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. 2025 Apr 8;20(4):e0321131. doi: 10.1371/journal.pone.0321131

The effect of health-promoting leadership of nursing managers on the work withdrawal behaviors and psychological safety of nurses

Darya Esmaeilbeigi 1, Mahdi Sahraei Beiranvand 2, Fatemeh Mohammadipour 3,*
Editor: Roaa Sabri Gassas4
PMCID: PMC11978039  PMID: 40198648

Abstract

Aim

Health-promoting leadership is a novel organizational strategy aimed at preventing the occurrence of diseases in the workplace and promoting the health needs of staff. The present study aimed to investigate the effect of health-promoting leadership of nursing managers on the nurses’ withdrawal behaviors and psychological safety.

Design

Structural equation modelling was used to verify the conceptual model.

Methods

A total of 346 nurses working in educational hospitals in the western provinces of Iran were included using stratified random sampling by 2023. The research instruments included a checklist of demographic and occupational characteristics, health-promoting leadership, withdrawal behaviors, and psychological safety questionnaires. Pearson’s correlation and structural equation modelling were used to investigate the relationships between the variables. We followed the STROBE Checklist.

Results

The findings showed a significant negative relationship between health-promoting leadership and withdrawal behaviors and a significant positive relationship with nurses’ psychological safety. There was also a negative and significant relationship between the withdrawal behaviors and psychological safety. Health-promoting leadership can explain 45% and 52% of the variance in psychological safety and withdrawal behaviors, respectively.

Conclusions

While emphasizing the importance of leadership styles, the findings of this study indicate that nurse leaders should acknowledge the significance of health promotion leadership as a crucial set of behaviors to foster psychological safety and reduce withdrawal behaviors among nurses, thereby enhancing their quality of care and performance.

Implications for nursing management

The results draw the attention of nursing managers to health-promoting leadership and its relationships, and create an impetus for changing leadership styles and addressing the lack of mutual understanding. Considering this finding, it appears necessary to create clearer prospect for the nursing profession by teaching health-promoting leadership principles to nursing managers and nurses without managerial positions.

Introduction

Health is a critical factor that individuals seek to maintain, and employees desire work environments that promote their well-being [1]. In medical settings, occupational hazards, including extended working hours and chronic stress, negatively impact the health of healthcare personnel, with nurses, as essential members of the health system, being exposed to extensive physical, biological, chemical, psychological, and ergonomic risks [2,3]. Additionally, the recent Covid-19 pandemic has played a prominent role in exacerbating physical and psychological burdens [4]. The healthcare system that purports to protect public health lacks a comprehensive plan to ensure and maintain the health of its staff, which has consequently become a significant challenge [2]. It is evident that neglecting nurses’ health affects healthcare system performance and diminishes quality of care [5]. In other words, leaders who put pressure on nurses to merely perform their duties will not reach their main goal of maximizing productivity [4].

Leadership styles have direct effects on the physical and mental health of staff and significant outcomes, such as the improvement of organizational performance, climate, and promotion of job satisfaction [6]. Health-promoting leadership (HPL) refers to the set of behaviors and experiences of leaders that aim to enhance the work environment and staff health [1,7]. HPL promotes health awareness, values, and health-promoting behaviors and plays an crucial role in fostering a healthy work culture in organizations [8], which ensures a reduction in job burnout, job hazards, and an increase in staff attention to the organization’s goals, ultimately affecting the improvement of the organization’s performance [1]. Indeed, successful HP leaders minimize the dissonance between staff and the environment [9].

The integration between HPL with environmental factors has been more precisely delineated by Jimenez et al. [1]. They identified six areas of work life, including appropriate workload, staff control, reward, values, fairness, and community, along with leaders’ awareness of staff’ health, as HPL components. Leaders who are cognizant of their staff’s health status, participate in related discourses, organize health-promotion programs, and encourage them to participate in these programs have demonstrably healthier staff [1]. It can be inferred that health-promoting leaders instill the understanding that staff are integral to organizations, and that their values are considered congruent with the organization’s values [8]. A previous study in Chinese industries during the Covid-19 pandemic shows that HPL, considering the numerous changes that organizations have implemented in response to the health needs of their staff, remains a guide for improving staff relations and promoting work engagement that has been jeopardized during the pandemic [10].

Work engagement is a key characteristic of any organization in the pursuit of success [11]. Staff with poor work engagement often exhibit withdrawal behaviors, which are a source of substantial organizational losses [12]. Work withdrawal behaviors result from staff members’ decisions to reduce their work participation. Withdrawal behaviors can manifest in physical and psychological forms: psychological withdrawal primarily encompasses diverse forms such as absurd thoughts, communication, pretending to work, misuse of working time, and web surfing; physical withdrawal refers to the creation of opportunities that staff do for short- or long-term physical escape and includes behaviors such as delays, extended breaks, and, in the most extreme case, turnover [13]. Therefore, it is important to address these costly behaviors and evaluate their underlying components [12]. Recent studies have also indicated that occupational hazards can lead to an escalation in withdrawal behaviors [14]. Few studies of withdrawal behaviors in nursing have elucidated the significant role of organizations. Extended working hours and the resultant stress can ultimately lead to job neglect [15]. One of the strategies employed by effective leaders is to cultivate environments where staff experience a sense of security as they believe that committed staff with high psychological safety will demonstrate superior organizational performance [6]. Psychological safety refers to the conditions under which staff feel secure in expressing novel ideas, challenging existing conditions, and accepting risks within the organization [16]. Nurses experience low psychological safety due to daily exposure to mortality, patients with certain diseases, observation of patients’ pain and suffering, psychological burden on patients’ companions, and a shortage of organizational resources [17]. According to previous studies, enhancing psychological safety in healthcare systems has yielded beneficial effects such as reducing burnout and creating a reliable environment for consultation and discussing errors [16]. Although recent studies have reported that psychological safety of nurses is only approximately 30%, which is not only a warning sign for the continuation of the high-quality nursing services in society, but also an indicator of inadequate leadership strategies in this profession [18].

