The Relationship Between Stress of Conscience and Quiet Quitting in Nurses: The Mediating Role of Compassion Fatigue

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

In section 4 (“Discussion”), the first paragraph is literally the MDPI template text (“Authors should discuss the results and how they can be interpreted...”), without having replaced it with their own text. This template paragraph should be deleted entirely and the beginning of the Discussion should be rewritten with a brief summary of the main findings, a systematic comparison with previous studies, practical and theoretical implications, and limitations and future directions.

The Discussion refers to “H1 hypothesis accepted,” “H2,” “H3,” but the Introduction/Methodology never explicitly formulates the hypotheses. A brief section such as “Study aims and hypotheses” should be added at the end of the Introduction, and consistency of nomenclature (H1, H2, H3) between the Introduction, Methods, and Discussion should be ensured.

The study is cross-sectional, but throughout the text there is talk of “mediating role,” “effect,” “leads to an increase,” etc., as if there were proven temporality or causality, for example: “Stress of Conscience led to an increase in compassion fatigue scores by 0.406 units...” (Abstract) or “conscience stress exerts a positive influence on quiet quitting...” (Results/Discussion). In a cross-sectional design, one can only speak of statistical associations and “indirect effects,” not actual cause and effect. The following should be done: soften the language throughout the manuscript (replace “led to,” “increased,” “exerts an influence” with “was positively associated with,” “showed an indirect effect consistent with...”), explicitly add in Limitations that the cross-sectional design does not allow for establishing causality or the temporal direction of the effects, and rewrite the Conclusion so that it does not sound causal, but associative.

They perform EFA and CFA on the same sample (n=205) and present it as complete validation. For a journal such as Healthcare, this is acceptable but must be argued and the limitation acknowledged. Standardized factor loadings are not reported in the text (they are only seen in the table/figure). Indices such as AVE or composite reliability are not provided, and “language validity” is mentioned in a somewhat confusing manner. It should be acknowledged in Limitations that EFA and CFA were performed on the same group and that validation on an independent sample would be desirable. It should be clearly specified in Methods that the same 205 subjects were used for EFA and CFA and the type of rotation used in the EFA. Change the term “language validity” to something like “cross-cultural adaptation and content validity.”

There are numerical inconsistencies. The text states: “the mean QQS total score was 2.29 ± 0.80,” while Table 3 shows 2.48 ± 0.65 for the QQS, and the Abstract gives coefficients of 0.406 and 0.004 without clarifying that they are standardized betas/regression coefficients, which is confusing and adds little value. Please review and correct all mean figures, SDs, and coefficients so that they match exactly between the text, tables, and abstract. In the abstract, replace very small coefficients (0.004) with more interpretable phrases.

In several places, the design is described as a “descriptive, correlational, and methodological study.” This mixes two different objectives: the adaptation and validation of an instrument (QQS, methodological part) and a correlational/mediational study in nurses. It should be clarified in the Introduction and Methods that the study has two objectives: to adapt and validate the QQS into Turkish and to analyze the relationship between conscientiousness stress, compassion fatigue, and quiet quitting, and the mediating role of compassion fatigue. The Methods section should also be restructured into two clear sub-phases: “Phase 1: Adaptation and psychometric validation of the Quiet Quitting Scale and Phase 2: Cross-sectional analysis and mediation model.”

Terminological inconsistencies. Sometimes they use “Stress of Conscience,” other times “conscience stress.” Sometimes “quiet quitting,” other times “silent resignation,” and in Table 2 it says “Lack of motivation” (typo). Terminology should be standardized, such as “Stress of conscience” (all lowercase, except at the beginning of a sentence), “Quiet quitting” always; eliminate “silent resignation” and correct “Lack of mativation” → “Lack of motivation.”

