Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is an interesting paper to read. Here are a couple of questions and comments that I have. 

Page 4, under objectives of the study: It is not clear how the first and fourth objectives differ from each other. It is also not clear how the second objective differs from the fifth, and the third objective differ from the sixth.

Clarifying these distinctions would improve readability.

It would also be helpful to explain more clearly how the analyses address each of these objectives.

Table 5: It is not clear whether Table 5 includes all the independent variables used in the analysis. If some variables are not shown, the authors may consider providing a complete table.

In addition, it would be helpful to explain why variables such as age, marital status, education, and years of experience were not included in the regression analysis, if that is the case.

Conceptual framework: The manuscript could be strengthened by including a conceptual framework that links sustainability consciousness, moral obligation, green advocacy, and sustained effort (grit). This would help clarify the theoretical basis of the study.

Regulation versus consciousness: It may be useful for the authors to discuss (briefly) how regulatory approaches to influencing nurses’ behavior compare with efforts to enhance nurses’ sustainability consciousness in promoting green practices in hospitals.

 

Author Response

Comment 1:

Page 4, under objectives of the study: It is not clear how the first and fourth objectives differ from each other. It is also not clear how the second objective differs from the fifth, and the third objective differ from the sixth.

It would also be helpful to explain more clearly how the analyses address each of these objectives.

Response:

We would like to clarify that the study includes only three research objectives, and there are no fourth, fifth, or sixth objectives.

The study objectives are as follows:

• To assess nurses’ levels of sustainability consciousness, green advocacy, and work grit in healthcare settings.
• To examine the relationships between sustainability consciousness, green advocacy, and work grit among nurses.
• To determine the predictive role of sustainability consciousness and work grit in explaining nurses’ green advocacy behaviors.

The analyses conducted directly correspond to these objectives. Objective 1 is addressed through Figure 1, which illustrates the levels of sustainability consciousness, green advocacy, and work grit among nurses. Objective 2 is addressed through Table 3, which presents the Pearson correlation matrix among the study variables. Objective 3 is addressed through Table 5, which reports the results of the multiple linear regression analysis predicting green advocacy among nurses.

Comment 2:

Table 5: It is not clear whether Table 5 includes all the independent variables used in the analysis. If some variables are not shown, the authors may consider providing a complete table.

In addition, it would be helpful to explain why variables such as age, marital status, education, and years of experience were not included in the regression analysis, if that is the case.

Response:
Table 5 presents the multiple linear regression analysis conducted to predict green advocacy among nurses. In this model, green advocacy was treated as the dependent variable, while Nurses’ Sustainability Consciousness, Work Grit, age, and educational qualification were included as independent variables. Therefore, all variables entered into the regression model are reported in Table 5, and no independent variables have been omitted.

Variables such as marital status and years of experience were not included in the final regression model because they did not meet the criteria for inclusion (e.g., lack of statistical significance in preliminary analyses).

Comment 3:

Conceptual framework: The manuscript could be strengthened by including a conceptual framework that links sustainability consciousness, moral obligation, green advocacy, and sustained effort (grit). This would help clarify the theoretical basis of the study.

Response:

We add detailed description to enhance conceptual framework that links sustainability consciousness, moral obligation, green advocacy, and sustained effort (grit) as you recommended.

Comment 4:

Regulation versus consciousness: It may be useful for the authors to discuss (briefly) how regulatory approaches to influencing nurses’ behavior compare with efforts to enhance nurses’ sustainability consciousness in promoting green practices in hospitals.

Response:
Thank you for this valuable suggestion. A brief discussion comparing regulatory approaches and sustainability consciousness has been added to the Discussion section.

Reviewer 2 Report

Comments and Suggestions for Authors

General Comments

This manuscript examines the relationships between sustainability consciousness, green advocacy, and work grit among nurses. The topic is relevant to sustainable healthcare and public health. The study provides useful empirical data; however, several methodological and conceptual issues should be addressed to improve rigor and clarity.

Major Comments

Introduction Structure and Study Purpose

The aim, objectives, and research questions are presented as separate subsections, which disrupts the flow of the Introduction. It is recommended to integrate them into the final paragraph of the Introduction and clearly link them to the study’s practical and public health implications. This will improve coherence and alignment with IJERPH standards.