In summary, it can be concluded that there exists a bidirectional relationship between staff health and organization, such that not only does the working environment affect the physical and mental health of staff, but staff health also influences the organization and its performance [3]. Withdrawal from an organization and the shortage of specialized and experienced personnel have directed organizational attentions to issues that affect the health and well-being of staff [19]. Withdrawal from an organization is not only an example of the loss of experienced human resources but also of the diminished desire to participate in work environments, which is known as work withdrawal behavior [13]. The maladaptive behavior of leaders and organizations plays a significant role in creating this disconnection [19]. However, no study has evaluated the relationship between HPL and withdrawal behavior in nursing. Conversely, many studies consider psychological safety as the missing link between different leadership styles and positive organizational outcomes [17], and the leadership style of managers is considered one of the factors affecting the psychological safety of healthcare treatment staff in related studies [18]. However, to date, no studies have been conducted on the relationship between HPL and psychological safety in nursing or other fields.

As HPL is a concept based on the creation of work environments that support the physical and mental health of staff, it has the potential to promote psychological safety and reduce uncivil behaviors, such as job withdrawal. Considering the critical role of nurses in promoting and stabilizing public health, as well as the increasing need to recognize and evaluate the characteristics of leaders and effective leadership styles in nursing, further studies on the effect of HPL on withdrawal behaviors and the psychological safety of nurses are essential.

The results of the present study will provide a deeper understanding of HPL and the studied outcomes and draw the attention of nursing managers to nurses’ health, which is at great risk in the current era. The present study was conducted in a nursing system, which is considered to be one of the most complex and challenging human environments. Structural equation modeling (SEM) was used to test the complex relationships between human variables, which met the objectives of this research. This study aimed to investigate the effect of nursing managers’ HPL on nurses’ withdrawal behaviors and psychological safety.

Method

This descriptive and analytical study utilizes the SEM approach. Using G * power (version 3.1.9.7), we determined that 325 nurses were required to achieve 0.8 power for effect size of 0.03, type 1 error of 0.05, and two predictors. Considering an expected dropout rate of 10%, 357 participants working in educational hospitals in western provinces were recruited by multi-stage stratified sampling. Using this sampling method, the share of each hospital was determined based on the calculated sample size. Then, in each hospital, the share of each department was also determined, and in each department, a random drawing was conducted from the list of nurses in each department, and self-administered questionnaires were provided to the nurses. Finally, 346 valid questionnaires were used in the final analysis. Data collection was done in 2023.

The inclusion criteria were consent to participate in the study, full-time hospital employment, and a minimum of six months of work experience. The exclusion criteria were incomplete completion of the questionnaires, history of a known mental illness, use of anti-anxiety and depression medications, presence of medical problems and chronic diseases. Questionnaires were administered to participants at the beginning of each shift and collected at the end of each shift. To mitigate bias, non-participation and absence of head nurses during the data collection phase were considered.

Instruments

Upon completion of the demographic and occupational information form, nurses were instructed to complete the initial questionnaire regarding their perception of their direct manager’s behaviors, specifically the head nurse of the ward, followed by two subsequent questionnaires pertaining to themselves.

Health-promoting leadership questionnaire (HPLQ).

The HPLQ has been developed by Jimenez et al [1]. This questionnaire consists of 21 items and seven components: workload, control, rewards, community, fairness, values, and health awareness, scored on a seven-point Likert Scale ranging from 0(never) to 6(always). The possible range is 0–162, with higher scores indicating that leaders pay more attention to HPL [1].

Example items of this survey include: “my leader takes care that work does not significantly affect private life” (workload); “my leader takes care that the resources and scope for personal development at work can be influenced”(control); “my leader takes care that work is appreciated” (rewards); “my leader take care that work colleagues support each other”(community); “my leader takes care that all resources are fairly distributed” (fairness); “my leader take care that the employees’ daily activities correspond with the organization’s objectives”(values); and “my leader takes care that all employees are motivated to take care of their health”(Health awareness).

The health-promoting leadership questionnaire was translated and its validity and reliability were assessed by Rashidi et al. [20]. The validity was assessed using confirmatory factor analysis The reliability for all components of this questionnaire was assessed above α = 0.7 using Cronbach’s alpha method.

Work withdrawal behaviors questionnaire.

This questionnaire developed by Hanisch & Hulin [21]. This is a 12-item questionnaire scored on an 8-point Likert scale ranging from 1(never), 2(once a year), 3(two or three times a year), 4(every few months), 5(once a month), 6(more than once a month), 7(once a week), and 8(more than once a week). The possible score range was 12–96, with higher scores indicating more severe withdrawal behavior. In their study, these two researchers reported a Cronbach’s alpha of 0.77. Example items of this survey include: “How likely is it that you will resign from your current job in the next several months”; “How often are you late for work” [22].

This questionnaire was translated, and its validity and reliability were assessed by Arshady et al. [23] The validity of this instrument was determined using confirmatory factor analysis and its reliability was assessed using Cronbach’s alpha (α = 0.88).

Edmonson’s psychological safety.

This is a 7-item questionnaire scored on a 5-point Likert scale ranging from 1(never) to 5(always). The possible score range was 7–35, with higher scores indicating greater psychological safety. The reliability of this questionnaire was assessed using Cronbach’s alpha (α = 0.84). A sample item is: If you make a mistake on your team, is it held against you? [24]. This questionnaire was translated by Hassani& Shohoodi [25], the validity was assessed using confirmatory factor analysis, and its reliability was assessed using Cronbach’s alpha (α = 0.8) [26].

