will have little to no knowledge about the study variables.The investigator also assumes that by the time of the second pre-test, the staff nurses may gather knowledge about the study variables which may act as a bias.Thus, obtaining two pre-tests would help us identify whether there were any changes, as well as help us identify whether the changes in the post-test data are due to the intervention or due to extraneous factors.
Competing Interests: There are no competing interests to declare.The author should explain more about the intervention (integrated Emotional-Self Enhancement (IESE) program among staff nurses.How the content of the training was chosen, and whether the competence of the trainer was examined?Suggestion: I only suggest that since four groups are involved in implementing the intervention, they should use the study's Quasi-experimental Solomon four-group research design.I did not mean the study design is problematic, but it's merely a suggestion to improve the quality of the research design.I was considering that the author had divided the study participants into four groups.If not, the decision is up to the author, and the four-group design may have much trouble.
Salmon's four-group design combines pre-test-post-test design with the control group and posttest design with the control group.However, when we intend to maximize the generalizability of the results of research and on the other hand, there are no clear reasons for the superiority of one of the two pre-test designs -post-test with the control group and post-test with the control group over the other.Salmon's four-group design is a logical choice.
As seen in Figure 5, groups A and B form a pre-test-post-test design with the control group, and groups C and D form a post-test design with the control group.Therefore, Solomon's four-group design is two completely independent studies analyzed in the design as mentioned above.
In comparing the post-test of group A and the post-test of group C, i.e., comparison number 7, the effectiveness of the combination of pre-test and experimental intervention is evaluated.If the comparison of number 7 becomes meaningless, it indicates the lack of adverse effect of familiarity with the test.
If the comparison of number 7 becomes significant, it is because the pre-test directly affected the post-test score (statistical return and familiarity with the test), or it was due to the effect of the pre-test on the experimental intervention.Suppose the difference between the post-test of groups A and B is the same as the difference between the post-test of groups C and D. In that case, there is no room to worry about the effect of the pre-test on the results, but if the differences between C5 and C1 are different, the possibility of the effect of the pre-test or interaction The pre-test (subjects) is presented with experimental intervention.Also, if the difference between post-test group D and B, i.e.C8 comparison, becomes meaningless, the neutrality of the pre-test effect is proven.However, if the mentioned comparison becomes significant, it tells about the major effect of the pre-test on the post-test.Comparing the pre-test of groups A and B with the post-test of group D is one of the most apparent aspects of salmon's four-group design.In the comparison of question C6, the difference between the pre-test of group B and the post-test of group D, becomes significant, it indicates the effect of life events and maturity.
In fact, the effect of maturation or local history between pre-test and post-test can be measured in salmon's four-group design.For example, the occurrence of a specific social-political situation or seasonal changes may cause changes in the scores of the subjects in the post-test.
In the comparison as mentioned above (comparison between the pre-test of groups A and B with the post-test of group D), the effect of maturity factors or life events on the post-test is measured.Maturity and life history factors are only controlled in the pre-test-post-test design with the control group, but in the Salmon design, the effect size of these factors is measured.The significance of the comparison of C3 shows the occurrence of problems in the process of random assignment.Reviewer Expertise: medical education I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.

Monalisa Saikia
Respected Reviewer, Thank you for your suggestions and comments.As per your suggestion, we have added some detail about the IESE program, how it was developed, and the credibility of the investigator to deliver the program to the study participants.
However, your suggestion about using the Solomon Four design will not be applicable in the present study.We apologise, as we think the previous version of the manuscript failed to make this part clearer-there will be only one group of nurses, but, they will be divided into smaller groups of 5-10 members in each group so that the delivery of the training program is effective and the participants can engage in the group activities to learn more efficiently.All the nurses in each group will receive the same training program without any deviation or difference.The study investigator does not plan to make a comparison between the groups.

Best regards.
Competing Interests: There are no competing interests.
The benefits of publishing with F1000Research: Your article is published within days, with no editorial bias • You can publish traditional articles, null/negative results, case reports, data notes and more • The peer review process is transparent and collaborative • Your article is indexed in PubMed after passing peer review • Dedicated customer support at every stage • For pre-submission enquiries, contact research@f1000.com

10 .
Is the rationale for, and objectives of, the study clearly described?YesIs the study design appropriate for the research question?YesAre sufficient details of the methods provided to allow replication by others?PartlyAre the datasets clearly presented in a useable and accessible format?Not applicableCompeting Interests: No competing interests were disclosed.
Reviewer Report 27 July 2022 https://doi.org/10.5256/f1000research.136310.r144719© 2022 Bazrafkan L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Leila Bazrafkan Clinical Education Research Center, Shiraz University of Medical Sciences (SUMS), Shiraz, Iran I think overall the paper is well written and elaborated a robust methodology.Is the rationale for, and objectives of, the study clearly described?Not applicable Is the study design appropriate for the research question?Not applicable Are sufficient details of the methods provided to allow replication by others?Not applicable Are the datasets clearly presented in a useable and accessible format?Not applicable Competing Interests: No competing interests were disclosed.Reviewer Expertise: medical education I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard.Version 1 Reviewer Report 13 July 2022 https://doi.org/10.5256/f1000research.122283.r141764© 2022 Bazrafkan L. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Leila Bazrafkan Clinical Education Research Center, Shiraz University of Medical Sciences (SUMS), Shiraz, Iran Is the rationale for, and objectives of, the study clearly described?PartlyIs the study design appropriate for the research question?YesAre sufficient details of the methods provided to allow replication by others?YesAre the datasets clearly presented in a useable and accessible format?Not applicableCompeting Interests: No competing interests were disclosed.

Table 2 .
Table showing outline of the IESE Program.

Table 3 .
Table showing the timeline of the current study.

Table 4 .
Summary of the study outcomes and measures.The Self Compassion Scale developed by Kristen Neff(Neff, 2003)will be used in the current study.The test-re-test reliability score of the scale is 0.92.The scale has 12 items that are scored on a five-point Likert scale from "almost never" to "almost always".The subscales measure self-kindness, self-judgement, humanity, isolation, and mindfulness.Average self-compassion score of 1-2.5 indicates low self-compassion, 2.5-3.5 indicates moderate, and 3.5-5.0indicates a high level of self-compassion.