A Cross-Cultural Validation of the Italian Version of the Nurse’s Environmental Awareness Tool (NEAT)

Quality of English Language: The English is fine and does not require any improvement.

Thank you for your positive feedback regarding the quality of the English language. We are glad to know it meets the required standards.

The research topic chosen by the authors is relevant at the present time because the healthcare sector plays a pivotal role in environmental sustainability, with nurses directly involved in waste production and energy consumption.

Thank you for recognizing the relevance of the research topic. We agree that the healthcare sector, and nurses in particular, play a key role in advancing environmental sustainability, making this an important area for further investigation.

The study is practical in nature, which is in line with the purpose of the study. This study aimed to adapt the NEAT to Italian and evaluate its psychometric properties. The results of the study are of practical value. The theoretical justification is not detailed but is in line with the purpose of the study.

We thank the reviewer for recognizing the practical value of our study and its alignment with the intended purpose of adapting and validating the NEAT in the Italian context. While the theoretical justification was intentionally concise to maintain focus on the tool’s validation, we appreciate this observation and have further clarified the underlying theoretical models to strengthen the conceptual grounding of the study.

(Page 2-3, Lines 93-99) “Given the complexity of environmental awareness, the NEAT offers a structured, theory-informed tool grounded in the Integrated Change Model and the EWT-E Wheel. These frameworks allow for the assessment of both cognitive and behavioral aspects of sustainability, aligning well with the multidimensional role of nurses in healthcare. In Italy, where nurses actively support sustainability efforts but lack a validated assessment tool, an Italian version of the NEAT is needed to support education, policy, and practice.

The NEAT questionnaire was developed to measure and evaluate environmental awareness among nurses, addressing two key constructs: awareness of the environmental impacts of nursing practice and ecological behaviors [15]. Originally developed and tested by Schenk et al. (2015), the questionnaire is grounded in two complementary theoretical frameworks: the Integrated Change Model and the EWT-E Wheel. The Integrated Change Model proposes that behavior change is influenced by awareness, motivation, and perceived ability to act, highlighting the importance of understanding beliefs and attitudes as precursors to ecological behaviors [16]. This framework supports the NEAT’s focus on both awareness and behavioral domains. In parallel, the EWT-E Wheel provides a practical lens for categorizing environmental impacts within healthcare, organized into four domains: energy, waste, toxicants, and engagement [12]. These domains are reflected in the NEAT’s subscales, which assess nurses’ awareness of how daily clinical practices intersect with resource consumption, pollution, and opportunities for sustainability engagement. Together, these models provide a solid theoretical foundation for the NEAT and support its application in evaluating nurses’ environmental awareness. The NEAT questionnaire serves as an essential tool for assessing and comparing nurses' environmental consciousness across different settings. Except for the validation conducted in Spanish [14], an assessment of the psychometric properties of the instrument has never been carried out in languages other than English [15]. Furthermore, to be used in non-English-speaking countries, the NEAT must undergo cross-cultural adaptation to verify its measurement properties, as well as its semantic and conceptual equivalence with the original version.”

To improve the quality of the article, in the reviewer's opinion, the authors should supplement paragraph 2 (Materials and Methods) with justification of the sample size and justification of the representativeness of the study results.

We appreciate the reviewer’s suggestion to provide greater detail regarding sample size and representativeness. We have now expanded the Materials and Methods section to include a rationale for the sample size calculation based on established guidelines for factor analysis.

(Page 6, Lines 254-261) “The sample size was determined based on methodological recommendations for factor analysis, which suggest a minimum of 5 to 10 participants per item of the instrument [25]. Given that the NEAT consists of 33 items, a sample of approximately 330 participants met the aforementioned criterion, allowing for a robust assessment of dimensionality and internal consistency [26]. This approach has also been consistently applied in previous cross-cultural validation studies of the NEAT, such as the Spanish version [18,22]. To account for potential incomplete or missing questionnaire responses, an additional 10% was added, resulting in a final target sample size of 363 participants.”

 In addition, we have provided a consideration about the potential issue in sample’s representativeness in the strengths and limitations section.

Also, the authors need to complete the conclusions of the study at the end of the paper.

Thank you for your valuable suggestion. Conclusions have been amended accordingly.

(Page 16-17, Lines 540-558) “This study adapted and psychometrically validated an Italian version of the NEAT, supporting its use in the Italian context. The instrument demonstrated satisfactory validity and reliability, confirming its potential for assessing environmental awareness among both nursing students and professionals. By capturing both cognitive and behavioral dimensions of sustainability, the NEAT represents a valuable resource for evaluating educational needs and monitoring the impact of interventions aimed at promoting environmentally responsible practices in healthcare.