Data analysis method

Quantitative variables were assessed using descriptive statistics and qualitative variables were investigated using frequencies and percentages. SEM establishes the relationship between the measurement model and the structural model based on the assumptions of the conceptual framework. It combines factor analysis and linear regression. Likewise, regression models are additive, whereas SEM is relational in nature, which distinguishes between the regression and SEM decision-making approaches. SEM attempts to justify the acceptance or rejection of a proposed hypothesis by examining the direct and indirect effects of mediators on the relationship between an independent variable and dependent variable [27]. Pearson correlation tests and partial least squares structural equation modeling (PLS-SEM) were used to investigate the relationships between variables. PLS-SEM is a robust statistical methodology extensively employed in the social sciences, including human resource management (HRM) research, to elucidate complex relationships among variables and evaluate sophisticated theoretical frameworks [28]. All statistical tests were performed using SPSS ver.25 and SEM in smart PLS ver.3 software. Statistical significance was set at P < 0.05. Data were screened for respondent misconduct (e.g., multiple or extreme responses). The screening was good, and all responses were considered for the analysis. Initially, the data were controlled for participant characteristics because of their probable relationship with dependent variables. The analysis revealed a nonsignificant association; thus, the model was estimated using the main study variables.

Ethical considerations

In this study, all participants were informed that their involvement was voluntary, and that their privacy was maintained. Prior to completing questionnaires, informed and written consent were obtained. Questionnaires were collected in a single envelope to ensure the confidentiality of nurses’ responses and anonymous data collection.

Ethical approval for the study was granted by the Ethics Committee of the Lorestan University of Medical Sciences with the Ethics Code (IR.LUMS.1401.102).

Results

In total, 346 completed questionnaires were included in the analysis.

The demographic data of the participants are presented in Table 1. The majority of participants were female, married, aged 20–30 years, had 11–20 years of work experience, possessed a bachelor’s degree, and were permanent employees.

Table 1. Nurses’ distribution according to their demographic and work-related characteristics.

Variable Category No. Percent (%) Cumulative percentage (%)
Age(years) 20–30 194 56.1 56.1
31–40 127 36.7 92.8
>40 25 7.2 100
Gender Male 67 19.4 19.4
Female 279 80.6 100
Marriage status Single 163 47.1 47.1
Married 183–52.9 100
Years of work experience 1–10 272 78.6 78.6
11–20 65 18.8 97.4
21–30 9 2.6 100
Type of employment Formal 168 48.5 48.5
Contract basis 40 11.6 60.1
Corporate 25 7.2 67.3
Human resources 113 32.7 100
Education B.SC. 322 93.1 93.1
MSc 24 6.9 100
Working unit ICUs 91 26.3 26.3
CCU 38 11 37.3
Surgical 47 13.6 50.9
Medical 99 28.6 79.5
Emergency Department 38 11 90.5
Pediatrics 33 9.5 100
Number of shifts 1–10 3 0.9 0.9
11–20 136 39.2 40.1
21–30 186 53.8 93.9
31–40 21 6.1 100
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According to the Pearson test (Table 2), there was a significant relationship between all research variables enabling the evaluation of these variables using SEM. The conceptual model’s fit was assessed in two stages: measurement and structural, which are elaborated upon in the subsequent sections.

Table 2. Matrices of correlation coefficients of research variables.

Variables Health promotion leadership Work withdrawal behaviors Psychological safety
Health promotion leadership 1.00 −0.28* 0.527*
Work withdrawal behaviors −0.28* 1.00 −0.19*
Psychological safety 0.527* −0.19* 1.00
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*

p < 0.01.

The standardized regression coefficients of Health-Promoting Leadership (HPL) for psychological safety and withdrawal behaviors were 0.651 and 0.56, respectively. Additionally, the coefficient of determination (R2) of HPL with psychological safety and withdrawal behaviors was 0.45 and 0.52, respectively. This indicates that, HPL could explain 45% and 52% of the variance in psychological safety and withdrawal behaviors, respectively (Fig 1).

Fig 1. Conceptual model of standardized coefficients for health-promoting leadership, work withdrawal behaviors, and psychological safety.

Fig 1

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Fig 2 illustrates the significance of each relationship (arrows). A T-value greater than 1.96 indicates a significant relationship. Consequently, it can be concluded that all relationships are significant. Thus, HPL demonstrates an impact on nurses’ psychological safety and withdrawal behaviors.

Fig 2. T-Value values for health-promoting leadership, work withdrawal behaviors, and psychological safety.

Fig 2

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The Cronbach’s alpha coefficients, composite reliability, and Average Variance Extracted (AVE) were all within the appropriate ranges, confirming the reliability and convergent validity of the external relations of the research model.

Table 3 presents the fit indices of the research model. Based on the obtained values and in accordance with Kok Wah et al. [27], the data collected for measuring the latent variables demonstrated adequate fit. Therefore, the estimation results of the research model can be considered reliable and valid.

Table 3. Goodness-of-fit statistic tests for hypothesis mode.

Variables Acceptable range Observed value Result
SRMR 1 <0.08 0.065 Good fit
d-ULS 2 <0.95 0.155 Good fit
d-G3 < 0.95 0.074 Good fit
NFI 4 >0.50 0.856 Good fit
GOF 5 >0.25 0.284 Good fit
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1standardized root mean squared residual,

2squared Euclidean distance,

3geodesic distance,

4Normed Fit Index,

5Goodness of Fit.

