Review Reports - Association Between Workplace Gaslighting and Perceived Quality of Care, Patient Safety and Quiet Quitting: A Cross-Sectional Study Among Nurses in Greece

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

I appreciate the opportunity to review this manuscript, which aim is to examine the impact of work gaslighting on perceived quality of care, patient safety, and quiet quitting among nursing staff.

Below, I offer a series of comments/suggestions to help improve the quality of your manuscript:

In Introduction section, you cite data on adverse events in US hospitals, taken from the Institute of Medicine (US) report “To Err is Human: Building a Safer Health System.” It might be helpful to add data on the number of adverse events occurring in Europe or Greece to provide more concrete context for the problem analyzed in your research.
You use a good number of current bibliographic references.
Materials and Methods section is correct and perfectly describes the process followed to carry out this research.

In Section 2.2, Measurements, you should include the abbreviation ‘QQS’ in parentheses the first time you mention the Quiet Quitting Scale. Accordingly, line 165 should read: ‘To assess quiet quitting among nurses, we used the 9-item Quiet Quitting Scale (QQS) [29].’

I believe that Table 3 could be improved by more clearly distinguishing the names of the scales from their corresponding subscales in the first column and by adjusting the alignment of the subsections. For example, rather than numbering the scales and subscales consecutively from 1 to 7, you might consider a hierarchical format: ‘1. Gaslighting the Work Scale’ with its subscales numbered as ‘1.a Self-Trust’ and ‘1.b Abuse of Power,’ and similarly for the Quiet Quitting Scale (‘2. Quiet Quitting Scale’ / ‘2.a Detachment’ / ‘2.b Lack of Initiative’ / ‘2.c Lack of Motivation’)."I commend the authors for including limitations.

Thank you very much.

Author Response

Dear Reviewer 1,

Thank you very much for the peer review of the manuscript “Association between workplace gaslighting and perceived quality of care, patient safety and quiet quitting: A cross-sectional study among nurses in Greece”. Thank you for your comments, which have improved the quality of the manuscript. We have addressed all the comments (highlighted with track changes) in the revised text. Also, we make changes in the manuscript according to the other Reviewers’ instructions.

Please, find below an item-by-item answer to your comments. Hoping the revised manuscript fulfils the journal’s standards, we thank you for your courtesy.

We are looking forward to your response.

Yours sincerely,

The authors

Dear Authors,

I appreciate the opportunity to review this manuscript, which aim is to examine the impact of work gaslighting on perceived quality of care, patient safety, and quiet quitting among nursing staff.

Below, I offer a series of comments/suggestions to help improve the quality of your manuscript:

Comment

Reply: Done

We added the following text: “Adverse events are not an issue confined to the United States; rather, they have a substantial global impact, placing a significant burden on healthcare systems across all continents, with the proportion of patients experiencing at least one adverse event ranging from 7.3% to 21.9%”. Also, we added a reference, a scoping review, regarding the occurrence of adverse events in countries all over the world.

Comment

Materials and Methods section is correct and perfectly describes the process followed to carry out this research.

Reply: done

Line 165 is now as follows.

To assess quiet quitting among nurses, we used the 9-item Quiet Quitting Scale (QQS) [29].

Comment

Reply: done

Dear Reviewer, thank you especially for this comment.

We rewrite the Table 3 as follows.

Scale	1.a	1.b	2	2.a	2.b	2.c
1. Gaslighting at Work Scale	0.938^**	0.968^**	0.305^**	0.221^**	0.300^**	0.198^**
1.a. Loss of self-trust		0.820^**	0.268^**	0.233^**	0.245^**	0.142^**
1.b. Abuse of power			0.308^**	0.195^**	0.317^**	0.224^**
2. Quiet Quitting Scale				0.822^**	0.836^**	0.695^**
2.a. Detachment					0.510^**	0.322^**
2.b. Lack of initiative						0.460^**
2.c. Lack of motivation

Comment

I commend the authors for including limitations.

Reply: done

Dear Reviewer, thank you for your kindness.

Thank you very much.

Reviewer 2 Report

Comments and Suggestions for Authors

In method:

The sampling method should be explained.