It only states that participants volunteered and that people on sick leave/leave of absence were excluded. However, it is unclear whether the 10 nurses from the pilot study were included in the final sample or not, and for STROBE it is customary to specify the flow more clearly: eligible, included, did not respond, etc. Inclusion criteria should be explicitly defined (e.g., “registered nurses providing direct patient care in X hospital during the data collection period”), it should be clarified whether the 10 from the pilot study are included in the 205 or not, and a sentence should be added with the flow: how many nurses were eligible, how many refused, how many were excluded, and why.

Methods mentions bootstrapping of 5,000 samples, but does not specify whether the CIs are 95% and whether they are bias-corrected, and Table 5 shows “β (Lower; Upper)” without stating that it is a 95% CI. The Methods section should clarify that “Indirect effects were tested using bootstrapping with 5,000 resamples and 95% bias-corrected confidence intervals.” And in Table 5, indicate in the footnote that the parentheses are 95% CIs.

The last sentence of the abstract states: “Stress of Conscience alone is not effective in reducing quiet quitting...” as if stress of conscience were an intervention. The final part of the Abstract and Conclusions should be rewritten and 2–3 sentences with practical recommendations (organizational support, compassion fatigue prevention programs, etc.) should be added.

Comments on the Quality of English Language

It is quite clear that the manuscript needs professional linguistic revision because there are long and unnatural sentences, minor grammar and punctuation errors, and some imprecise expressions (“language validity,” “inability,” etc.). A thorough review of the English by a native speaker or professional editing service should be conducted before acceptance.

Author Response

Dear Reviewer,

Thank you for your constructive and detailed feedback, which you have provided by taking the time to review. In line with your comments, the article has been thoroughly reviewed and all necessary revisions have been made. Specifically, expressions with causal connotations have been reorganized using more relational language, and the Discussion section has been restructured to include the main findings, comparisons with previous studies, theoretical and practical implications, limitations, and future research directions. The theoretical foundation of the study has been strengthened within the framework of Moral Distress Theory and the Job Demands-Resources (JD-R) Model. Furthermore, methodological explanations regarding the scale adaptation process have been clarified, psychometric limitations have been explicitly stated, and the abstract and conclusion sections have been revised with practical recommendations. We believe your contributions have enhanced the scientific quality of the study, and we thank you again for your valuable feedback.

Sincerely.

Comment 1: In section 4 (“Discussion”), the first paragraph is literally the MDPI template text (“Authors should discuss the results and how they can be interpreted...”), without having replaced it with their own text. 

Response 1: Dear reviewer, thank you very much for your evaluation. The relevant section has been deleted.

Comment 2: This template paragraph should be deleted entirely and the beginning of the Discussion should be rewritten with a brief summary of the main findings, a systematic comparison with previous studies, practical and theoretical implications, and limitations and future directions.

Response 2: Dear reviewer, the discussion section of the study has been revised in line with your suggestions.

Comment 3: The Discussion refers to “H1 hypothesis accepted,” “H2,” “H3,” but the Introduction/Methodology never explicitly formulates the hypotheses. A brief section such as “Study aims and hypotheses” should be added at the end of the Introduction, and consistency of nomenclature (H1, H2, H3) between the Introduction, Methods, and Discussion should be ensured.

Response 3: Dear reviewer, in line with your suggestions, the following statements have been added to the end of the introduction.  Study aims and hypotheses This study aims to explore the mediating role of compassion fatigue in the relationship between stress of conscience and quiet quitting in nurses. The hypotheses of the study are as follows: H1. There is a significant positive relationship between stress of conscience and compassion fatigue. H2. There is a significant positive relationship between stress of conscience and quiet quitting. H3. Compassion fatigue partially mediates the relationship between stress of conscience and quiet quitting.