Furthermore, the Q2 (Stone–Geisser) statistic, which represents the predictive fit of the model, yielded values of 0.25, 0.42, and 0.32 for the HPL, psychological safety, and withdrawal behavior variables, respectively. The positive values for these variables indicated an acceptable predictive fit for these constructs. In summary, the results substantiated the conceptual model employed in this study.

Discussion

This study aimed to evaluate the impact of HPL on nurses’ psychological safety and withdrawal behavior. A comprehensive literature review revealed that this evaluation has not been previously conducted in nursing. As this is one of the initial nursing studies to evaluate these components, other relevant studies and concepts analogous to the components investigated in this study were utilized to discuss the results. The findings of the present study showed that HPL explained 45% and 52% of the variance in psychological safety and withdrawal behaviors, respectively. To predict human collisions, the values of the coefficients of determination are typically less than 50%. Human behavior is not as readily predicted as physical performance [29].

The results of the present study showed that HPL had an impact on psychological safety, which is aligns with a study on police officers that suggested a negative relationship between health-oriented leadership and health problems (burnout, depression, and physical problems) [9]. Gorgenyi-Hegyes et al. [4] identified the three dimensions of emotional health, physical health, and the provision of health services by the organization as the primary dimensions of a health-promoting environment, which ensures the achievement of outcomes such as employee loyalty. Other studies have shown that HPL aims to meet the basic psychological needs of staff (including a sense of belonging, competence, and autonomy) by enhancing their level of health knowledge and skills, appropriate workload, and job control, which ultimately reduces emotional fatigue [7]. The results of this study also contribute to the promotion of nurses’ psychological safety by addressing their psychological needs.

Leaders who foster an organizational climate by promoting creative thinking, face-to-face communication, opportunities to discuss errors, and tolerance of interpersonal risks enhance the psychological safety of the healthcare staff [18]. However, nurses’ perceptions of health-promoting leaders pertain to the psychological aspects of the process rather than the physical aspects, such that nurses consider responsibility, promotion of professional capabilities, open communication, and pragmatism as the characteristics of such leaders [30]. The significant effect of safe and healthy working conditions, sense of safety and opportunity for growth, adequate reward, community, work-life harmony on the psychological empowerment of nurses is referenced in the study by Permarupan et al. [31]. They found that these components exhibited a high affinity for the HPL concept. Additionally, the role of establishing open communication, employee participation in decision-making, availability and fair treatment of employee errors, which are among the characteristics of inclusive leadership and are closely related to the principles of HPL, in promoting the psychological safety of nurses are mentioned in Lee et al. [32].

Research on psychological safety, particularly in relation to change-oriented leadership, has been highlighted in several other studies. This leadership style, while emphasizing environmental monitoring, encouraging creative thinking, and envisioning changes, facilitates the improvement of nurses’ psychological safety and team performance. The aforementioned characteristics significantly overlap with the HPL concept, which from the nurses’ perspective encompasses being alert, promoting career progression, establishing open communication, and being pragmatic [30]. The literature review and results of the current study show a significant close relationship between the factors that contribute to the promotion of psychological safety and the improvement of the mental health of staff based on the HPL concept.

The findings also indicate that HPL can explain 52% of the variance in withdrawal behaviors, which aligns with Karimi et al. [15], who posited that creating work environments characterized by equality, positive leader-staff relationships, encouragement, and workload revision are effective in reducing withdrawal behaviors among nurses. It appears that among the organizational components, leader–member relationships are strongly associated with withdrawal behaviors.

HP leaders facilitate increased job satisfaction and work engagement by providing necessary organizational resources and establishing mutually beneficial relationship with staff [7]. This phenomenon was also observed in a study by Aggarwal et al. [12], who determined that leaders capable of establishing positive bidirectional communication with their staff through the enhancement of staff’s psychological capabilities observed lower withdrawal behaviors. A study examining the effect of Machiavellianism on work engagement revealed that managers solely focused on achieving goals through any means, including potentially harming their staff, will not enhance work engagement in contemporary organizations. Consequently, the influence of leadership styles is comprehensible in conjunction with the behavioral characteristics of leaders, which are associated with the human values encompassed in HPL and Yao’s intelligent description, wherein HPL is not just a style but also a set of leadership characteristics [7,33]. However, Liu et al.’s 2021 study revealed that health-promoting leaders serve as a catalyst for promoting work engagement by reducing workload, allocating sufficient organizational resources to each employee, and fostering a sense of value among staff by addressing their health needs. The author references the role of leadership in promoting individual health. In other words, emphasizing personal health values, which are considered an individual’s life capital, is effective approach to elicit cooperation from all organizational staff. Another significant organizational factor related to withdrawal behavior is staff’s perception of leadership styles. For example, Nauman et al. [34] found that an authoritarian leadership style increases the frequency of withdrawal behavior and decreases job performance. The aforementioned study mentions the role of quality of work life, which is closely associated with the HPL concept, in mitigating the detrimental effects of authoritarian leadership. Leadership style exerts numerous effects on staff personality. Song and Lee [13] found that servant leadership style functioned as a mediating factor between the components of active personality and withdrawal behaviors, indicating that employees with an active personality who benefited from servant leadership exhibited withdrawal behaviors less frequently.

Specifically, support, empowerment, and guidance, which are characteristics of servant leadership and are emphasized in HPL, can contribute to the reduction of withdrawal behaviors by adjusting individual characteristics, which is aligns with the results of the present study. However, the results of the study by Houlihan [8] are inconsistent with those of the current study. The findings indicated that leaders who adopted a democratic leadership style reported experiencing withdrawal behaviors more frequently, whereas those who employed an autocratic leadership style reported these behaviors less frequently. This discrepancy can be attributed to differences in the study populations, cultural differences between developing and developed countries, and data collection instruments. In the aforementioned study, only physical withdrawal behaviors such as lateness or leaving the workplace early and extended breaks were investigated, whereas psychological withdrawal behaviors are more complex and extensive than their physical dimensions. That is, staff are physically present in the organization but do not show proper work efficiency. It can also be inferred that the HPL encompasses a more logical form of democratic leadership. Democratic leadership emphasizes the autonomy of the staff and expression of opinions [34]. Indeed, the higher prevalence of withdrawal behaviors in democratic leadership styles compared to autocratic ones can be attributed to the fact that autocratic leadership styles have been practiced in organizations for a long time. However, to implement styles such as democratic leadership, leaders need to be more goal-oriented and possess a better understanding; this goal orientation has reached maturity in the HPL.

