The Role of Nurse Managers in Promoting Psychological Safety and Patient Safety Culture in Nursing Teams: A Scoping Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The article, "The Role of Nurse Managers in Promoting Psychological Safety and Patient Safety Culture in Nursing Teams: A Scoping Review," presents a current and important topic regarding the role of nurse managers in shaping psychological safety and patient safety culture in nursing teams.

 

After reading the article, I have the following observations/comments:

Abstract

• The purpose of the article is well-articulated, but it is worth further emphasizing the novelty of the literature review

Introduction

• The introduction contains numerous repetitions of the same content
• The originality of the literature review should be better justified through critical reference to previously published systematic reviews
• A research gap has been identified but requires more convincing justification.
• It is worth more clearly distinguishing between the concepts of psychological safety, patient safety culture, and the role of nursing leadership, as these terms are sometimes used interchangeably

Materials and Methods

• The article search strategy requires more detailed description. It is recommended to include full search strategies for all databases as supplementary material

Results

• Table 2 contains a large amount of information and is difficult to read. It is recommended to simplify it or move some of the data to supplementary material
• The presentation of results occasionally contains elements of interpretation that should be left open for discussion

Discussion

• The authors should be more critical of the limitations of the available scientific evidence
• The impact of organizational, cultural, and healthcare system differences on the generalizability of the results should be discussed in more detail

Conclusions

• Conclusions should be more concise and focus on the most important messages emerging from the review

General comments:

- Bibliographic sources included not in accordance with the style of the MDPI publishing house, font; It is recommended to standardize the entry of bibliographic items in accordance with the applicable MDPI citation style

Author Response

Dear Reviewer,

We thank you for the careful and constructive review of our manuscript. We greatly appreciate the time invested and the valuable suggestions provided. Our point-by-point responses to each of your comments, along with a description of the corresponding changes made to the manuscript, are provided in the attached Response Letter.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

This study is a scoping review examining the roles of nurse managers in ensuring psychological safety. Especially under the changing working conditions following the pandemic, the impact of the "speaking up" culture among nurses on patient safety makes this topic critical. My suggestions are included below:

• Although quality assessment is not mandatory in scoping review protocols, readers will be curious about the "weight of evidence" of the 25 included studies. It would be beneficial for the authors to summarize the methodological diversity of the studies (how many are qualitative, how many are cross-sectional, etc.) with a clearer table.

• The article findings are presented across seven dimensions. However, these sections sometimes feel like a list of literature. The authors need to further synthesize the interaction between managers' competencies and institutional barriers. For example, a deeper answer based on the data should be provided for the question: "How exactly does the high workload barrier hinder or transform a manager's competency in providing feedback?"

• The most significant gap in the article is the lack of a visual Conceptual Framework or Logic Model. An original figure/diagram summarizing the findings as Input (Manager Competencies) -> Process/Mediator (Psychological Safety) -> Output (Patient Safety / Speaking up Culture), while integrating "Barriers" and "Facilitators," would multiply the impact of the article.

• The authors have focused on "relational leadership." However, a more critical approach should be brought to the issue of hierarchical structure and "power asymmetry" in nursing. To what extent is psychological safety sustainable through individual manager effort within a punitive institutional culture? This tension between "institutional constraints" and "individual leadership" should be emphasized more in the discussion section.

• The concepts of "Psychological Safety," "Patient Safety Culture," and "Just Culture" are sometimes intertwined. A brief conceptual clarification (perhaps a small definition box) should be provided regarding how these concepts relate to each other and exactly where the manager stands within these concepts.

• The authors have drawn important implications for nurse managers. However, there is a need for more concrete suggestions for Hospital CEOs and Policy Makers. For example: How can "intra-team psychological safety indicators" be included in the performance evaluation criteria for managers? Which concrete skills found in this article—such as "active listening" and "conflict management"—should manager training programs focus on beyond just theory?

• Overall, the language is academic and professional. However, very long and complex sentence structures should be avoided in the Results sections to enhance readability.

• The study fills a significant gap in the nursing management literature with methodological discipline. If the suggested visual model is added and the critical discussion is deepened, it has the potential to be published in the top journals of the field.