Study Design and Causality
The cross-sectional design limits causal inference. Some statements imply causation.
Revise to emphasize associations only and strengthen limitations.

Theoretical Framework
The manuscript lacks a clear theoretical underpinning.
Incorporate relevant frameworks (e.g., TPB, Social Cognitive Theory).

Measurement of Green Advocacy and results
Green advocacy is the main outcome variable in this study and is used as the dependent variable in the regression analysis. However, its presentation in the Results section is relatively limited compared to other variables.

It is recommended that the authors provide more detailed descriptive statistics for green advocacy (e.g., mean, standard deviation, and distribution levels). If applicable, additional item-level or dimensional information should also be presented. This would improve the clarity and interpretability of the findings and better support the subsequent inferential analyses.

The use of only 3 items may limit validity. Provide justification and discuss as a limitation.

Statistical Analysis
Regression diagnostics (e.g., multicollinearity, assumptions) are not reported. Add VIF/tolerance and model diagnostics.

Author Response

General Comment

This manuscript examines the relationships between sustainability consciousness, green advocacy, and work grit among nurses. The topic is relevant to sustainable healthcare and public health. The study provides useful empirical data; however, several methodological and conceptual issues should be addressed to improve rigor and clarity.

Response:

We sincerely thank the reviewer for this valuable and constructive feedback. We greatly appreciate the recognition of the relevance of our study to sustainable healthcare and public health.

In response to the reviewer’s comments, we have thoroughly revised the manuscript to enhance its methodological rigor and conceptual clarity. Specifically:

• The Introduction has been restructured to improve coherence and to better align the study purpose with its public health implications.
• A theoretical framework has been incorporated to strengthen the conceptual foundation of the study.
• The statistical analysis section has been expanded to include regression diagnostics and assumption testing.
• The presentation of green advocacy has been enhanced through the inclusion of additional descriptive statistics.
• The limitations section has been strengthened to more clearly acknowledge methodological constraints.

We believe that these revisions have substantially improved the overall quality, clarity, and scientific rigor of the manuscript.

Major Comments

Comment1:
The aim, objectives, and research questions are presented as separate subsections, which disrupts the flow of the Introduction. It is recommended to integrate them into the final paragraph of the Introduction and clearly link them to the study’s practical and public health implications.

Response:

We sincerely thank the reviewer for this valuable suggestion. In response, the Introduction has been carefully revised to improve coherence and ensure alignment with IJERPH standards.

Specifically, the aim, objectives, and research questions have been consolidated into a single, cohesive paragraph at the end of the Introduction, rather than presented as separate subsections. Additionally, we have strengthened the connection between the study purpose and its practical and public health implications, with particular emphasis on the role of nurses in promoting environmentally sustainable healthcare practices.

 

Comment2:
The cross-sectional design limits causal inference. Some statements imply causation. Revise to emphasize associations only and strengthen limitations.

Response:

We sincerely thank the reviewer for this important methodological comment. We acknowledge that the cross-sectional design limits the ability to establish causal relationships.

Accordingly, the manuscript has been carefully revised to ensure that all findings are presented as associations rather than causal inferences, and causal language has been avoided throughout the text.

In addition, the Methods and Discussion sections have been updated to explicitly acknowledge this limitation, and the Limitations section has been strengthened to clearly reflect the constraints of the study design.

Comment 3:
The manuscript lacks a clear theoretical underpinning. Incorporate relevant frameworks (e.g., TPB, Social Cognitive Theory).

Response:
We thank the reviewer for this constructive comment. A dedicated Theoretical Framework section has now been incorporated into the manuscript. This section outlines the study’s conceptual foundation using Theory of Planned Behavior and Social Cognitive Theory, highlighting the interrelationships among sustainability consciousness, work grit, and green advocacy.

Specifically, the Theory of Planned Behavior is used to explain how nurses’ attitudes, perceived behavioral control, and professional norms may predict green advocacy behaviors. In contrast, Social Cognitive Theory emphasizes the dynamic interaction of personal, behavioral, and environmental factors in shaping sustained engagement in environmentally sustainable practices.

Comment 4:

Measurement of Green Advocacy and results. Green advocacy is the main outcome variable in this study and is used as the dependent variable in the regression analysis. However, its presentation in the Results section is relatively limited compared to other variables.