The findings have important implications for nursing education and policy. The NEAT can be used in academic settings to guide curriculum development and in clinical contexts to inform professional training and sustainability initiatives. Furthermore, the instrument provides a foundation for future research exploring the factors that influence environmental awareness in nursing and its relationship to practice change.

While the use of a convenience sample limits generalizability, the inclusion of a diverse population across educational and clinical settings enhances the ecological relevance of the findings. Future studies should consider broader and more representative samples to further validate the tool and support its international application.

In conclusion, the Italian NEAT is a theoretically grounded and psychometrically sound instrument that can contribute to building sustainability competencies among nurses, paving the path toward achieving environmentally responsible healthcare.”

Quality of English Language: The English could be improved to more clearly express the research.

Thank you for your comment. While I appreciate your suggestion, I would kindly note that the other three reviewers found the English to be clear. It would be helpful to have more specific examples or indications of which parts of the manuscript were unclear or require further clarification. This would allow for more targeted and meaningful revisions to improve the clarity of the research.

While the study demonstrates methodological rigor, there are areas that require clarification or enhancement to enable transparency, strength, and academic clarity.

Thank you for acknowledging the methodological rigor of the study. We carefully considered your feedback and addressed the areas requiring clarification and enhancement to improve transparency, strength, and academic clarity.

The introduction provides a background picture of the environmental footprint of healthcare and the contribution of nurses towards sustainability. The context is set for the measurement of environmental awareness and introduces the NEAT tool as the only validated tool, quoting the necessity of its application beyond English and Spanish environments.

We thank the reviewer for this encouraging comment. We are pleased that the introduction effectively conveyed the relevance of environmental sustainability in healthcare and the unique contribution of nurses in this context. We also appreciate the reviewer’s recognition of the rationale for cross-cultural validation of the NEAT tool beyond English- and Spanish-speaking settings.

Introduction

1.        Literature-aim development is gradual. The primary research purpose appears too late in the introduction (line 97). Predict the study purpose and research gap sooner to promote clarity and visibility.

2.        There is a bit of repetition of material (e.g., discussing nurses' effect on the environment in multiple standalone paragraphs). Combine repeated arguments about nurses' environmental impact and summarize the paragraphs.

3.        Even though the NEAT tool is introduced, its theoretical basis and applicability may be better connected to the study's rationale. Previously explain why NEAT is an appropriate tool and why Italian validation is needed.

We thank the reviewer for this valuable suggestion. We agree that presenting the study purpose and research gap earlier in the introduction improves clarity and supports reader engagement. Accordingly, we have revised the introduction by adding a concise summary of the research aim and gap earlier in the text, while retaining the full aim statement at the end for consistency and emphasis.

(Page 2, Lines 55-60) “Although nurses play a pivotal role in promoting sustainable practices, there is limited understanding of their actual environmental awareness in clinical contexts [8]. Few tools are available to assess this construct, and validated instruments for use in non-English-speaking contexts are particularly scarce. To address this gap, this study focuses on the adaptation and validation of a tool capable of evaluating nurses’ environmental awareness in the Italian healthcare context.”

Thank you for pointing out this issue. We have tried to combine repeated the potential nurses’ responsibilities and summarized two paragraphs together.

(Page 2, Lines 76-86) “Recent literature further emphasize that climate-related competencies among nurses and nursing students are increasingly recognized as critical to sustainable healthcare delivery. For instance, nursing students have shown high levels of environmental awareness and literacy, underlining the importance of integrating environmental health content into both nursing curricula and ongoing professional training [13,14]. At the same time, HCPs report recognizing the relevance of climate change but feeling inadequately informed or equipped to address it in clinical practice, often due to time constraints, limited information, and insufficient training materials [15]. Together, these findings underscore a global need for targeted interventions and validated instruments to assess and enhance environmental awareness and climate literacy within the nursing profession.”

We thank the reviewer for this valuable observation. To strengthen the connection between the theoretical basis of the NEAT and the rationale for this study, we have added a paragraph clarifying why the NEAT is an appropriate instrument for assessing nurses’ environmental awareness. We also explain why a cross-cultural validation in the Italian context is essential, given the lack of existing tools adapted for the local healthcare system.

(Page 3, Lines 97-99) “In Italy, where nurses actively support sustainability efforts but lack a validated assessment tool [9], an Italian version of the NEAT is needed to support education, policy, and practice.”

Literature review

The review incorporates global statistics and cross-references the Spanish adaptation and development of the NEAT. It refers to conceptual frameworks (Integrated Change Model, EWT-E Wheel) but only briefly incorporates them.