Comment 4: The study is cross-sectional, but throughout the text there is talk of “mediating role,” “effect,” “leads to an increase,” etc., as if there were proven temporality or causality, for example: “Stress of Conscience led to an increase in compassion fatigue scores by 0.406 units...” (Abstract) or “conscience stress exerts a positive influence on quiet quitting...” (Results/Discussion). In a cross-sectional design, one can only speak of statistical associations and “indirect effects,” not actual cause and effect. The following should be done: soften the language throughout the manuscript (replace “led to,” “increased,” “exerts an influence” with “was positively associated with,” “showed an indirect effect consistent with...”), explicitly add in

Response 4: Dear reviewer, thank you for your valuable feedback. As the reviewer noted, our study has a cross-sectional design, and therefore, making causal or temporal inferences is not methodologically appropriate. Accordingly, all expressions implying causality in the revised text have been carefully reviewed and corrected. In particular, expressions such as “led to,” “caused an increase,” and “shows an effect” have been replaced with more cautious language, more appropriate to the cross-sectional research design, such as “found to be positively related,” “statistically significant relationship was found,” and “showed a significant indirect effect.” Furthermore, the expression “mediating role” has been addressed in the context of “statistically significant indirect effect” or “partial mediation” to more accurately reflect the methodological limitations of the study. With these adjustments, we believe that the language used throughout the text has been brought into line with the cross-sectional design and that the findings of the study are interpreted only at the relational level.

Comment 5: Limitations that the cross-sectional design does not allow for establishing causality or the temporal direction of the effects, and rewrite the 

Response 5: Dear reviewer, due to the cross-sectional design of the study, the following statement has been added to the limitations section: "Secondly, the cross-sectional design of the study does not allow for determining causality and the temporal aspect of the effects."

Comment 6: Conclusion so that it does not sound causal, but associative.

Response 6: Dear reviewer, the conclusion section has been revised to be less causal.

Comment 7: They perform EFA and CFA on the same sample (n=205) and present it as complete validation. For a journal such as Healthcare, this is acceptable but must be argued and the limitation acknowledged.

Response 7: Dear reviewer, in line with your suggestions, the following statement has been added to the limitations section of the study: "However, a significant limitation of this study is that the EFA and CFA of the QQS scale were performed on the same sample. Future research suggests that EFA and CFA should be conducted on independent samples to more strongly validate the factor structure of the scale."

Comment 8: Standardized factor loadings are not reported in the text (they are only seen in the table/figure). 

Response 8: Dear reviewer, standardized factor loadings have been added to the text.

“Standardized factor loading indicates how strongly a scale item relates to its latent variable. Standardized factor loadings were found to be between 0.48 and 0.77 for the Detachment dimension, between 0.50 and 0.77 for the Lack of Initiative dimension, and between 0.82 and 0.84 for the Lack of Motivation dimension.”

Comment 9: Indices such as AVE or composite reliability are not provided, and “language validity” is mentioned in a somewhat confusing manner.

Response 9: Dear reviewer, the adjustments made in accordance with your suggestions are listed below and highlighted in red in the article. 

First, the scale was translated into Turkish independently by four translators who were fluent in English and whose native language was Turkish. Then, a reverse translation of the scale from Turkish to English was carried out independently by four different translators who were fluent in both Turkish and English. The original scale and its reverse-translated forms were examined for clarity, inconsistencies, semantic errors, and differences in expression (Çapık et al., 2018). It was found that the scale items were culturally and mutually consistent and conveyed the same meaning. 

Convergent validity is a concept that expresses the relationship between the statements in the variables and the factors they form (Yaşlıoğlu, 2017). CR and AVE values ​​were calculated to ensure convergent validity. For convergent validity to be achieved, CR > AVE; AVE > 0.5 must be met. Divergent validity is the requirement that the statements related to the variables are less related to factors other than the factor they belong to (Yaşlıoğlu, 2017). To ensure divergent validity, two more values ​​need to be calculated. One of these is MSV and the other is ASV. For divergent validity to exist, MSV<AVE; ASV < MSV must be met, and the square root of AVE must also be greater than the interfactor correlation. In this study, the CR, AVE, MSV, and ASV values ​​were found to be 0.903; 0.516; 0.132; and 0.079, respectively. According to the results obtained, both convergent and divergent validity of the scale have been established.