Statistical tests and statistical software and significance level should be reported.

Demographic characteristics should be reported.

Results should be more concise.

The introduction is long.

However, the gap is not clear.

The questionnaire was administered via Google Forms and shared through nurses’ media groups in Facebook, Instagram and LinkedIn. With this sampling method, are the results valid and generalizable? The calculation of the sample size is not clear.

The method of conducting the study should be fully described.

The validity, reliability, and scoring of the instrument should be described.

The data analysis is too long, make it more concise.

The abstract states that the quality of care was good, but these findings are not reflected in the results.

For Table 2, it would be better to report the status of each variable. Instead of the mean and standard deviation.

For results, it is not necessary to repeat all the results in the text.

Key findings should be stated in the text and then referred to in the table.

All the results of the table are also given in the text, which is not appropriate.

The discussion is incomplete, all hypotheses should be discussed.

The similarity percentage is high.

Author Response

Dear Reviewer 2,

Please, find below an item-by-item answer to your comments. Hoping the revised manuscript fulfils the journal’s standards, we thank you for your courtesy.

We are looking forward to your response.

Yours sincerely,

The authors

Comment

In abstract:

The sampling method should be explained.

Statistical tests and statistical software and significance level should be reported.

Demographic characteristics should be reported.

Results should be more concise.

Reply: done

Dear Reviewer, we sincerely thank you for this insightful comment and for your valuable guidance in helping us improve the clarity and presentation of our Abstract. We follow all your suggestions.

We add the sampling method:

…A cross-sectional study with a convenience sample was conducted in Greece…

We add statistical tests and statistical software and significance level.

… We used IBM SPSS 28.0 to perform logistic regression analysis and linear regression analysis. Significance level was set at 0.05…

We add demographic characteristics.

…Mean age of nurses was 42.98 years, while females comprised 82.1% of them…

We shorten the Results section from 206 words to 83 words.

We totally rewrite the Abstract as follows.

Background: Workplace gaslighting, as a form of psychological manipulation, may negatively affect nurses’ work behaviours and perception of care. However, its connection to perceived quality of care, patient safety and quiet quitting has not been sufficiently explored. Objectives: To examine the impact of workplace gaslighting on perceived quality of care, patient safety and quiet quitting in nurses. Methods: A cross-sectional study with a convenience sample was conducted in Greece. We used the Gaslighting at Work Scale and the Quiet Quitting Scale to measure workplace gaslighting and quiet quitting, respectively. We used IBM SPSS 28.0 to perform logistic regression analysis and linear regression analysis. Significance level was set at 0.05. Results: Mean age of nurses was 42.98 years, while females comprised 82.1% of them. More than half of our nurses (52.0%) evaluated the quality of care in their unit as good, while 33.1% perceived patient safety as good. Higher level of workplace gaslighting was significantly associated with lower odds of reporting perceived quality of care to be good or excellent. Increased workplace gaslighting was also associated with decreased odds of good-to-excellent patient safety. Moreover, workplace gaslighting was significantly and positively associated with quiet quitting. Conclusions: Our study supports the negative impact of workplace gaslighting on perceived quality of care, patient safety and quiet quitting. Establishment of clear policies and procedures that encourage staff to report such behaviours, is essential to dismantle the barriers created by psychological manipulation.

Comment

The introduction is long. However, the gap is not clear.

Reply: Done

The introduction is extensive, as we had to present all the concepts and their significance that are examined in this study (safety and quality of care, leadership, gaslighting, quiet quitting). We removed some small sections from the Introduction section that we considered redundant.

Regarding the gap in the literature, we added the following text in the end of the Introduction section to highlight the gap in the literature on the subject of the study: “To date, the literature examining the relationship between leadership and the quality and safety of patient care has primarily focused on the positive effects of specific leadership models (e.g., transformational leadership), as well as on the detrimental impact of toxic leadership. Although gaslighting has been extensively studied within sociological and psychological frameworks, particularly in the context of interpersonal relationships, there remains a notable gap in the literature regarding its prevalence in the healthcare workplace and its impact on the quality and safety of nursing care delivery”.

