Knowledge, Attitudes, and Behaviors of Critical Care Nurses Regarding Environmentally Sustainable Clinical Practice: A Longitudinal Study Protocol and Framework

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

• The manuscript is clear, relevant to the field, presented in a well-structured manner, and covering a very important topic. 
• All of the cited references are recently published and relevant
• The manuscript is scientifically sound, well designed and executed.
• The manuscript’s results are reproducible based on the details given in the Methods section.
• The results are well presented and interpreted. The statistical analysis is appropriate.
• The conclusions are consistent with the evidence and arguments presented.
• The ethics and data availability statements are adequate.

Author Response

Comments 1: 

The manuscript is clear, relevant to the field, presented in a well-structured manner, and covering a very important topic.

All of the cited references are recently published and relevant

The manuscript is scientifically sound, well designed and executed.

The manuscript’s results are reproducible based on the details given in the Methods section.

The results are well presented and interpreted. The statistical analysis is appropriate.

The conclusions are consistent with the evidence and arguments presented.

The ethics and data availability statements are adequate.

Responses 1: 

We sincerely thank Reviewer 1 for the time and care devoted to the evaluation of our manuscript. We greatly appreciate the thoughtful and encouraging assessment, which highlighted the clarity and structure of the work, the soundness of the research design and methods, the relevance of the references, the appropriateness of the analyses, and the coherence between the results and conclusions, as well as the adequacy of the ethical and data availability statements.

Reviewer 2 Report

Comments and Suggestions for Authors

The topic addressed in this manuscript is highly relevant, and the overall analysis is very interesting. The paper provides a detailed and well-structured discussion of green infrastructure strategies, offering a comprehensive overview that is both informative and useful for readers interested in urban sustainability and planning. The report succeeds as a solid review, clearly contextualizing the Belgrade Green Infrastructure Strategy within broader policy, planning, and governance frameworks, and highlighting its potential for scaling and replication

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From a formal perspective, some minor issues should be addressed. In particular, the spacing and formatting in Figure 2 and Figure 4 should be carefully checked and standardized to improve readability and visual clarity. In addition, Figure 2 contains bilingual elements; for consistency with the rest of the manuscript, it is suggested that all figure labels and captions be fully translated into English.

Finally, although the topic itself is not entirely new, the reference list would benefit from an update, incorporating more recent literature to better reflect the latest scientific and policy developments in the field.

Author Response

Comments 1: 

The topic addressed in this manuscript is highly relevant, and the overall analysis is very interesting. The paper provides a detailed and well-structured discussion of green infrastructure strategies, offering a comprehensive overview that is both informative and useful for readers interested in urban sustainability and planning. The report succeeds as a solid review, clearly contextualizing the Belgrade Green Infrastructure Strategy within broader policy, planning, and governance frameworks, and highlighting its potential for scaling and replication

sustainability-4066354-peer-rev…

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From a formal perspective, some minor issues should be addressed. In particular, the spacing and formatting in Figure 2 and Figure 4 should be carefully checked and standardized to improve readability and visual clarity. In addition, Figure 2 contains bilingual elements; for consistency with the rest of the manuscript, it is suggested that all figure labels and captions be fully translated into English.

Finally, although the topic itself is not entirely new, the reference list would benefit from an update, incorporating more recent literature to better reflect the latest scientific and policy developments in the field.

Response 1: 

We thank Reviewer 2 for their time. However, we would like to respectfully note that several aspects of this comment do not appear to pertain to the current manuscript (ID: sustainability-4078282). Specifically, the manuscript focuses on environmental sustainability in intensive care nursing practice and does not address urban sustainability or green infrastructure strategies. In addition, the manuscript includes only one figure (Figure 1), which is fully presented in English, and no Figures 2 or 4 are present. We therefore believe that this comment may refer to a different manuscript. We remain, however, fully available to address any specific comments relevant to the present work.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for inviting me to review this interesting manuscript. The manuscript was well written and the study was properly designed and described with sufficient details. I have a few minor comments as follows:

a. Specific objective #1 should be revised to make it clearer. "To validate the KABQES-ICU" is not clear enough. Presume the objective here is to develop, validate and pretest the KABQES-ICU among ICU nurses. 

b. The authors should consider a baseline data collection before training. The differences between the baseline and immediate post-training scores will show the immediate impact of the training before the long-term impact is measured at 3- and 6-month. 