 Comment 10: It should be acknowledged in Limitations that EFA and CFA were performed on the same group and that validation on an independent sample would be desirable.

Response 10: Dear reviewer, in line with your suggestions, the following statement has been added to the limitations section of the study: "However, a significant limitation of this study is that the EFA and CFA of the QQS scale were performed on the same sample. Future research suggests that EFA and CFA should be conducted on independent samples to more strongly validate the factor structure of the scale."

Comment 11: It should be clearly specified in Methods that the same 205 subjects were used for EFA and CFA and the type of rotation used in the EFA. 

Response 11: Dear Reviewer, the following statement has been added to the data analysis section of the article: “Exploratory Factor Analysis (EFA) and Confirmatory Factor Analysis (CFA) were performed using data from 205 participants in the same sample group. The varimax rotation method was used in the EFA process to account for the relationships between factors.” Thank you very much for your valuable evaluation.  

Comment 12: Change the term “language validity” to something like “cross-cultural adaptation and content validity.”

Response 12: Dear reviewer, the necessary correction has been made and is indicated in red.

Comment 13: There are numerical inconsistencies. The text states: “the mean QQS total score was 2.29 ± 0.80,” while Table 3 shows 2.48 ± 0.65 for the QQS, and the Abstract gives coefficients of 0.406 and 0.004 without clarifying that they are standardized betas/regression coefficients, which is confusing and adds little value. Please review and correct all mean figures, SDs, and coefficients so that they match exactly between the text, tables, and abstract. In the abstract, replace very small coefficients (0.004) with more interpretable phrases.

Response 13: Dear reviewer, the values ​​in the text have been aligned with the table. The abstract section of the study has also been revised in line with your suggestions. Furthermore, instead of using non-standardized regression coefficient values, standardized regression coefficient values ​​were calculated by repeating the analysis process and are presented in Table 5. 

Comment 14: In several places, the design is described as a “descriptive, correlational, and methodological study.” This mixes two different objectives: the adaptation and validation of an instrument (QQS, methodological part) and a correlational/mediational study in nurses. It should be clarified in the Introduction and Methods that the study has two objectives: to adapt and validate the QQS into Turkish and to analyze the relationship between conscientiousness stress, compassion fatigue, and quiet quitting, and the mediating role of compassion fatigue. 

Response 14: Dear reviewer, in line with your suggestions, the purpose of the study has been revised. (Abstract, introduction and methods) This study aims to adapt the Quiet Quitting Scale into Turkish for nurses and to investigate the mediating role of compassion fatigue in the relationship between conscience of stress and quiet quitting among nurses.

Comment 15: The Methods section should also be restructured into two clear sub-phases: “Phase 1: Adaptation and psychometric validation of the Quiet Quitting Scale and Phase 2: Cross-sectional analysis and mediation model.”

Response 15: Dear reviewer, in line with your suggestions, the relevant correction has been made and is indicated in red in the methods section.

Comment 16: Terminological inconsistencies. Sometimes they use “Stress of Conscience,” other times “conscience stress.” Sometimes “quiet quitting,” other times “silent resignation,” and in Table 2 it says “Lack of motivation” (typo). Terminology should be standardized, such as “Stress of conscience” (all lowercase, except at the beginning of a sentence), “Quiet quitting” always; eliminate “silent resignation” and correct “Lack of mativation” → “Lack of motivation.”

Response 16: Dear reviewer, the relevant formatting has been revised in line with your suggestions regarding terminological inconsistencies.

Comment 17: It only states that participants volunteered and that people on sick leave/leave of absence were excluded. However, it is unclear whether the 10 nurses from the pilot study were included in the final sample or not, and for STROBE it is customary to specify the flow more clearly: eligible, included, did not respond, etc. Inclusion criteria should be explicitly defined (e.g., “registered nurses providing direct patient care in X hospital during the data collection period”), it should be clarified whether the 10 from the pilot study are included in the 205 or not, and a sentence should be added with the flow: how many nurses were eligible, how many refused, how many were excluded, and why.