Therefore, it can be concluded that there is an increased necessity for HP leaders due to the complex and challenging nature of working in medical environments, particularly in the nursing profession, as well as the shortage of staff. Indeed, healthcare system personnel incur substantial personal costs to save lives and promote public health, often at the expense of their own well-being. In the meantime, HP leaders not only assist in maintain valuable human resources within the healthcare system but also reduce the frequency of withdrawal behaviors by addressing the psychological needs of staff and providing them with psychological safety, which itself is considered a significant organizational challenge. As there have been few studies on HPL in the nursing field thus far, we hope that the current study will garner the attention of researchers and encourage further investigation in the future.

One of the strengths of the present study is that it is the first in the nursing field; therefore, it can contribute to the formation of a conceptual framework in this domain, particularly regarding how HPL can improve performance and aid in retaining valuable and expert nursing staff. One of the major limitations of this study was the self-reported evaluation of the components (questionnaire), which could have influenced the results. Additionally, nurses may be reluctant to report withdrawal behaviors as organizational behaviors; therefore, to mitigate this limitation, each participant was provided with a separate envelope to enclose the completed questionnaires.

Conclusion

The results of the present study revealed the effect of HPL on nurses’ withdrawal behavior and psychological safety. As this is one of the initial first nursing studies to evaluate these the above components, subsequent studies can observe and capture staffs’ perceptions and subconscious behaviors through interviews and experiments to ensure the accuracy of the data.

Implications for nursing management

It is anticipated that the results of the present study will draw the attention of nursing managers to HPL and its positive outcomes, and engender a desire to modify leadership styles that lack mutual understanding. Considering the crucial role of nursing managers in enhancing psychological safety and reducing the frequency of withdrawal behaviors, HPL principles can be incorporated into the continuous curriculum review of nursing managers. In addition, incorporation of the HPL principles in the continuous curriculum for nurses without managerial positions can also facilitate the identification of HP leaders, generate demands for this leadership style among nursing leaders, and contribute to the training of future nursing leaders.

Acknowledgments

This manuscript is extracted form data of research project (the number 2666) approved by Lorestan University of Medical Sciences, Khorramabad, Iran. We wish to thank the Deputy-in-Research of the University, and the nurses who helped us greatly in filling and returning the questionnaires.

Data Availability

Data cannot be shared publicly because of The ethical, confidential, and organizational nature of the variables under investigation. Data are available from the Iran National Committee for Ethics in Biomedical Research (contact via: ethics@behdasht.gov.ir, Phone umber: +982181455618) for researchers who meet the criteria for access to confidential data.

Funding Statement

The author(s) received no specific funding for this work.