Author Response

Dear Reviewer,

We thank you for the careful and constructive review of our manuscript. We greatly appreciate the time invested and the valuable suggestions provided. Our point-by-point responses to each of your comments, along with a description of the corresponding changes made to the manuscript, are provided in the attached Response Letter.

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

Reviewer Report

Dear Authors,

Thank you for the opportunity to review this well-written and timely scoping review.

The manuscript addresses an increasingly important topic in nursing leadership by synthesizing the available evidence regarding the role of nurse managers in promoting psychological safety and patient safety culture. The topic is highly relevant for nursing management, organizational behavior, and healthcare quality improvement.

The review demonstrates several strengths, including adherence to the Joanna Briggs Institute methodology, registration in the Open Science Framework, use of the PRISMA-ScR reporting guideline, a comprehensive search strategy across multiple databases, and a clear thematic synthesis of the available evidence.

Overall, the manuscript is scientifically sound and contributes meaningful knowledge to the literature. Nevertheless, several methodological and reporting issues require clarification before publication. Most comments relate to methodological transparency, consistency of terminology, cautious interpretation of the findings, and improvement of the discussion of the limitations inherent to scoping reviews.

 

Comments on the Abstract

1. The abstract is well structured and accurately reflects the study objectives and main findings. However, several statements imply stronger evidence than can be supported by a scoping review. Expressions such as "psychological safety functions as a mediating mechanism" should be softened to indicate that the reviewed literature suggests or proposes such relationships rather than demonstrating them.
2. Consider briefly reporting the types of studies included (e.g., predominantly cross-sectional and qualitative studies), allowing readers to better appreciate the level of available evidence.

 

Comments on the Introduction

1. The Introduction provides an excellent overview of psychological safety, patient safety culture, and nursing leadership. However, the literature review could be slightly condensed to improve readability, as several concepts are discussed repeatedly.
2. Although the authors justify the choice of a scoping review, a slightly more explicit explanation of why this methodology was preferred over a systematic review (e.g., conceptual heterogeneity and exploratory objectives) would further strengthen the rationale.
3. Since psychological safety and patient safety culture are complex and overlapping constructs, it would be helpful to include a brief conceptual explanation describing how these constructs differ while interacting with one another.

 

Comments on the Materials and Methods

1. The methodology follows JBI recommendations appropriately. However, greater detail regarding the search strategy would improve reproducibility. Although the supplementary material contains the search strings, the main manuscript could briefly indicate whether both controlled vocabulary (e.g., MeSH terms) and free-text keywords were combined in all databases.
2. The study selection process indicates that two reviewers independently screened studies. Please specify whether inter-reviewer agreement (e.g., Cohen's kappa or percentage agreement) was assessed during screening. Although not mandatory for scoping reviews, reporting reviewer agreement (if assessed) would further enhance methodological transparency.
3. The manuscript states that thematic synthesis was conducted; however, additional details regarding how themes were generated would improve transparency. Please clarify whether coding was performed inductively, deductively, or using a hybrid approach.
4. Since the review includes systematic reviews among the eligible evidence, the authors should briefly explain how overlap of primary studies across reviews was managed during thematic synthesis.
5. Although critical appraisal is not mandatory in scoping reviews, it would be useful to explicitly state that no methodological quality assessment was performed, consistent with JBI guidance.

 

Comments on the Results

1. The PRISMA flow diagram is clear and appropriately presented.
2. Table 2 represents one of the major strengths of the manuscript by providing a concise synthesis of the available evidence. Nevertheless, several categories partially overlap (e.g., "Role of nurse managers", "Facilitators", and "Speaking up"), resulting in some repetition throughout the Results section. Consider reducing redundancy by integrating overlapping concepts.
3. The manuscript reports that most studies originated from the United States and South Korea. A brief discussion regarding the geographical distribution of the evidence would help readers understand the transferability of findings to different healthcare systems.  