Good luck with the study and I look forward to reading the findings of this beautiful study.

Author Response

Comments 1: 

Thank you for inviting me to review this interesting manuscript. The manuscript was well written and the study was properly designed and described with sufficient details. I have a few minor comments as follows:

1. Specific objective #1 should be revised to make it clearer. "To validate the KABQES-ICU" is not clear enough. Presume the objective here is to develop, validate and pretest the KABQES-ICU among ICU nurses.
2. The authors should consider a baseline data collection before training. The differences between the baseline and immediate post-training scores will show the immediate impact of the training before the long-term impact is measured at 3- and 6-month.

Good luck with the study and I look forward to reading the findings of this beautiful study.

Response 1: 

We sincerely thank Reviewer 3 for the careful and constructive evaluation of our manuscript and for the positive assessment of the clarity of the writing and the robustness of the study design.

In response to the reviewer’s comments, we have revised Specific Objective #1 to more explicitly reflect the sequential phases of instrument development, pretesting, and psychometric validation of the KABQES-ICU among ICU nurses. This revision has been implemented in the Objectives section of the revised manuscript (Section 3.1, page 6, lines 176–177), which now states: “to develop, pretest, and psychometrically validate the KABQES-ICU among ICU nurses”.

Regarding the suggestion to include baseline data collection prior to the training intervention, we would like to clarify that this component was already incorporated into the study design. Baseline assessment (T0) is conducted before the intervention, followed by immediate post-training assessment (T1) and subsequent follow-ups at 3 and 6 months (T2 and T3). To improve clarity, we have further specified the timing and rationale of these assessments in the Data Collection section (Section 4.5, page 9, lines 335–338), now stating: “Baseline assessment (T0), conducted prior to the training intervention, will serve as the reference point for evaluating both the immediate (T1) and long-term (T2–T3) effects of the sustainability training program”.

Reviewer 4 Report

Comments and Suggestions for Authors

Overall the protocol is very-well described and written. I find the article very close to be published and I've highlighted very few comments. See below:

Abstract - well written, no comments to add

1. Introduction - nicely written, framing the problem perfectly

L.2 comma (,) after “emissions” (same in L.32 after “aspects”, - check also through the manuscript e.g., L.127)

2. Conceptual Framework - nicely described

3. Objectives and Hypotheses

L.170 move “to” in L.170, so that the text writes “The specific objectives are to:

4. Design and Methods - nicely written and stated

5. Discussion - 8. Implications for research and practive

Ok, the discussion is well-written, however you may also have to add a paragraph, in this section or in the next section (6. Limitations - Strengths) on this framework can be applied and to what scale can be applied etc.

 

 

 

 

 

 

 

 

Author Response

Comments 1: Overall the protocol is very-well described and written. I find the article very close to be published and I've highlighted very few comments. See below:

Abstract - well written, no comments to add

1. Introduction - nicely written, framing the problem perfectly

L.2 comma (,) after “emissions” (same in L.32 after “aspects”, - check also through the manuscript e.g., L.127)

2. Conceptual Framework - nicely described
3. Objectives and Hypotheses

L.170 move “to” in L.170, so that the text writes “The specific objectives are to:

4. Design and Methods - nicely written and stated
5. Discussion - 8. Implications for research and practive

Ok, the discussion is well-written, however you may also have to add a paragraph, in this section or in the next section (6. Limitations - Strengths) on this framework can be applied and to what scale can be applied etc.

Response 1: We sincerely thank the reviewer for the overall positive evaluation of the manuscript and for the constructive and detailed comments.