References

  • 1.Jiménez P, Winkler B, Dunkl A. Creating a healthy working environment with leadership: the concept of health-promoting leadership. Int J Hum Resour Manag. 2016;28(17):2430–48. doi: 10.1080/09585192.2015.1137609 [DOI] [Google Scholar]
  • 2.Gillet N, Huyghebaert-Zouaghi T, Réveillère C, Colombat P, Fouquereau E. The effects of job demands on nurses’ burnout and presenteeism through sleep quality and relaxation. J Clin Nurs. 2020;29(3–4):583–92. doi: 10.1111/jocn.15116 [DOI] [PubMed] [Google Scholar]
  • 3.Ou Y-K, Liu Y, Chang Y-P, Lee B-O. Relationship between musculoskeletal disorders and work performance of nursing staff: a comparison of hospital nursing departments. Int J Environ Res Public Health. 2021;18(13):7085. doi: 10.3390/ijerph18137085 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Gorgenyi-Hegyes E, Nathan R, Fekete-Farkas M. Workplace health promotion, employee wellbeing and loyalty during Covid-19 pandemic—large scale empirical evidence from Hungary. Economies. 2021;9(2):55. [Google Scholar]
  • 5.Atashzadeh-Shoorideh F, Parvizy S, Hosseini M, Raziani Y, Mohammadipour F. Developing and validating the nursing presence scale for hospitalized patients. BMC Nurs. 2022;21(1):138. doi: 10.1186/s12912-022-00896-0 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 6.Sahraei Beiranvand M, Beiranvand S, Beiranvand S, Mohammadipour F. Explaining the effect of authentic and ethical leadership on psychological empowerment of nurses. J Nurs Manag. 2021;29(5):1081–90. doi: 10.1111/jonm.13246 [DOI] [PubMed] [Google Scholar]
  • 7.Yao L, Li P, Wildy H. Health-promoting leadership: concept, measurement, and research framework. Front Psychol. 2021;12:1–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 8.Houlihan F. Autocratic, democratic and laissez-faire leadership styles: is there a link between these leadership styles and absenteeism/withdrawal amongst millennials? Dublin: National College of Ireland; 2020. [Google Scholar]
  • 9.Santa Maria A, Wolter C, Gusy B, Kleiber D, Renneberg B. The impact of health-oriented leadership on police officers’ physical health, burnout, depression and well-being. Policing: J Policy Pract. 2019;13(2):186–200. [Google Scholar]
  • 10.Liu L, Zhang C, Fang C-C. Effects of health-promoting leadership, employee health on employee engagement: employability as moderating variable. Int J Workplace Health Manag. 2021. doi: 10.1108/IJWHM-10-2020-0135 [DOI] [Google Scholar]
  • 11.Farzi K, Mohammadipour F, Toulabi T, Heidarizadeh K, Heydari F. The effect of blended learning on the rate of medication administration errors of nurses in medical wards. Iran J Nurs Midwifery Res. 2020;25(6):527–32. doi: 10.4103/ijnmr.IJNMR_188_20 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Aggarwal A, Chand PK, Jhamb D, Mittal A. Leader-member exchange, work engagement, and psychological withdrawal behavior: the mediating role of psychological empowerment. Front Psychol. 2020;11:423. doi: 10.3389/fpsyg.2020.00423 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 13.Song C, Lee C. The effect of service workers’ proactive personality on their psychological withdrawal behaviors: a moderating effect of servant leadership. Leadersh Organ Dev J. 2020:ahead-of-print. [Google Scholar]
  • 14.Shaukat N, Ali DM, Razzak J. Physical and mental health impacts of COVID-19 on healthcare workers: a scoping review. Int J Emerg Med. 2020;13(1):40. doi: 10.1186/s12245-020-00299-5 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Karimi L, Leggat SG, Cheng C, Donohue L, Bartram T, Oakman J. Are organisational factors affecting the emotional withdrawal of community nurses?. Aust Health Rev. 2017;41(4):359–64. doi: 10.1071/AH16027 [DOI] [PubMed] [Google Scholar]
  • 16.Grailey KE, Murray E, Reader T, Brett SJ. The presence and potential impact of psychological safety in the healthcare setting: an evidence synthesis. BMC Health Serv Res. 2021;21(1):773. doi: 10.1186/s12913-021-06740-6 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 17.Newman A, Donohue R, Eva N. Psychological safety: a systematic review of the literature. Hum Resour Manage Rev. 2017;27(3):521–35. [Google Scholar]
  • 18.O’donovan R, Mcauliffe E. A systematic review of factors that enable psychological safety in healthcare teams. Int J Qual Health Care. 2020;32(4):240–50. doi: 10.1093/intqhc/mzaa025 [DOI] [PubMed] [Google Scholar]
  • 19.Buerhaus P. Current nursing shortages could have long-lasting consequences: time to change our present course. Nurs Econ. 2021;39(5):247–50. [Google Scholar]
  • 20.Rashidi M. Studying and analyzing the impact of health-promoting leadership on employees’ intention to stay. Career Organ Couns. 2019;11(41):109–34. [Google Scholar]
  • 21.Hanisch K, Hulin C. Job attitudes and organizational withdrawal: an examination of retirement and other voluntary withdrawal behaviors. J Vocat Behav. 1990;37(1):60–78. [Google Scholar]
  • 22.Hanisch KA, Hulin CL. General attitudes and organizational withdrawal: an evaluation of a causal model. J Vocat Behav. 1991;39(1):110–28. doi: 10.1016/0001-8791(91)90006-8 [DOI] [Google Scholar]
  • 23.Arshady N. Designing and testing a model of some outcomes of witnessing workplace incivility. Q Soc Psychol Res. 2018;7(28):23–40. [Google Scholar]
  • 24.Edmondson A. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350–83. [Google Scholar]
  • 25.Hassani M, Shohoodi M. The relationship between Secure-Base Leadership and psychological safety with workaholism dimensions: Orumiye university employees’ perspective. J Exec Manag. 2014;5(10):85–106. [Google Scholar]
  • 26.Faghernejad F, Hassani M. The effect of spirituality on the quality of work life and entrepreneurship as mediated by professional ethics in the staff of Lorestan University. J Pizhūhish dar dīn va salāmat. 2021;6(4):101–16. [Google Scholar]
  • 27.Kok Wah N, Fitriana M, Arumugam T. Assumptions for Structure Equation Modeling (SEM), Normality of Data Distribution Analysis & Model Fit Measures. Normality of Data Distribution Analysis & Model Fit Measures. 2023.
  • 28.Ringle C, Sarstedt M, Mitchell R, Gudergan S. Partial least squares structural equation modeling in HRM research. Int J Hum Res manag. 2020;31(12):1617–43. [Google Scholar]
  • 29.Ogunfowora B. It’s all a matter of consensus: leader role modeling strength as a moderator of the links between ethical leadership and employee outcomes. Hum Relat. 2014;67(12):1467–90. [Google Scholar]
  • 30.Furunes T, Kaltveit A, Akerjordet K. Health-promoting leadership: a qualitative study from experienced nurses’ perspective. J Clin Nurs. 2018;27(23–24):4290–301. doi: 10.1111/jocn.14621 [DOI] [PubMed] [Google Scholar]
  • 31.Permarupan P, Al Mamun A, Samy N, Saufi R, Hayat N. Predicting nurses burnout through quality of work life and psychological empowerment: a study towards sustainable healthcare services in Malaysia. Sustainability. 2020;12(1):388. [Google Scholar]
  • 32.Lee SE, Dahinten VS. Psychological safety as a mediator of the relationship between inclusive leadership and nurse voice behaviors and error reporting. J Nurs Scholarsh. 2021;53(6):737–45. doi: 10.1111/jnu.12689 [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Habiba U, Kausar S, Waqas A, Ullah K. The relationship between ethical leadership and work engagement: Moderation of Machiavellianism. Int J Acad Res Bus Soc Sci. 2019;9(3). doi: insert-doi-here [Google Scholar]
  • 34.Nauman S, Zheng C, Basit AA. How despotic leadership jeopardizes employees’ performance: the roles of quality of work life and work withdrawal. Leadersh Organ Dev J. 2020. [Google Scholar]

Decision Letter 0

Roaa Sabri Gassas

2 Jan 2025

PONE-D-24-49553The effect of health-promoting leadership of nursing managers on the

 work withdrawal behaviors and psychological safety of nursesPLOS ONE

Dear Dr. Mohammadipour,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Feb 16 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're 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.