 

Comments on the Discussion

1. Overall, the Discussion is comprehensive and well referenced. However, several statements imply causal mechanisms. Expressions such as "psychological safety operates as a mediating mechanism" should be interpreted more cautiously, since the included evidence is largely observational and heterogeneous.
2. The discussion would benefit from a more explicit acknowledgment that the thematic synthesis reflects patterns identified across diverse study designs rather than quantitative estimates of effectiveness.
3. The authors appropriately discuss implications for nursing practice. However, they should distinguish more clearly between conclusions supported by empirical evidence and recommendations derived from theoretical interpretation.
4. The limitations section should be expanded. In addition to the predominance of cross-sectional studies, the authors should acknowledge: substantial heterogeneity in study designs and outcome measures; variability in definitions of psychological safety across studies; possible limitations arising from incomplete coverage of unpublished evidence, which limits interpretation of the strength of the evidence.
5. Future research recommendations are appropriate. The authors could additionally emphasize the need for implementation studies evaluating leadership interventions in real-world clinical settings.
6. The Discussion could more explicitly acknowledge that the included evidence largely reflects observational, qualitative, and conceptual studies, limiting conclusions regarding the effectiveness of leadership interventions.

 

Comments on the Conclusions

1. The conclusions appropriately summarize the main findings. However, several statements remain stronger than warranted by the evidence synthesized in a scoping review.
2. Rather than stating that psychological safety "is a critical operational mechanism" through which nurse managers influence patient safety culture, consider wording such as "appears to be an important mechanism suggested by the current evidence."
3. The recommendation for leadership development programs is highly relevant. Nevertheless, it should be acknowledged that future longitudinal and intervention studies are still required before establishing the effectiveness of specific leadership strategies.

 

Overall Recommendation

This manuscript presents a high-quality scoping review addressing an important and increasingly relevant topic in nursing leadership and patient safety. The review follows established JBI methodology, adheres to PRISMA-ScR reporting standards, and provides a comprehensive synthesis of the current evidence regarding the role of nurse managers in promoting psychological safety and patient safety culture.

The manuscript is well organized, methodologically robust, and offers valuable implications for nursing management, healthcare organizations, and future research. The thematic synthesis represents a particular strength, successfully integrating findings across diverse study designs while identifying important facilitators, barriers, and research gaps.

Nevertheless, several aspects require clarification before publication. These primarily concern improving methodological transparency, providing additional detail regarding the thematic synthesis process, acknowledging the limitations inherent to scoping review methodology, reducing causal language when interpreting observational evidence, and expanding the discussion of methodological limitations.

Addressing these relatively minor issues would further strengthen the methodological rigor, transparency, and overall impact of this review.

Recommendation: Minor Revision

 

Author Response

Dear Reviewer,

We thank you for the careful and constructive review of our manuscript. We greatly appreciate the time invested and the valuable suggestions provided. Our point-by-point responses to each of your comments, along with a description of the corresponding changes made to the manuscript, are provided in the attached Response Letter.

Author Response File: Author Response.pdf

Reviewer 4 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this scoping review entitled "The Role of Nurse Managers in Promoting Psychological Safety and Patient Safety Culture in Nursing Teams: A Scoping Review." This is a relevant and potentially valuable scoping review addressing an important area of nursing leadership. However, several areas require further refinement before the manuscript is suitable for publication. My comments are outlined below.

Title and Abstract 

The title reflects the content and design of the review. The abstract is well structured and summarizes the review appropriately.

Introduction

This section highlights the importance of psychological safety, patient safety culture, and the role of leadership in nursing profession. The progression from psychological safety to patient safety culture is logical, and the research gap is generally well articulated. 

However, the authors state "despite the growing body of evidence on psychological safety, patient safety culture and leadership in healthcare, current knowledge remains fragmented. In particular, the specific contribution of nurse managers to the integrated promotion of psychological safety and patient safety culture within nursing teams is not yet clearly mapped." Please cite previous reviews or studies that explicitly identify this gap in the literature. The authors also should explicitly distinguish how this review differs from previous reviews and what unique contribution it provides.

Methods

The authors use Joanna Briggs Institute guidance and PRISMA-ScR recommendations, which strengthens the methodological rigor of the review. The eligibility criteria are clearly described, and the search strategy appears comprehensive across multiple databases.

However, I several minor methodological issues which need clarification.

First, the authors should clarify how non-English studies were assessed and whether language translation resources were available.