Breadth: The review lacks support from recent literature (post-2022) on nurses' sustainability behavior or environmental education interventions. Include recent European or international studies that examine sustainability competencies in healthcare (e.g., climate literacy, green behavior).

Depth: There are theoretical models mentioned but not fully developed. Describe how the Integrated Change Model explains the awareness/behavior relationship and how the EWT-E Wheel maps onto the NEAT's subscales.

Alignment: The alignment of the review and the emphasis on validation (e.g., justification for psychometric testing) is weak. Add references to cross-cultural validation procedures and semantic equivalence in psychological test translation.

We thank the reviewer for this insightful suggestion. We have now revised the introduction to include recent European and international literature (post-2022) related to nurses’ sustainability behaviors and environmental education interventions. This addition strengthens the rationale for our study and supports the urgent need for validated tools such as the NEAT in diverse healthcare systems.

(Page 2, Lines 76-86) “Recent literature further emphasize that climate-related competencies among nurses and nursing students are increasingly recognized as critical to sustainable healthcare delivery. For instance, nursing students have shown high levels of environmental awareness and literacy, underlining the importance of integrating environmental health content into both nursing curricula and ongoing professional training [13,14]. At the same time, HCPs report recognizing the relevance of climate change but feeling inadequately informed or equipped to address it in clinical practice, often due to time constraints, limited information, and insufficient training materials [15]. Together, these findings underscore a global need for targeted interventions and validated instruments to assess and enhance environmental awareness and climate literacy within the nursing profession.”

Thank you for your valuable comment. To improve theoretical clarity, we have expanded the description of the Integrated Change Model and the EWT-E Wheel in the introduction. We now explain how the Integrated Change Model supports the relationship between awareness and behavior, and how the EWT-E Wheel conceptually aligns with the NEAT’s subscales. These revisions enhance the theoretical justification for using the NEAT in this study.

(Page 3, Lines 102-114) " Originally developed and tested by Schenk et al. (2015), the questionnaire is grounded in two complementary theoretical frameworks: the Integrated Change Model and the EWT-E Wheel. The Integrated Change Model proposes that behavior change is influenced by awareness, motivation, and perceived ability to act, highlighting the importance of understanding beliefs and attitudes as precursors to ecological behaviors [19]. This framework supports the NEAT’s focus on both awareness and behavioral domains. In parallel, the EWT-E Wheel provides a practical lens for categorizing environmental impacts within healthcare, organized into four domains: energy, waste, toxicants, and engagement [16]. These domains are reflected in the NEAT’s subscales, which assess nurses’ awareness of how daily clinical practices intersect with resource consumption, pollution, and opportunities for sustainability engagement. Together, these models provide a solid theoretical foundation for the NEAT and support its application in evaluating nurses’ environmental awareness.”

Thank you for your suggestion. We have provided a reference to support cross-cultural validation.

(Page 3, Lines 121) Citation #21 - Stevelink, S., & Brakel, W. (2013). The cross-cultural equivalence of participation instruments: a systematic review. Disability and Rehabilitation, 35, 1256 - 1268. https://doi.org/10.3109/09638288.2012.731132.

The process follows a five-step model of validation involving forward and backward translation, synthesis, expert consultation, face validity, and pilot testing. It also clarifies data collection, characteristics of the participants, and psychometric assessment.

We sincerely thank the reviewer for this positive remark. We are pleased that the description of the five-step validation process, as well as the details provided regarding data collection, participant characteristics, and psychometric assessment, were clear and informative.

Sample Description

The students and professionals in nursing might well offer variability as a combined group, but there is no subgroup analysis provided. Justify combining the two groups or give subgroup comparisons.

Convenience Sampling is used without critical thinking. Discuss the possibility of bias and how it can restrict generalizability.

We thank the reviewer for this insightful comment. While we recognize the potential for variability between nursing students and nurses, our decision to analyze them as a single group aligns with the primary objective of this study: to validate an instrument that can be broadly applied across different stages of the nursing profession. The NEAT is intended to be used for educational purposes, to assess environmental awareness, and to inform sustainability-related policies in healthcare. Including both students and practicing nurses supports this comprehensive approach by capturing perspectives along the continuum of nursing education and clinical experience. We have clarified this in the limitations.