With regard to the minor editorial issues, we have corrected punctuation throughout the manuscript, including the insertion of commas after “emissions” and “aspects” (page 2, lines 2 and 32) and a consistency check across the text. We have also revised the wording in the Objectives section to ensure correct syntax (“The specific objectives are to:” – page 6, lines 175-187).

In response to the reviewer’s suggestion concerning the applicability and scale of the proposed framework, we have added a dedicated paragraph to the Strengths and limitations section (page 15, lines 558-569). This new paragraph explicitly discusses how the framework can be applied at different levels (individual, unit, and organizational) within ICU settings and clarifies the conditions under which it may be adapted to other high-acuity healthcare contexts. These additions aim to improve clarity regarding the potential scope and transferability of the framework without altering its ICU-specific foundation.

Reviewer 5 Report

Comments and Suggestions for Authors

The manuscript presents a methodologically robust, theoretically well-founded, and highly relevant protocol for the emerging field of environmental sustainability in intensive care units. One of its main strengths is the integration of the KAB model with organizational determinants and outcomes at multiple levels (professional, clinical, organizational, and environmental), as well as the use of advanced psychometric and analytical methods. As a suggestion, the authors could consider explicitly addressing, in a final subsection of the Methods or Discussion, potential strategies for future cross-cultural adaptation of the KABQES-ICU instrument, which would further broaden the international impact of the study. However, this suggestion does not compromise the overall quality, clarity, or consistency of the protocol in any way.

Author Response

Comments 1: The manuscript presents a methodologically robust, theoretically well-founded, and highly relevant protocol for the emerging field of environmental sustainability in intensive care units. One of its main strengths is the integration of the KAB model with organizational determinants and outcomes at multiple levels (professional, clinical, organizational, and environmental), as well as the use of advanced psychometric and analytical methods. As a suggestion, the authors could consider explicitly addressing, in a final subsection of the Methods or Discussion, potential strategies for future cross-cultural adaptation of the KABQES-ICU instrument, which would further broaden the international impact of the study. However, this suggestion does not compromise the overall quality, clarity, or consistency of the protocol in any way.

Response 1: We sincerely thank Reviewer 5 for the thoughtful and highly positive evaluation of our manuscript and for the constructive suggestion regarding the future cross-cultural adaptation of the KABQES-ICU. In response, we have added a brief subsection outlining key considerations and strategies for cross-cultural adaptation and validation of the instrument, including standardized translation procedures, cultural adaptation of items, and testing of measurement invariance across different contexts (Section 4.7, page 13, lines 459–470). This addition aims to strengthen the international relevance and future applicability of the instrument without altering the core design of the protocol.

Reviewer 6 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this protocol. The manuscript addresses a timely and clinically relevant challenge. Overall, it is ambitious and well-motivated, with clear potential to contribute practical guidance for implementation in ICUs. My comments below focus on strengthening internal validity and interpretability, conceptual coherence, reproducibility, and methodological specificity to ensure the protocol is robust, transparent, and readily replicable.

Introduction, Conceptual Framework. 

—Psychological safety and organizational well-being are described as moderators in one place and mediators in another. Please make the conceptual model (Figure 1), hypotheses (H4), and text consistent.

Design and Methods.

—If Phase 2 is intended as a single-arm pre-post, please explicitly acknowledge the resulting limitations for internal validity (e.g., susceptibility to secular trends, seasonality, concurrent institutional initiatives, and supply-chain changes) and align causal language with what the design can support.

—Please justify why a comparator is not feasible and describe the concrete design features you will use to strengthen attribution, including how these choices will be reflected in the analysis plan.

—Please complete the description of the intervention according to the TIDieR checklist to improve transparency and replicability.

—Please specify audit frequency and sampling windows, observer training, inter-rater reliability targets, and strategies to reduce Hawthorne effects, including how audit metrics will be standardized (e.g., per patient-day).

Discussion, Expected Contributions

—Please soften causal pathway claims unless the design is strengthened. Reframe to "test hypothesized pathways" or "examine associations consistent with the framework" unless you add a comparator.