It is recommended that the authors provide more detailed descriptive statistics for green advocacy (e.g., mean, standard deviation, and distribution levels). If applicable, additional item-level or dimensional information should also be presented. This would improve the clarity and interpretability of the findings and better support the subsequent inferential analyses.

The use of only 3 items may limit validity. Provide justification and discuss as a limitation.

Response:

Thank you for this insightful comment. Green advocacy has been clearly presented in the Results section, including mean scores, standard deviations, and distribution levels (high, moderate, and low), to enhance clarity and support interpretation of the findings.

Green advocacy was assessed using a three-item scale adopted from a previously validated instrument, which demonstrated good internal consistency in the current study (Cronbach’s α = 0.882). While the scale captures key aspects of advocacy behavior, we acknowledge that the limited number of items may restrict the comprehensiveness of the construct measurement. This limitation has now been added to the Study Limitations section, and future research is encouraged to use more comprehensive measures.

Comment 5:
Regression diagnostics (e.g., multicollinearity, assumptions) are not reported. Add VIF/tolerance and model diagnostics.

Response:
We thank the reviewer for this valuable comment. Regression diagnostics have now been incorporated into the revised manuscript. Specifically, Variance Inflation Factor (VIF) and tolerance values were calculated to assess multicollinearity among predictors, and all values were within acceptable thresholds (VIF < 5; tolerance > 0.2), indicating no evidence of multicollinearity.

In addition, key regression assumptions—including linearity, normality, and homoscedasticity of residuals—were evaluated and confirmed to be satisfied. These details have been added to the Statistical Analysis section and are also referenced in the Results section when presenting the regression model.

Reviewer 3 Report

Comments and Suggestions for Authors

This manuscript explores a highly relevant and innovative intersection between environmental sustainability and nursing professional attributes. By examining the relationships between Sustainability Consciousness, Green Advocacy, and Work Grit, the authors address a significant gap in the literature regarding the role of nursing professionals in driving sustainable healthcare practices. While the study provides valuable insights and utilizes a robust sample size, there are several methodological and presentation-related areas that require further clarification and refinement. The following critique is intended to assist the authors in enhancing the statistical rigor, theoretical depth, and overall clarity of the paper to meet the high standards of international academic publication.

Comments for author File: Comments.pdf

Author Response

We extend our sincere thanks to the reviewer for their valuable and encouraging evaluation of our manuscript. We deeply appreciate their recognition of the study's importance and its contribution to addressing the relationship between environmental sustainability and the characteristics of the nursing profession. In response to the reviewer's constructive feedback, we have thoroughly revised the manuscript to enhance its methodological rigor, theoretical depth, and overall clarity. We believe these revisions have significantly improved the quality of the research and addressed the concerns raised. We thank the reviewer for their valuable comments, which have helped us refine and develop our work.

Comment 1:

The title and abstract are clear, but the results section could be strengthened by including Adjusted R² and standardized coefficients for the significant predictors in the regression analysis. This will help readers easily identify which factor, Work Grit or Sustainability Consciousness, has the greatest influence on nurses’ green advocacy.

Response:
We thank the reviewer for this insightful suggestion. We have now included the Adjusted R² and standardized coefficients (β) for all significant predictors in the multiple linear regression analysis within the Results section. These additions clarify the relative influence of Work Grit and Sustainability Consciousness on nurses’ green advocacy. Table 5 has been updated accordingly to reflect these values.

Comment 2: Introduction and Theoretical Framework
The reason for this study is very clear, especially given how much healthcare impacts the environment.
Linking the UN’s Sustainable Development Goals (SDGs) to nursing is a great touch. To make the
Research Gap even stronger, try to explain more simply why Work Grit matters: while having a
Sustainability Consciousness means a nurse wants to do good, Work Grit is what gives them the staying
power to actually make changes when the hospital environment gets tough.

Response:

We thank the reviewer for highlighting the importance of clarifying the research gap. In response, the Introduction and Theoretical Framework have been revised to better emphasize the role of Work Grit in nursing practice.

Specifically, we clarify that while Sustainability Consciousness reflects a nurse’s intention to engage in environmentally sustainable practices, Work Grit represents the persistence and resilience required to consistently translate these intentions into action, even within challenging hospital environments.

This revision strengthens the study rationale by clearly articulating how the combined influence of these constructs contributes to Green Advocacy among nurses.