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Roaa Sabri Gassas

Academic Editor

PLOS ONE

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

Reviewers' comments:

Reviewer's Responses to Questions

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: Yes

Reviewer #2: Partly

**********

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

Reviewer #1: I Don't Know

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: Yes

Reviewer #2: Yes

**********

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

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: No

**********

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: 1.SEM model should be more detailed, such as predecessors if the study of SEM model

2.RESULTS：There should be no such thing as “Zero”. It should be precise to the number of women. The number of women is not shown in Table 1. Please complete.

3.The indicators in the table 2. do not meet the requirements, please check

Reviewer #2: Thank you for the opportunity to review this manuscript. The topic of health-promoting leadership and its association with organizational outcomes is both timely and significant. The study has the potential to contribute meaningfully to the literature; however, I would like to provide some feedback to enhance the clarity, rigor, and interpretability of the manuscript.

General Comments

The manuscript demonstrates substantial effort and commitment to exploring an important area in organizational health research. However, the translation to English has introduced some challenges. Specifically:

1. Language and Terminology:

- The manuscript contains instances of imprecise terminology, phrasing, and redundancy that could potentially mislead readers. For example, terms such as "proven" are not typically used in scientific writing when describing findings from correlational studies. Phrases like "associated with" or "linked to" would be more appropriate in this context.

- The language in the manuscript could benefit from significant refinement to improve readability and avoid ambiguity. I strongly recommend seeking the assistance of a professional English editor familiar with scientific writing to ensure clarity and accuracy.

Specific Comments

1. Study Methodology:

- The manuscript would benefit from additional details about the methodology:

- Effect Size: The choice of an effect size threshold of 0.03. Could the authors elaborate on why this threshold was chosen and how it aligns with the study’s objectives?

- Sampling: It is unclear whether the sample was a convenience sample or selected through other means. Additional information on sampling strategy and its implications for generalizability would strengthen the manuscript.

- Please include a table with descriptive statistics of all study variables including participant demographics.

2. Measurement Instruments:

- The manuscript uses several instruments, but more detail is needed to enhance transparency:

- Health Promoting Leadership Questionnaire: Providing a brief description of this instrument, including sample questions, would help readers better understand the construct being measured. The authors should clarify whether they used the employee-perception component, the leader self-assessment component, or both. Additionally, it would be helpful to specify whom the employees were asked to consider when completing the questionnaire (e.g., head nurse, nurse manager) as different organizations use different nursing leadership structures.

- Work Withdrawal Behaviors Questionnaire: Providing a brief description of this instrument, including sample questions, would help readers better understand the construct being measured.

- Edmonson’s Psychological Safety Questionnaire: Similarly, a brief discussion of this instrument and a few example questions would clarify how psychological safety was operationalized.

3. Findings and Interpretation:

- Some of the conclusions drawn in the manuscript are presented in a causal manner, which is not supported by the study’s design. For example, in the Abstract, the statement: "The results of the present study showed that leaders who put health-promoting leadership on their agenda witnessed positive organizational outcomes, including improved psychological safety and fewer withdrawal behaviors" implies causation which the authors extend to organizational outcomes -- which are not examined as an outcome in this study. As this study appears to be descriptive and correlational, it is more appropriate to describe relationships as associations rather than causal effects. This issue may stem from translation challenges rather than conceptual errors, but it requires correction for accuracy.

Suggestions for Revision

1. Revise language and terminology throughout the manuscript for precision and scientific rigor. Focus on using phrasing consistent with correlational findings.

2. Provide more detail on the methodology, including the rationale for the effect size threshold, sampling strategy, and the use of measurement instruments.

3. Clarify how the Health Promoting Leadership Questionnaire was applied, and specify the target leaders employees were asked to evaluate.

4. Include sample items from the Work Withdrawal Behaviors Questionnaire and Edmonson’s Psychological Safety Questionnaire to enhance understanding of the constructs.

5. Ensure that all findings and conclusions are framed in a way that reflects the study’s correlational nature.

6. Ensure that all findings and conclusions are not extended beyond the study's scope to include outcomes that were not measured (e.g. "positive organizational outcomes,"

Concluding Remarks

This manuscript addresses an important topic and has the potential to contribute valuable insights. I hope the feedback provided here is helpful for the authors in refining their work. I look forward to seeing the revised version and commend the authors for their efforts in conducting and presenting this study.

**********

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: Yes:  guoguo zhao

Reviewer #2: No

**********

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PLoS One. 2025 Apr 8;20(4):e0321131. doi: 10.1371/journal.pone.0321131.r003

Author response to Decision Letter 1

29 Jan 2025

Response to Comments from Editor and Reviewers

Dear Editor

The authors would like to thank reviewers and editor for careful review of our manuscript and providing us with their comments and suggestion to improve the quality of the manuscript. The following responses have been prepared to address all of the reviewers’ comments in a point -by-point fashion. Please note that changes are in Track changes or blue marked in the revised manuscript.

Dear Reviewers

Dear Reviewer 1

Comment 1: SEM model should be more detailed, such as predecessors if the study of SEM model Response to Comment 1: Thank you for your comment . Dear reviewer, due to the length of the “introduction part”, explanations related to SEM model were added in the Methods section, Data Analysis, page 10.

Comment 2: RESULTS：There should be no such thing as “Zero”. It should be precise to the number of women. The number of women is not shown in Table 1. Please complete.