Comment

Reply: done

Dear Reviewer, we recognize that our convenience sample introduces bias in our study. Thus, we add the following text in the limitations section.

Since we used a convenience sample of nurses to examine the association between workplace gaslighting, quality of care, patient safety and quiet quitting, we cannot generalizable our finding in the population of nurses in Greece or other countries. Further studies with random, stratified and more representative samples of nurses should be conducted to further validate our findings.

Also, we further clarify the sample size calculation. Now the text is the following.

We used G*Power v.3.1.9.2 for sample size determination. Sample size determination was conducted a priori. The calculation was based on the analytical requirements of our multivariable regression models, which included five variables (gender, age, years of work experience, working in shifts and working in an understaffed department) considered potential confounders in the association between our predictor (i.e. workplace gaslighting) and our study outcomes (perceived quality of care, perceived patient safety, quiet quitting). We assumed an effect size of 0.03 between our predictor and outcomes, corresponding to a small effect. To ensure robust statistical inference, the analysis was set at a high desired statistical power of 95% (1-β=0.95), thereby reducing the risk of type II error. The significance level (α) was set at the conventional threshold of 0.05. Under these specifications, the power analysis indicated that a minimum sample size of 436 nurses was required to reliably detect the expected effect size after adjusting for the five confounding variables.

Comment

The method of conducting the study should be fully described.

Reply: done

We further expand the methods section. Now the text is the following.

A cross-sectional study was conducted in Greece and data were collected using an online survey during October to November 2025. The questionnaire was administered via Google Forms, chosen for its accessibility and compatibility with multiple digital devices. To facilitate broad dissemination, the survey link was shared through nurses’ professional social media groups on Facebook, Instagram and LinkedIn. Nurses’ networks represented institutional and association networks of nurses, enabling efficient outreach to practicing professional nurses across various healthcare settings. This process yielded a convenience sample, as participation depended on voluntary engagement through these digital channels.

Eligible participants were required to meet specific inclusion criteria. First, individuals had to be currently employed as clinical nurses working in hospitals. Second, they had to occupy subordinate clinical roles, meaning they were not supervisors or managers of other nurses. Third, participants were required to have at least one year of work experience in their current nursing position to ensure adequate exposure to clinical routines and workplace environments. Finally, all nurses were required to provide informed consent electronically before accessing and completing the study questionnaire. Only participants who met all inclusion criteria and consented to participate were included in the final sample.

Comment

The validity, reliability, and scoring of the instrument should be described.

Reply: done

Regarding the “Gaslighting at Work Scale”, we add the following.

Total and subscale scores are calculated as an average of all responses (1–5), with higher scores indicating more frequent behaviors of supervisor gaslighting. In particular, we add the answers to the 11 items, and we divide the sum with 11. Also, to calculate “loss of self-trust” score, we add the answers to the five items, and we divide the sum with five, while to calculate “abuse of power” score, we add the answers to six items, and we divide the sum with six. The developers of the scale recommend an optimal cut-off point of 2.1. Employees with a total GWS score greater than or equal to this value are classified as experiencing high levels of workplace gaslighting, while those with a total score below the cut-off point are considered to exhibit normal levels of workplace gaslighting. Several aspects of validity of GWS have already been demonstrated, including content validity, face validity, construct validity and concurrent validity.

Regarding the “Quiet Quitting Scale”, we add the following.

Score for each factor was derived by calculating the average value of the responses to items, ranging from 1 to 5. Similarly, the total score on the QQS is calculated as the mean of the nine items. Specifically, the responses to all nine items are summed, and the resulting total is then divided by nine. Higher scores are associated with higher levels of quiet quitting. The validated version of the QQS in Greek was used [22]. Multiple forms of evidence supporting the validity of the QQS have already been established, including its content, face, construct, and concurrent validity. In our study, Cronbach's alpha for the QQS was 0.814, for the factor “detachment” was 0.737, for the factor “lack of initiative” was 0.693, and for the factor “lack of motivation” was 0.810.

Comment

The data analysis is too long, make it more concise.

Reply: done

We have condensed the Statistical Analysis section, reducing its length from 343 words in the original manuscript to 253 words in the revised version.