Comment3:

Methodology: The study design fits the goals well, and the high reliability of your surveys shows the data is trustworthy. Two things would make this section better:

Broadening the Scope: Since the data comes from only two hospitals, it’s fair to mention that nurses in other regions or private settings might have different experiences.

Clear Scoring: Please explain how you decided what counts as “High”, “Moderate”, or “Low”. Adding a simple reference (like Best’s criteria) helps readers understand how you translated survey scores into these categories.

Response:

We thank the reviewer for these insightful suggestions. The Methodology section has been revised accordingly as follows:

Broadening the Scope: We now explicitly acknowledge that the study was conducted in only two university hospitals in Upper Egypt, which may limit the generalizability of the findings to nurses in other regions, private hospitals, or different healthcare settings. This limitation has been clearly stated in the manuscript.

Clear Scoring: We have clarified the classification of survey scores into “High,” “Moderate,” and “Low” levels. Best’s criteria were applied as a reference for score interpretation, enabling clearer understanding of how responses were categorized. Specifically, scores above 75% were classified as “High,” scores between 50% and 75% as “Moderate,” and scores below 50% as “Low.”

Comment 4:
Moving from simple correlations to a regression model is well-designed, but we need to see the “steps” you took:

Choosing Variables: Mention that you picked variables for the final model based on their performance in the initial correlation (p < 0.20 or 0.25).

The Multicollinearity Check: Since your sustainability measures are closely related (r > .80), please report the VIF values. This proves that your results aren’t being “double-counted”. If the values are too high, consider combining them into one Sustainability Index.

The Approach: Clearly state if you used the “Enter” or “Stepwise” method. This helps show exactly how much extra value Work Grit adds to the equation.

Response:

We thank the reviewer for these valuable suggestions. Variables with p < 0.25 from the initial correlation analysis were selected for inclusion in the regression model. To address the high intercorrelations among the sustainability consciousness dimensions (r > 0.80), we constructed a composite Sustainability Index by averaging the knowingness, attitudes, and behaviors subscales. This approach reduces the risk of multicollinearity while preserving the overall construct of sustainability consciousness.

Regression diagnostics confirmed the absence of multicollinearity (all VIF < 5; tolerance > 0.2). Multiple linear regression using the Enter method was then conducted to assess the unique contribution of each predictor, including Work Grit, to green advocacy. The Statistical Analysis section has been revised accordingly to clearly describe these procedures.

Comment 5: Results
• Table 1: Double-check that all percentages add up correctly.
• Text vs. Images: Instead of using Figure 1, simply describe the levels (High/Low) in the text; it
flows better.
• Simplify: Table 3 should show all six variables clearly. If you do this, you can remove Figure 2
since it tells the same story.
• Terminology: Use a lowercase "n" (e.g., n = 377) for your sample size. The notation for the
sample size should be changed from uppercase 'N' to lowercase 'n' (e.g., n = 377), which is the
standard convention when reporting inferential statistics for a study sample

Response:

We sincerely thank the reviewer for these valuable and constructive comments, which have helped improve the clarity and presentation of the Results section (double-check). Accordingly, the notation for sample size has been revised throughout the manuscript, replacing uppercase “N” with lowercase “n” in line with standard reporting conventions.

Comment 6: Discussion and Practical Implications
The discussion successfully links findings to nursing education and organizational support. Policy-Level: Suggestions should provide more concrete "Green Nursing" policy recommendations. For example, suggesting the inclusion of sustainability metrics in nursing performance appraisals or clinical competency frameworks. Psychological resilience should be discussed Grit not just as a trait, but as a potential area for professional development-suggesting that fostering Grit could simultaneously reduce burnout and increase environmental advocacy.

Response:

We sincerely thank the reviewer for this insightful and constructive comment. We have revised the Discussion and Practical Implications sections to provide more concrete and actionable recommendations.

Comment 7: Study Limitations

It’s always helpful to be open about what the study doesn't cover. Mention that because this was a "snapshot in time" (cross-sectional), we can’t say for certain that Grit causes advocacy, only that they go together. Also, acknowledge that since nurses answered about themselves, they might have been a bit more “green” in their answers than in real life (social desirability bias). Thus, limitations of the study should demonstrate in the last paragraph of the discussion part

Response:

We acknowledge the limitations of this study. First, due to the cross-sectional design, causal relationships between Work Grit and Green Advocacy cannot be established; only associations can be inferred. Second, as the data were self-reported, participants may have overreported environmentally friendly behaviors due to social desirability bias.