Second, the literature search was conducted on January 20, 2026. This needs justification. Please clarify whether the search was updated prior to manuscript submission to capture recently published studies.

Finally, although critical appraisal is not mandatory for scoping reviews, the authors should acknowledge that the absence of quality assessment limits interpretation of the strength of the evidence.

Results

The PRISMA flow diagram is clearly presented. This section is well-organized.

Discussion

This section is well written. The authors link the review findings with existing literature. 

However, the manuscript would benefit from a dedicated paragraph addressing its novelty and unique contribution to the existing literature. The authors need to explain how this scoping review advances current knowledge beyond previously published reviews. Clearly articulating the novelty would strengthen the rationale and significance of the study.

Additionally, the manuscript lacks a dedicated subsection describing the limitations of the review. The authors should include a list of limitations that may influence the interpretation and generalizability of the findings.

Author Response

Dear Reviewer,

We thank you for the careful and constructive review of our manuscript. We greatly appreciate the time invested and the valuable suggestions provided. Our point-by-point responses to each of your comments, along with a description of the corresponding changes made to the manuscript, are provided in the attached Response Letter.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

I thank the authors for addressing my comments from the first review..
The manuscript has been significantly improved, and most of my concerns have been addressed.

I thank the authors for addressing the comments from the first review. The manuscript has been significantly improved, and most of the concerns raised have been appropriately addressed.

I have only a few minor editorial comments before publication:
1. The article presents the authors' conceptual model (Figure 2). It is worth clearly stating, both in the figure caption and in the discussion, that it is the result of the authors' thematic synthesis and not an empirically validated model.
2. In the Limitations section, it could be further emphasized that the lack of an assessment of the methodological quality of the studies is consistent with scoping review methodology, but also limits the ability to formulate a strength of recommendation. This will avoid any potential reader confusion.
3. The bibliographic references in the text are not included in accordance with MDPI publishing standards.

After taking into account the above minor clarifications, the manuscript will be suitable for publication.

Author Response

Comment 1: The article presents the authors'conceptual model (Figure 2). It is worth clearly stating, both in the figure caption and in the discussion, that it is the result of the authors' thematic synthesis and not an empirically validated model.

Response: Thank you for this valuable suggestion. We agree that the nature of the conceptual model should be made explicit. We have revised both the figure caption and the Discussion section to clarify that the model represents the authors' conceptual interpretation derived from the thematic synthesis of the included studies and should not be interpreted as an empirically validated framework.

 

Comment 2: In the Limitations section, it could be further emphasized that the lack of an assessment of the methodological quality of the studies is consistent with scoping review methodology, but also limits the ability to formulate a strength of recommendation. This will avoid any potential reader confusion.

Response: Thank you for this valuable suggestion. We have revised the Limitations section to clarify that the absence of methodological quality appraisal is consistent with scoping review methodology and that this limits the ability to determine the strength of the evidence or formulate recommendations.

 

Comment 3: The bibliographic references in the text are not included in accordance with MDPI publishing standards.

Response: Thank you for highlighting this issue. We have revised the in-text citations throughout the manuscript to ensure full compliance with MDPI reference formatting requirements.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

I would like to thank the authors for their comprehensive and rigorous responses to the suggestions I provided during the initial evaluation stage. Upon reviewing the revised version of the manuscript, I observe that all requested corrections and additions have been implemented with scientific precision. The authors have not only made textual additions but have also significantly strengthened the conceptual depth and practical potential of the study. The authors have successfully addressed all critical points raised in the reviewer report. With its methodological discipline and the original conceptual framework it offers, the article makes a significant contribution to the nursing management literature. I find the study suitable for publication in its current form.

Author Response

Dear Reviewer,

Thank you very much for your positive evaluation of our revised manuscript. We sincerely appreciate your careful review and your recognition of our efforts to address all the comments and strengthen the scientific quality of the study.

Reviewer 4 Report

Comments and Suggestions for Authors

I have no further comments. 

 

Good luck.

Author Response

Dear Reviewer,

Thank you very much for your positive evaluation of our revised manuscript. We sincerely appreciate your careful review and your recognition of our efforts to address all the comments and strengthen the scientific quality of the study.