Dear Reviewer, please see the revised version below.

We use mean, standard deviation (SD), median, and interquartile range to present continuous variables. Also, we use numbers and percentages to present categorical variables. Continuous variables followed the normal distribution. Workplace gaslighting was the predictor, and perceived quality of care, perceived patient safety and quiet quitting were the outcomes. Demographic variables (gender, age, years of work experience, working in shifts, and working in an understaffed department) were considered as confounding factors.

Logistic regression analysis was used to explore associations between workplace gaslighting, perceived quality of care and perceived patient safety. Final multivariable logistic regression models were built to determine the independent effect of workplace gaslighting, after adjustment for confounding. Age was highly correlated with years of work experience (Pearson’s correlation coefficient = 0.912, p<0.001) suggesting multicollinearity issues, thus we added one of these two variables into the final multivariable models (work experience instead of age). The findings are reported as crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) and p-values.

Linear regression analysis was performed to detect the association between workplace gaslighting and quiet quitting. We finally built a multivariable model controlled for the confounders we mentioned above. We present crude and adjusted betas, 95% CI, and p-values. Additionally, we evaluated the assumptions of multivariable linear regression models, such as multicollinearity , multivariable normality, homoscedasticity and linearity [33]. P-values less than 0.05 were considered statistically significant. We performed statistical analyses with IBM SPSS 28.0 (IBM Corp. Released 2021. IBM SPSS Statistics for Windows, Version 28.0. Armonk, NY, USA: IBM Corp.).

Comment

The abstract states that the quality of care was good, but these findings are not reflected in the results.

Reply: done

We add the following text.

3.3 Quality of care and patient safety

Almost half of the participants (52.0%, n=256) evaluated the quality of care in their unit as good, while 23.6% (n=116) evaluated it as fair, 19.7% (n=97) as excellent and 4.7% as (n=4.7%) poor. Thus, five out of ten nurses considered the quality of care in their unit as good, and two out of ten nurses considered the quality of care as excellent.

Moreover, 33.1% (n=163) of nurses perceived patient safety as good, 28.5% (n=140) as very good, 20.7% (n=102) as fair, 11.2% (n=55) as excellent and 6.5% (n=32) as poor. Therefore, 61.6% of nurses perceived patient safety as good/very good.

Comment

For Table 2, it would be better to report the status of each variable. Instead of the mean and standard deviation.

Reply: done

Dear Reviewer, as you suggest, we have updated Table 2 to report the status of each variable to provide a clearer profile of the study participants. Please, see Table 2 in the Manuscript.

Also, we add in text the following.

In our sample, 24.4% nurses suffered high levels of workplace gaslighting due to GWS score. Moreover, more than half of our nurses (55.3%) were considered quiet quitters according to their score on QQS. Status of the study scales is presented in Table 2.

Comment

For results, it is not necessary to repeat all the results in the text.

Key findings should be stated in the text and then referred to in the table.

All the results of the table are also given in the text, which is not appropriate.

Reply: done

Dear Reviewer, we followed all your suggestions.

We rewrite the following three paragraphs.

Table 3 presents the Pearson correlation coefficients between study scales and their subscales. The Gaslighting at Work Scale had a highly positive relationship with its two subscales, loss of self-trust (r = 0.938, p < 0.01) and abuse of power (r = 0.968, p < 0.01), suggesting strong internal coherence. Workplace Gaslighting was significantly and positively associated with the QQS (r = 0.305, p < 0.01), and its subscales: detachment (r = 0.221, p < 0.01), lack of initiative (r = 0.300, p < 0.01) and lack of motivation(r =0.198,p <.01).

Similarly, both workplace gaslighting subscales were significantly associated with quiet quitting and its sub-scales. Loss of self-trust was positively correlated with total quiet quitting score (r = 0.268, p < 0.01), detachment (r = 0.233, p < 0.01), lack of initiative (r = 0.245, p < 0.01), and lack of motivation (r = 0.142, p < 0.01). Abuse of power had similar or somewhat stronger associations with quiet quitting (r = 0.308, p < 0.01), detachment (r = 0.195, p < 0.01), lack of initiative (r = 0.317, p < 0.01), and lack of motivation (r = 0.224, p < 0.01).