These limitations should be taken into account when interpreting the findings and when designing future research.

Reviewer 4 Report

Comments and Suggestions for Authors

Dear Authors,

Please find below the comments and observations regarding your submitted work. We kindly ask you to review and address these points to strengthen the manuscript:

1. It is recommended that the contextual framework established in the introduction—particularly regarding climate change—be explicitly linked to the discussion and conclusion sections. Additionally, please specify which SDGs are directly related to your research.
2. The authors should expand the bibliographic references with more recent and relevant studies. A more robust literature review is essential to enhance the depth of the analysis in the discussion and the validity of the conclusions.
3. As this study relies on self-reported behavioral data, there is a potential risk of response bias (e.g., social desirability bias). It is recommended to explain how this was controlled or to include it as a formal limitation of the study.
4. To ensure optimal transparency and reproducibility, we suggest including the survey instrument (questionnaire) and the individual response data as an appendix or supplementary material.
5. The study fails to demonstrate how nurses' 'sustainability awareness' or 'grit' actually impacts tangible environmental indicators (e.g., carbon footprint reduction, waste management).

Comments for author File: Comments.pdf

Author Response

We sincerely thank the reviewer for these insightful and constructive comments, which have significantly contributed to improving the quality and clarity of our manuscript. We have carefully addressed each point as follows:

1. Linking the contextual framework to discussion and conclusion & specifying SDGs:
   The Introduction, Discussion, and Conclusion sections have been revised to ensure a clearer and more explicit linkage between the climate change context and the study findings. In addition, we have now explicitly identified the relevant Sustainable Development Goals (SDGs) associated with this research, particularly SDG 3 (Good Health and Well-being), SDG 12 (Responsible Consumption and Production), and SDG 13 (Climate Action), and discussed their relevance within the manuscript.
2. Expanding and updating bibliographic references:
   The literature review has been strengthened by incorporating more recent and relevant studies. This enhancement improves the depth of analysis in the Discussion section and supports the validity and contextualization of the study findings.
3. Addressing potential response bias:
   We acknowledge the potential for response bias, particularly social desirability bias, due to the use of self-reported data. This issue has now been explicitly addressed in the Methods and Limitations sections, where we clarify its possible impact on the findings and interpretation.
4. Inclusion of survey instrument and data for transparency:
   To enhance transparency and reproducibility, we have included the survey instrument (questionnaire) as supplementary material. We have also clarified the availability of the dataset in accordance with ethical considerations and institutional policies.
5. Linking constructs to tangible environmental outcomes:
   We appreciate this important observation. While the current study focuses on behavioral intentions and advocacy as proximal indicators of sustainable practice, we have now clarified this scope within the manuscript. The Discussion section has been expanded to acknowledge the need for future research that examines the direct impact of nurses’ sustainability consciousness and work grit on measurable environmental outcomes (e.g., waste reduction and carbon footprint).

The manuscript has been carefully revised to address each comment, as detailed below:

Comment 1: It is recommended to include citations for this statement.
Response:
Thank you for this important suggestion. Appropriate and recent references have been added to support the indicated statement, ensuring that all claims are adequately grounded in the existing literature.

Comment 2: It is recommended to improve the figure.
Response:
We appreciate this suggestion. The figure has been revised to enhance its clarity, readability, and overall presentation. Specifically, labeling, formatting, and visual quality have been improved to ensure better alignment with the journal’s standards and to facilitate interpretation by readers.

Comment 3: Check if this paragraph corresponds to the text.
Response:
Thank you for highlighting this point. The paragraph has been carefully reviewed and removed.

Comment 4: It is recommended to include other research for a corresponding analysis.
Response:
We appreciate this valuable recommendation. Additional relevant and recent studies have been incorporated into the Discussion section to strengthen the comparative analysis and contextualize the study findings within the broader literature. This has enhanced the depth and rigor of the interpretation.

Round 2

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you very much for the update. The content has been fully revised and improved according comments. 

Reviewer 4 Report

Comments and Suggestions for Authors

Thank you for addressing the observations.