Ethics

—Replace "consent to publish this paper" with consent for participation.

Author Response

Comments 1: Thank you for the opportunity to review this protocol. The manuscript addresses a timely and clinically relevant challenge. Overall, it is ambitious and well-motivated, with clear potential to contribute practical guidance for implementation in ICUs. My comments below focus on strengthening internal validity and interpretability, conceptual coherence, reproducibility, and methodological specificity to ensure the protocol is robust, transparent, and readily replicable.

Response 1: We sincerely thank the reviewer for the thorough, methodologically rigorous, and constructive evaluation of our protocol. We greatly appreciate the detailed suggestions aimed at strengthening conceptual coherence, internal validity, transparency, and reproducibility. We have addressed each point below and revised the manuscript accordingly to improve clarity and methodological precision, while maintaining the overall design of the study.

Comments 2: Introduction, Conceptual Framework.

—Psychological safety and organizational well-being are described as moderators in one place and mediators in another. Please make the conceptual model (Figure 1), hypotheses (H4), and text consistent.

Response 2: We thank the reviewer for this important observation and fully agree that conceptual consistency is essential for interpretability and methodological rigor. In response, we conducted a targeted revision to harmonize the conceptual role of psychological safety and organizational well-being across the manuscript, the conceptual model (Figure 1), and the hypotheses. These constructs are now consistently defined as contextual moderators, not mediators, reflecting their role as organizational and relational conditions that shape the extent to which individual-level mechanisms translate into sustainable nursing behaviors over time.

1. Figure 1 caption: we refined the figure caption and its description to explicitly differentiate mediating mechanisms (attitudes and self-efficacy) from contextual moderators (psychological safety and organizational well-being), substituting the generic word “key” with “distinct” (page 3, Figure 1 caption, line 53).
2. Conceptual Framework – Section 2.2 (“Mediating Mechanisms”): we removed wording that incorrectly implied a mediating role for psychological safety and organizational well-being and revised the paragraph to explicitly state that these constructs function as contextual moderators. In the same subsection, we clarified that the mediating mechanisms within the proposed pathway are sustainability-related attitudes and self-efficacy (page 4-5, lines 116-121).
3. Conceptual Framework – Section 2.3.5 (“Environment”): we revised the integrative description of the framework to clearly distinguish between mediating mechanisms and contextual moderators, thereby improving conceptual clarity and narrative coherence (page 5, lines 163-164)
4. Objectives and Hypotheses – Section 3.1 (“Objectives”): we refined the wording of Objective #4 avoiding overly causal phrasing and emphasizing the examination of hypothesized pathways and conditional relationships (page 6, line 183).
5. Objectives and Hypotheses – Section 3.2 (“Hypotheses”): we revised the wording of H4 to reflect moderation rather than mediation, aligning the hypothesis with the conceptual framework and the intended analytical approach (page 6, lines 197-198).
6. Data analysis – Section 4.6: we aligned the analytical description, accordingly, specifying that mediation analyses pertain to changes in sustainability-related knowledge, attitudes, and self-efficacy, whereas psychological safety and organizational well-being are examined as moderators of the longitudinal relationships (page 12, lines 424-430).

Comments 3: Design and Methods.

—If Phase 2 is intended as a single-arm pre-post, please explicitly acknowledge the resulting limitations for internal validity (e.g., susceptibility to secular trends, seasonality, concurrent institutional initiatives, and supply-chain changes) and align causal language with what the design can support.

—Please justify why a comparator is not feasible and describe the concrete design features you will use to strengthen attribution, including how these choices will be reflected in the analysis plan.

Response 3: We thank the reviewer for this important methodological comment. We would like to clarify that Phase 2 is not designed as a single-arm pre–post study, but as a quasi-experimental controlled longitudinal pre–post study including a comparison group of ICU nurses from different hospitals who do not receive the intervention. The manuscript has been revised to explicitly describe this design (page 7, lines 236-246) and to clarify how the inclusion of a comparator group strengthens internal validity by enabling the examination of differential changes over time between groups (page 7, lines 251-256).