These findings indicate that higher perceived workplace gaslighting, particularly experiences related to abuse of power and loss of self-trust, is associated with greater levels of quiet quitting and its subscales.

Now, the text for the three paragraphs above is the following.

Table 3 presents the Pearson correlation coefficients between study scales and their subscales. Workplace gaslighting was significantly and positively associated with the QQS. Similarly, all workplace gaslighting subscales were significantly and positively associated with all quiet quitting sub-scales. These findings indicate that higher perceived workplace gaslighting was correlated with greater levels of quiet quitting.

Moreover, we removed odds ratios, confidence intervals, and p-values from the following paragraphs.

In the univariate comparisons, greater workplace gaslighting was significantly associated with lower odds of reporting perceived quality of care to be good or excellent (OR = 0.650, 95% CI: 0.527–0.803; p < 0.001). This association was still statistically significant in the multivariable model after gender, years of work experience, working in shifts and working in an understaffed department were included (adjusted OR = 0.655; 95% CI: 0.529–0.810; p < 0.001).

Workplace gaslighting was also strongly related to perceived patient safety. In the univariate analysis increased workplace gaslighting was associated with decreased odds of good-to-excellent patient safety (OR = 0.553, 95% CI: 0.445–0.686, p < 0.001). This association remained after controlling for the potential confounders (adjusted OR = 0.561, 95% CI: 0.450–0.700, p < 0.001).

Moreover, we removed betas, confidence intervals, and p-values from the following paragraphs.

In the univariate analysis, workplace gaslighting was significantly and positively associated with quiet quitting (beta = 0.223, 95% CI = 0.161 to 0.284, p <.001), indicating that higher levels of workplace gaslighting were related to increased quiet quitting behaviors. This association was still significant even when gender, years of work experience, working in shifts and working in an understaffed department were considered (adjusted beta = 0.224, 95% CI = 0.163 to 0.285, p < 0.001).

Finally, we rewrite the sentences

“Figure S1 indicates multivariable normality for the multivariable model with quiet quitting as the dependent variable since the residuals followed a normal distribution. Figure S2 indicates homoscedasticity and linearity of the multivariable model, with quiet quitting as the dependent variable. VIF for the final multivariable model ranged from 1.006 to 1.247, indicating an absence of multicollinearity between independent variables.

as follows

Multivariable regression model assumptions were met (see Figures S1 and S2, while VIFs ranged from 1.006 to 1.247).

Comment

The discussion is incomplete, all hypotheses should be discussed.

Reply: Done

We added the following text at the Discussion section: “The results of the present study revealed that higher perceived workplace gaslighting was related to worse perceptions of quality care and patient safety, even after adjusting for key demographic/work-related variables. Since this study is the first to examine the impact of gaslighting on the quality and safety of nursing care, the aforementioned finding will be discussed within the broader context of leadership’s overall influence on the quality and safety of care. When models of toxic nursing leadership are implemented, healthcare organizations report increased adverse outcomes, particularly a higher incidence of hospital-acquired infections, patient falls, medication errors, and complaints from patients’ family members, compared with work environments in which transformational, authentic, and inclusive leadership are practiced [40]. When nurse managers adopt inclusive leadership, they enhance nurses’ intention to report errors [40]. Error reporting constitutes a fundamental prerequisite for investigating the factors that contribute to errors and, consequently, for improving the safety of care delivery. The characteristics of authentic leadership, which emphasize the development of a healthy workplace environment and focus on core leader qualities, such as self-awareness, relational transparency, an internalized moral perspective, and balanced processing, are associated with a decrease in nurse-assessed adverse events and an increase in the quality of care [41]”.

Comment

The similarity percentage is high.

Reply: done

Dear Reviewer, thank you especially for this comment. The journal provided us with the manuscript’s similarity report, and we have revised the content accordingly to address any issues identified.

Reviewer 3 Report

Comments and Suggestions for Authors

REVIEW - Association between workplace gaslighting and perceived quality of care, patient safety and quiet quitting: A cross-sectional study among nurses in Greece (healthcare-4101444).