Response 17: Dear reviewer, the relevant correction has been made as follows. Nurses who provided direct patient care at the hospital where the study was conducted and who voluntarily agreed to participate were included in the study. Nurses who participated in the pilot phase of the study (n=10) and nurses who were on leave due to reasons such as childbirth, illness, or other reasons during the data collection period (n=10) were excluded from the study. Apart from these nurses, no data was lost, and all questionnaires were completed.

Comment 18: Methods mentions bootstrapping of 5,000 samples, but does not specify whether the CIs are 95% and whether they are bias-corrected, and 

The Methods section should clarify that “Indirect effects were tested using bootstrapping with 5,000 resamples and 95% bias-corrected confidence intervals.”

Response 18: Dear reviewer, the statement " In this study, indirect effects were tested using 5,000 bootstrap resamples with 95% bias-corrected confidence intervals. " has been added to the method section.

Comment 19: Table 5 shows “β (Lower; Upper)” without stating that it is a 95% CI. And in Table 5, indicate in the footnote that the paren

Response 19: Dear reviewer, the relevant correction has been made in Table 5.

Comment 20: The last sentence of the abstract states: “Stress of Conscience alone is not effective in reducing quiet quitting...” as if stress of conscience were an intervention. The final part of the Abstract and Conclusions should be rewritten and 2–3 sentences with practical recommendations (organizational support, compassion fatigue prevention programs, etc.) should be added.

Response 20: Dear reviewer, the abstract and conclusion sections of the study have been revised in accordance with your suggestions.

 

Reviewer 2 Report

Comments and Suggestions for Authors

This manuscript addresses a timely and underexplored issue in nursing workforce research by examining quiet quitting through the ethical–psychological lens of stress of conscience and compassion fatigue. The topic is highly relevant given global nursing shortages and increasing moral distress in healthcare. The study makes a novel conceptual contribution by testing compassion fatigue as a mediator, and it additionally contributes methodologically by adapting the Quiet Quitting Scale (QQS) into Turkish.

The manuscript would benefit from several improvements. First, causal language should be avoided and replaced with associative terminology, as the cross-sectional design does not allow causal inference. The theoretical foundation could be strengthened by explicitly grounding the study in established frameworks such as Moral Distress Theory or the Job Demands–Resources Model to better justify the proposed mediation pathway. Greater attention should be paid to the interpretation of effect sizes, particularly where statistically significant coefficients are small, by discussing their practical and clinical relevance. The potential for common method bias arising from self-reported, single-source data should be acknowledged more explicitly, and statistical checks could be considered. Generalizability should be discussed more cautiously, emphasizing the single-center setting and recommending replication in diverse healthcare contexts. The psychometric evaluation of the Turkish version of the Quiet Quitting Scale could be further strengthened by reassessing items with low item–total correlations and validating the scale in larger, independent samples. The explanatory power of the model could be improved by incorporating additional organizational variables such as burnout, leadership style, staffing adequacy, or organizational support. Also mention university times (Reduced burnout in medical and health science students during the pandemic COVID-19 - a follow-up study of a single institution in Hungary - PubMed). Practical implications should be expanded to include more concrete and actionable recommendations for nurse managers and policymakers. Finally, future research should consider longitudinal or mixed-methods designs to better capture temporal dynamics and lived experiences, while also more clearly distinguishing quiet quitting from related constructs such as burnout, disengagement, and turnover intention.

Author Response

Dear Reviewer,

Thank you very much for your valuable feedback. Your suggestions have been taken into consideration and the necessary corrections have been made. I have learned a great deal from your evaluation and suggestions. Your contributions to strengthening the theoretical framework of the study, addressing methodological limitations more clearly, and interpreting the findings more cautiously have enhanced the scientific quality of the work. Thank you again for your constructive feedback, for taking the time to provide it, and I hope these adjustments will contribute to a more robust and understandable presentation of the study.

Sincerely.