(Page 14, Lines 512-529) “With regard to the representativeness of the sample, the participating nurses were drawn from a variety of clinical settings, ensuring diversity in terms of working environments. However, they shared a relatively homogeneous educational background. Similarly, the nursing students had completed internships across different care contexts, which contributed to capturing diverse perspectives on environmental awareness in healthcare. The decision to analyze students and nurses as a single group was guided by the aim of validating a tool that can be used in both educational and clinical contexts to assess environmental awareness and support sustainability-related policies in nursing. Furthermore, this study used a convenience sampling approach, which may introduce selection bias and limit the generalizability of the findings. Participants were recruited from specific academic and clinical settings, and may not fully represent the broader population of Italian nurses and nursing students. As a result, the sample may be skewed toward individuals with a particular interest in sustainability or those more available to participate in research. While the diversity of clinical contexts adds some variability, caution is warranted when extrapolating the results to the entire nursing workforce. Future studies employing probabilistic sampling methods could help to strengthen the external validity of the NEAT's psychometric properties.”

We thank the reviewer for this important observation. We acknowledge that the use of convenience sampling may introduce selection bias and limit the generalizability of our findings. In response, we have added a statement to the Limitations section of the manuscript to critically reflect on this issue and its implications for external validity. We also suggest that future studies adopt probabilistic sampling methods to further strengthen the generalizability of the NEAT’s psychometric properties.

(Page 14, Lines 512-529) “With regard to the representativeness of the sample, the participating nurses were drawn from a variety of clinical settings, ensuring diversity in terms of working environments. However, they shared a relatively homogeneous educational background. Similarly, the nursing students had completed internships across different care contexts, which contributed to capturing diverse perspectives on environmental awareness in healthcare. The decision to analyze students and nurses as a single group was guided by the aim of validating a tool that can be used in both educational and clinical contexts to assess environmental awareness and support sustainability-related policies in nursing. Furthermore, this study used a convenience sampling approach, which may introduce selection bias and limit the generalizability of the findings. Participants were recruited from specific academic and clinical settings, and may not fully represent the broader population of Italian nurses and nursing students. As a result, the sample may be skewed toward individuals with a particular interest in sustainability or those more available to participate in research. While the diversity of clinical contexts adds some variability, caution is warranted when extrapolating the results to the entire nursing workforce. Future studies employing probabilistic sampling methods could help to strengthen the external validity of the NEAT's psychometric properties.”

New Items

There were two new items added to the NPEB subscale, but their development and psychometric performance are not discussed. Rationale for reintroduction and item-level analysis (e.g., factor loading, item-total correlation) must be given.

Thank for pointing out this issue. We thank the reviewer for this insightful comment. In response, we have expanded the Methods section to clarify the development process of the two new items, which were derived from expert suggestions, refined by the research team, and subsequently tested. We have also added a brief comment on their psychometric performance in the Results section and included detailed item-level data in Supplementary Table S1.

(Page 5, Lines 212-224) “Experts independently rated each item of the instrument using a four-point Likert scale, ranging from 0 (not representative) to 4 (strongly representative), and were invited to suggest new items if they identified missing content areas. Based on their input, two new items related to healthcare waste minimization and segregation were proposed. These topics are closely aligned with environmental awareness, as effective healthcare waste management is considered a core component of safe and sustainable care, in line with WHO recommendations [24]. The research team drafted the items based on the experts’ suggestions and refined them through iterative review before incorporating them into the NPEB subscale. Notably, these items were part of the original NEAT tool developed by Schenk et al. but were removed during the validation [16,20]. After obtaining authorization from the original authors, the two items were reintroduced in the Italian version and included in subsequent pilot testing and psychometric evaluation.”

We have now discussed the psychometric performance, as well as the motivation for retention of the two new items added to the NPEB subscale.

(Page 12, Lines 432-434) “Their reintroduction in the Italian version is supported by positive psychometric performance and allows for the assessment of these aspects within the specific context of Italian nursing practice.”

Test-Retest Reliability is lacking. Acknowledge this as a shortcoming and recommend longitudinal measurement in subsequent research.

We thank the reviewer for this important observation. We agree that test–retest reliability is a key aspect of psychometric evaluation. While this limitation was noted in the original manuscript, we have now expanded the statement in the Limitations section to more clearly acknowledge the lack of longitudinal data and to recommend that future research address this aspect of the instrument’s validity.

(Page 14, Lines 529-534) “Finally, a test–retest reliability assessment should be conducted to evaluate the instrument’s stability over time. The lack of longitudinal data in the present study represents a methodological limitation, as temporal stability is an essential component of construct validation. Future research should assess the NEAT’s reliability over time to confirm its consistency and usefulness for repeated measurement in educational or clinical interventions.”

Normality Assumption

Despite non-normality being mentioned by the authors, no statistical tests (i.e., skewness/kurtosis, Shapiro-Wilk) are mentioned. Include normality diagnostics or use robust estimators (e.g., MLR or WLSMV).