This manuscript addresses a timely and relevant topic in the field of nursing, patient safety, and psychosocial work environments. The study is methodologically sound and well aligned with its stated objectives, and the manuscript's overall structure is clear. The topic of workplace gaslighting and its association with quality of care, patient safety, and quiet quitting represents a meaningful contribution to the literature and is well-suited to the scope of Healthcare.

The abstract of this manuscript requires complete revision. The background section is written broadly and primarily emphasises patient safety, without clearly stating the study's main objective. I suggest making the background more focused and directly aligned with the central research theme, namely workplace gaslighting and its potential impact on quality of care, patient safety, and work-related behaviours such as quiet quitting. For instance: “Workplace gaslighting represents a form of psychological manipulation that may negatively impact nurses’ work behaviours and perceptions of care. However, its connection to perceived quality and safety of care has not been sufficiently explored.” The methodology description is overly detailed for an abstract and includes unnecessary information (e.g., the exact period of data collection). I suggest summarising the methodology, keeping only essential elements such as the study design, sample, and primary instruments. In the results section, it is recommended to limit the number of numerical indicators and avoid duplicating similar data from univariate and multivariable models. The conclusions in the abstract are quite broad and include strong normative suggestions for leadership. For an abstract, it would be better to emphasise the specific contribution this study makes to existing knowledge. Furthermore, claiming that this is the “first” study to explore these relationships appears somewhat overstated at this level, especially without clear contextual boundaries such as country, population, or a specific framework. I suggest softening this statement or providing clarification.

Finally, the overall length of the abstract seems too long, probably due to the detailed methodology and results. Authors should review the journal’s word limits and further shorten the content. I also recommend checking whether all keywords match MeSH terms; notably, "quiet quitting" is not a MeSH term.

Although all key concepts relevant to the research topic are presented in the introduction, their order and narrative structure do not fully align with the logic of the manuscript's title and the defined study aim. Currently, the introduction broadly addresses patient safety and adverse events, while central variables such as workplace gaslighting and quiet quitting are introduced only later. This may create the impression that gaslighting and quiet quitting are secondary phenomena, although they are, in fact, the study's main explanatory variables. Considering the manuscript's title "Association between workplace gaslighting and perceived quality of care, patient safety and quiet quitting" and the clearly defined study objective, a reorganisation of the introduction following the “from causes to outcomes” principle is recommended. Specifically, it would be beneficial to start the introduction with a clear conceptual framework of workplace gaslighting, including its definition, key features, and its role within toxic and destructive leadership styles, with an early reference to its psychological and organisational consequences for nurses. Subsequently, introduce quiet quitting as a relevant work-related behaviour that may reflect a response to chronic exposure to psychosocial stressors, including gaslighting, particularly within the healthcare context. Only then, explicitly link gaslighting and quiet quitting to system-level outcomes, namely perceived quality of care and patient safety, drawing on existing theoretical models of safety culture, organisational climate, and leadership. Within this framework, sections addressing patient safety, quality of care, and leadership remain highly relevant but would gain greater analytical strength if clearly presented as consequences and part of a broader context of toxic work environments, rather than as the starting point of the narrative.

The Materials and Methods section is well organised, clearly written, and largely adheres to the STROBE reporting guidelines. The study design, eligibility criteria, sample size calculation, and ethical considerations are appropriately detailed. The use of validated instruments with reliable psychometric properties enhances the study's methodological objectivity. However, the Statistical Analysis subsection seems overly detailed for a methods section. While the analyses applied are appropriate and well justified, I suggest condensing the description of routine statistical procedures (e.g., normality testing, residual diagnostics, and multicollinearity checks). These details could be summarised more succinctly without compromising methodological clarity. Additionally, the repeated distinction between univariate and multivariable models could be streamlined by focusing on the regression models used, the outcomes examined, and the confounders adjusted for. Top of Form