Response to Comment 2: Thanks for your careful review. Dear reviewer we did not have a variable for women in Table 1. In fact, it turned out that Table 1, which was related to demographic information, was accidentally deleted. Based on your comment, the table was added back to the revised file.

Comment 3. The indicators in the table 2. do not meet the requirements, please check

Response to Comment 3: We appreciate the reviewer’ insightful comments and helpful suggestions. We rechecked the table and only in the first part, due to translation errors, the number was typed incorrectly, which we corrected.

Dear Reviewer 2

Comment 1. General Comments

The manuscript demonstrates substantial effort and commitment to exploring an important area in organizational health research. However, the translation to English has introduced some challenges. Specifically:

1. Language and Terminology:

- The manuscript contains instances of imprecise terminology, phrasing, and redundancy that could potentially mislead readers. For example, terms such as "proven" are not typically used in scientific writing when describing findings from correlational studies. Phrases like "associated with" or "linked to" would be more appropriate in this context.

- The language in the manuscript could benefit from significant refinement to improve readability and avoid ambiguity. I strongly recommend seeking the assistance of a professional English editor familiar with scientific writing to ensure clarity and accuracy.

Response to Comment 1: Thank you for your comment. Dear reviewer we used the services of translation agencies to translate the article, and a native editing certificate was attached to the article. However, this time a native Persian-speaking professor also edited the article for content, grammar, and academic accuracy, and the changes are visible in the file with a track changes.

Comment 2. Measurement Instruments:

- The manuscript uses several instruments, but more detail is needed to enhance transparency:

- Health Promoting Leadership Questionnaire: Providing a brief description of this instrument, including sample questions, would help readers better understand the construct being measured. The authors should clarify whether they used the employee-perception component, the leader self-assessment component, or both. Additionally, it would be helpful to specify whom the employees were asked to consider when completing the questionnaire (e.g., head nurse, nurse manager) as different organizations use different nursing leadership structures.

- Work Withdrawal Behaviors Questionnaire: Providing a brief description of this instrument, including sample questions, would help readers better understand the construct being measured.

- Edmonson’s Psychological Safety Questionnaire: Similarly, a brief discussion of this instrument and a few example questions would clarify how psychological safety was operationalized.

Response to Comment 2: Thank you for your comment. All items requested by the reviewer were added to the Method section. Please refer to pages 7-9.

3. Findings and Interpretation:

- Some of the conclusions drawn in the manuscript are presented in a causal manner, which is not supported by the study’s design. For example, in the Abstract, the statement: "The results of the present study showed that leaders who put health-promoting leadership on their agenda witnessed positive organizational outcomes, including improved psychological safety and fewer withdrawal behaviors" implies causation which the authors extend to organizational outcomes -- which are not examined as an outcome in this study. As this study appears to be descriptive and correlational, it is more appropriate to describe relationships as associations rather than causal effects. This issue may stem from translation challenges rather than conceptual errors, but it requires correction for accuracy.

Response to Comment 3: We appreciate the reviewer’ insightful comments and helpful suggestions. The abstract was modified based on the suggestions.

Suggestions for Revision

1. Revise language and terminology throughout the manuscript for precision and scientific rigor. Focus on using phrasing consistent with correlational findings.

2. Provide more detail on the methodology, including the rationale for the effect size threshold, sampling strategy, and the use of measurement instruments.

3. Clarify how the Health Promoting Leadership Questionnaire was applied, and specify the target leaders employees were asked to evaluate.

4. Include sample items from the Work Withdrawal Behaviors Questionnaire and Edmonson’s Psychological Safety Questionnaire to enhance understanding of the constructs.

5. Ensure that all findings and conclusions are framed in a way that reflects the study’s correlational nature.

6. Ensure that all findings and conclusions are not extended beyond the study's scope to include outcomes that were not measured (e.g. "positive organizational outcomes,"

Response to Comment: Thank you for your time and effort. We appreciate the reviewer’ insightful comments and helpful suggestions. We have made all changes suggested by the Reviewer.

Attachment

Submitted filename: RES. to. Reviewer Comments-1.docx

pone.0321131.s001.docx (19.6KB, docx)

Decision Letter 1

Roaa Sabri Gassas

2 Mar 2025

The effect of health-promoting leadership of nursing managers on the

 work withdrawal behaviors and psychological safety of nurses

PONE-D-24-49553R1

Dear Dr. Fatemeh Mohammadipour

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Roaa Sabri Gassas

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

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 #1: All comments have been addressed

**********

2. 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: Yes

**********

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

Reviewer #1: Yes

**********

4. 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: Yes

**********

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

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

**********

6. 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: This study focuses on the impact of health promotion leadership (HPL-RRB- on nurses' psychological safety and work withdrawal behaviThe the topic selection is closely related to the practical needs of the high-pressure environment in the nursing industry, which has important practical value.The author has responded well to my questions.

**********

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 #1: No

**********

Acceptance letter

Roaa Sabri Gassas

PONE-D-24-49553R1

PLOS ONE

Dear Dr. Mohammadipour,

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on behalf of

Dr. Roaa Sabri Gassas

Academic Editor

PLOS ONE

Associated Data

    This section collects any data citations, data availability statements, or supplementary materials included in this article.

    Supplementary Materials

    Attachment

    Submitted filename: RES. to. Reviewer Comments-1.docx

    pone.0321131.s001.docx (19.6KB, docx)

    Data Availability Statement

    Data cannot be shared publicly because of The ethical, confidential, and organizational nature of the variables under investigation. Data are available from the Iran National Committee for Ethics in Biomedical Research (contact via: ethics@behdasht.gov.ir, Phone umber: +982181455618) for researchers who meet the criteria for access to confidential data.

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