Random assignment was not feasible due to organizational and operational constraints related to hospital-level implementation. We have also acknowledged that, despite the inclusion of a comparison group, the quasi-experimental design remains susceptible to potential confounding factors, such as baseline differences between hospitals and concurrent organizational or policy changes.

To strengthen attribution, the study incorporates repeated measurements at multiple time points, longitudinal modeling of within- and between-group change, adjustment for relevant contextual variables, and the integration of objective audit-based indicators alongside self-reported measures. The analysis plan has been aligned accordingly, emphasizing group-by-time interaction effects consistent with the proposed conceptual framework. In line with this strengthened design and analytic approach, Hypothesis H6 has been reworded to avoid definitive causal language and to explicitly refer to support for hypothesized pathways rather than confirmation of causal effects (page 6, lines 205-206).

Comments 4: —Please complete the description of the intervention according to the TIDieR checklist to improve transparency and replicability.

Response 4: We thank the reviewer for this valuable suggestion and fully agree that a structured and transparent description of the intervention is essential to enhance reproducibility. In response, we have revised the Methods section by introducing a dedicated subsection entitled “Description of the intervention”, explicitly aligned with the TIDieR checklist (pages 8-9, lines 306-332).

As part of this revision, we also removed a previously included descriptive paragraph detailing intervention duration, session structure, delivery format, and faculty composition (pages 7-8, lines 257-269). This information was reorganized and streamlined within the new TIDieR-aligned subsection to avoid redundancy and to ensure a clearer, more standardized presentation of the intervention components.

The revised subsection now systematically reports the intervention rationale, materials, procedures, mode and setting of delivery, providers, intensity and duration, planned tailoring, and fidelity monitoring, thereby improving transparency and replicability without altering the content or objectives of the intervention.

Comments 5: —Please specify audit frequency and sampling windows, observer training, inter-rater reliability targets, and strategies to reduce Hawthorne effects, including how audit metrics will be standardized (e.g., per patient-day).

Response 5: We thank the reviewer for this helpful and constructive comment. In response, we have expanded the Data collection section to provide a clearer and more detailed description of audit procedures (page 10, lines 374-384).

Specifically, we now specify the timing of audit-based data collection and the use of standardized sampling windows, describe observer training procedures and inter-rater reliability assessment during pilot audits, clarify how audit metrics will be standardized (e.g., per patient-day or per procedure), and outline strategies implemented to minimize potential Hawthorne effects, including integrating audits into routine clinical activities and separating observers from intervention delivery and outcome assessment.

These additions were made to enhance methodological transparency and reproducibility without altering the overall study design or increasing participant burden.

Comments 6: Discussion, Expected Contributions

—Please soften causal pathway claims unless the design is strengthened. Reframe to "test hypothesized pathways" or "examine associations consistent with the framework" unless you add a comparator.

Response 6: We thank the reviewer for this important comment. Following the clarification and strengthening of the study design described in response to the previous comment, Phase 2 is now explicitly framed as a quasi-experimental controlled longitudinal study with a comparison group. In light of this strengthened design and the careful alignment of the analytical strategy with the conceptual framework, we verified the Discussion section and confirmed that causal claims were already appropriately framed.

Accordingly, no further modifications to the Discussion were deemed necessary, as interpretations are consistently expressed in terms of hypothesized pathways, associations, and differential changes over time, rather than definitive causal effects.

Comments 7: Ethics

—Replace "consent to publish this paper" with consent for participation.

Response 7: We thank the reviewer for pointing this out. The Informed Consent section has been revised to clarify that written informed consent will be obtained from all participants prior to their participation in the study, rather than for publication (page 16). In addition, a dedicated paragraph on Ethical considerations (page 13, section 4.8) has been added to the Methods section to explicitly report Ethics Committee approval and key ethical safeguards.