The Results section is well organised, methodologically robust, and aligned with the study objectives. The presentation of descriptive data, correlations, and regression analyses is clear, and the tables are informative and properly structured. However, to improve conciseness, I recommend moderate condensation of the narrative text, particularly where numerical details already appear in tables. For example, the detailed reporting of multiple correlation coefficients and subscale-level associations could be summarised in one sentence, emphasising the overall pattern of associations, with exact values retained in Table 3. Similarly, in Sections 3.4 and 3.5, the text could emphasise the direction and importance of the associations while avoiding repetition of odds ratios, confidence intervals, and p-values, which are fully presented in Tables 4 and 5. Additionally, detailed descriptions of model diagnostics (e.g., residual normality, homoscedasticity, VIF values, and references to Figures S1 and S2) could be shortened or moved to the Supplementary Materials, with a brief statement in the main text indicating that model assumptions were met.

The discussion is coherent, well supported by the literature, and provides a clear interpretation of the findings, with appropriate connections to leadership, psychological safety, and patient safety culture. The authors explicitly recognise key limitations (cross-sectional design, self-reported outcomes, and lack of objective patient safety indicators), which enhances transparency. The conclusions concisely summarise the main implications and are pertinent for organisational policy and practice.

Overall, the manuscript is of good quality and presents clear and relevant findings. The comments provided are mainly intended to improve clarity, structure, and conciseness, rather than to address substantive methodological concerns. Therefore, I recommend a minor revision.

Author Response

Dear Reviewer 3,

Please, find below an item-by-item answer to your comments. Hoping the revised manuscript fulfils the journal’s standards, we thank you for your courtesy.

We are looking forward to your response.

Yours sincerely,

The authors

Comment

Reply: done

Dear Reviewer, we sincerely thank you for this insightful comment and for your valuable guidance in helping us improve the clarity and presentation of our Abstract. We follow all your suggestions.

We totally rewrite the Abstract as follows.

Background: Workplace gaslighting, as a form of psychological manipulation, may negatively affect nurses’ work behaviors and perception of care. However, its connection to perceived quality of care, patient safety and quiet quitting has not been sufficiently explored. Objectives: To examine the impact of workplace gaslighting on perceived quality of care, patient safety and quiet quitting in nurses. Methods: A cross-sectional study with a convenience sample was conducted in Greece. We used the Gaslighting at Work Scale and the Quiet Quitting Scale to measure workplace gaslighting and quiet quitting, respectively. We used IBM SPSS 28.0 to perform logistic regression analysis and linear regression analysis. Significance level was set at 0.05. Results: Mean age of nurses was 42.98 years, while females comprised 82.1% of them. More than half of our nurses (52.0%) evaluated the quality of care in their unit as good, while 33.1% perceived patient safety as good. Higher level of workplace gaslighting was significantly associated with lower odds of reporting perceived quality of care to be good or excellent. Increased workplace gaslighting was also associated with decreased odds of good-to-excellent patient safety. Moreover, workplace gaslighting was significantly and positively associated with quiet quitting. Conclusions: Our study supports the negative impact of workplace gaslighting on perceived quality of care, patient safety and quiet quitting. Establishment of clear policies and procedures that encourage staff to report such behaviours, is essential to dismantle the barriers created by psychological manipulation.

Comment

Reply: done

We shorten the Abstract from 391 words to 236 words.

We remove "quiet quitting" from the keywords. We use the term “nurses” instead of term “nurse”. We use the term “patients” instead of term “patient”. We use the term “quality of health care” instead of term “quality of care”.

Comment

Reply: Done

Thank you very much for this important comment. We have revised and restructured the Introduction as suggested and have added a definition of gaslighting along with a discussion of its impacts on nurses.

Comment

Reply: done

We have condensed the Statistical Analysis section, reducing its length from 343 words in the original manuscript to 253 words in the revised version.

Dear Reviewer, please see the revised version below.

Comment

Reply: done

Dear Reviewer, we followed all your suggestions.

We rewrite the following three paragraphs.

Now, the text for the three paragraphs above is the following.

Moreover, we removed odds ratios, confidence intervals, and p-values from the following paragraphs.

Moreover, we removed betas, confidence intervals, and p-values from the following paragraphs.

Finally, we rewrite the sentences

as follows

Multivariable regression model assumptions were met (see Figures S1 and S2, while VIFs ranged from 1.006 to 1.247).