Comment 1: This manuscript addresses a timely and underexplored issue in nursing workforce research by examining quiet quitting through the ethical–psychological lens of stress of conscience and compassion fatigue. The topic is highly relevant given global nursing shortages and increasing moral distress in healthcare. The study makes a novel conceptual contribution by testing compassion fatigue as a mediator, and it additionally contributes methodologically by adapting the Quiet Quitting Scale (QQS) into Turkish. 

Comment 2: The manuscript would benefit from several improvements. First, causal language should be avoided and replaced with associative terminology, as the cross-sectional design does not allow causal inference.

Comment 3: The theoretical foundation could be strengthened by explicitly grounding the study in established frameworks such as Moral Distress Theory or the Job Demands–Resources Model to better justify the proposed mediation pathway.

Comment 4: Greater attention should be paid to the interpretation of effect sizes, particularly where statistically significant coefficients are small, by discussing their practical and clinical relevance.

Comment 5: The potential for common method bias arising from self-reported, single-source data should be acknowledged more explicitly, and statistical checks could be considered.

Comment 6: Generalizability should be discussed more cautiously, emphasizing the single-center setting and recommending replication in diverse healthcare contexts.

Comment 7: The psychometric evaluation of the Turkish version of the Quiet Quitting Scale could be further strengthened by reassessing items with low item–total correlations and validating the scale in larger, independent samples.

Response 1: Dear reviewer, thank you very much for your valuable feedback Response 2: We thank the reviewer for this important observation. In response, causal language throughout the manuscript has been carefully revised and replaced with associative terminology (e.g., “is associated with,” “is related to,” “shows an indirect association”) to accurately reflect the cross-sectional design of the study and to avoid causal inference. Response 3: Dear reviewer, thank you very much for your valuable feedback. The introduction and discussion sections of the study have been revised in line with your suggestions. Response 4: Dear reviewer, thank you very much for your valuable feedback. The study in question initially provided non-standardized regression coefficients. During the article review process, standardized regression coefficients were calculated in accordance with your suggestions. Table and Figure 2 have been revised. Following these changes, the abstract, findings, and discussion sections have also been revised. Response 5: In this study, the fact that data were collected from a single source and based on self-reporting methods brings with it the potential for common methodological bias. This may have caused the relationships between variables to appear stronger than they actually are. It is recommended that appropriate statistical methods be used in future studies to evaluate and control for such biases. Response 6: Dear Reviewer, the corrections made in accordance with your suggestions are given in the limitations section of the article. Response 7: We thank the reviewer for this valuable suggestion. In line with this comment, we acknowledged in the Study Limitations section that although the Turkish version of the Quiet Quitting Scale demonstrated acceptable psychometric properties, some items exhibited relatively lower item–total correlations and both EFA and CFA were conducted on the same sample. We therefore emphasized the need for future studies to re-evaluate these items and to validate the scale using larger, independent samples to further strengthen its psychometric robustness.

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for your hard work once again. I appreciate that some of my comments have been incorporated. However, I still do not see any mention of the university timelines in the study titled "Reduced Burnout in Medical and Health Science Students During the COVID-19 Pandemic: A Follow-up Study of a Single Institution in Hungary." These timelines are crucial for understanding attrition, burnout, and quiet quitting as well.

Comments on the Quality of English Language

Fine

Author Response

Comments1: Thank you for your hard work once again. I appreciate that some of my comments have been incorporated. However, I still do not see any mention of the university timelines in the study titled "Reduced Burnout in Medical and Health Science Students During the COVID-19 Pandemic: A Follow-up Study of a Single Institution in Hungary." These timelines are crucial for understanding attrition, burnout, and quiet quitting as well.

Response 1: We thank the reviewer for referring us to this relevant student-based study. Although our sample consists of practicing nurses, the referenced research provides important insight into how burnout and disengagement may develop earlier during professional education under institutional and temporal influences. We have incorporated this perspective into the Discussion section to strengthen the theoretical grounding of our findings. (page 352-357)