We thank the reviewer for this helpful suggestion. As noted, we assessed the normality of our data using skewness and kurtosis values, which confirmed the presence of non-normality consistent with previous NEAT validation studies. While we did not include these values in the original manuscript for the sake of conciseness, we have now amended the Data Analysis section to reflect this assessment and added a table with item-level skewness and kurtosis values in the supplementary materials (Table S1).

Factor Retention

Based only on eigenvalues ≥ 1. Use parallel analysis or scree plot for more optimal factor retention determination

We thank the reviewer for this suggestion. In addition to retaining factors with eigenvalues ≥ 1, we also used a scree plot to support the decision regarding factor retention, although this was not mentioned in the original version of the manuscript. We have now updated the Methods section to include this information.

(Page 6, Lines 280-281) “In the EFA, factors with an eigenvalue ≥ 1 were retained, and a visual inspection of the scree plot was used to support the determination of the number of factors to extract.”

EFA Loadings

Presented only in supplementary material. Include a summary table of factor loadings in the main text to make it more readable.

Thank you for your suggestion. We have now provided three summary tables of factor loadings in the main text (Tables 2, 3, 4).

Pearson Correlations used for ordinal data.

Use Spearman's rho or polychoric correlations on Likert-type items.

We thank the reviewer for this important observation. We acknowledge that Likert-type items are ordinal in nature, and therefore, Spearman’s rho is more appropriate than Pearson’s coefficients. In response to this comment, we have revised our analysis by replacing Pearson correlations with Spearman’s rho where appropriate, to better reflect the ordinal properties of the NEAT items. These changes have been updated in the Results and the corresponding table (Table 7).

No item-level performance data is presented for the additional items.

Present item statistics for the two additional NPEB items.

Thank you for your suggestion. We have now provided the item-level performance of the two additional items in Supplementary Table S1. Furthermore, the factor loadings of individual items, including the new ones, are now presented in the main text (Table 4). This allows for a more comprehensive evaluation of the performance and contribution of the newly added items.

CFA indices may be interpreted more completely. Define what moderate fit in NAS II and NPEB II entails and if model revision may be needed.

Thank you for raising this point. We have provided a definition of our hypotheses in the discussion.

(Page 12-13, Lines 433-454) “While the CFA supported the overall structure identified in previous validation studies [18,20], two subscales (NAS II and NPEB II) showed moderate fit indexes. This may suggest that certain items within these subscales did not perform as strongly in the Italian context. A possible explanation could cultural and systemic differences in how Italian nurses and nursing students perceive the environmental impact of healthcare, particularly regarding institutional-level environmental practices (NAS II) or challenges in carrying out professional ecological behaviors (NPEB II). In particular, organizational structures, policy environments, and interprofessional dynamics in Italian healthcare may differ from those in the contexts where the original NEAT was developed and validated. Further research should explore whether refinement of these subscales or cultural adaptation of specific items may enhance model fit and conceptual relevance.”

Subscale Correlation Analysis is demonstrated but not explained. the implication of high correlations (e.g., PEB I and PEB II) for conceptual overlap or construct distinctiveness.

Thank you for your suggestion. We have discussed the possible conceptual overlapping of the subscales starting from the new findings obtained.

(Page 13, Lines 457-461) “These findings, together with evidence supporting the construct validity of the NEAT subscales, confirm the internal consistency of the instrument. With the exception of one non-significant correlation, possibly reflecting distinct underlying constructs between NAS II and NPEB II, the remaining correlations were mostly weak to moderate and consistent across dimensions, thereby limiting the risk of conceptual overlap.”

Discussion

The discussion restates the findings of validation, refers to significant findings such as narrow knowledge (NAS I), and places results in context with prior validations. It proposes educational interventions and outlines limitations.

We thank the reviewer for this positive and encouraging feedback. We are pleased that the discussion effectively contextualizes the validation findings, highlights key results such as the limited knowledge observed in NAS I, and outlines both educational implications and study limitations. We appreciate your thoughtful review.

Transitions between practice implications and psychometric findings are abrupt.

Bridging sentences to link statistical outcomes with practice applications (e.g., why certain subscales might be useful for educational planning).

Implications for education and policy are underdeveloped.

 Suggest specific mechanisms through which the NEAT could be integrated into nursing school curricula or continuing education.

We thank the reviewers for these insightful comments. In response, we have expanded the Discussion section to include a dedicated paragraph linking psychometric findings with practical applications. This new content outlines how the NEAT subscales can be used to inform educational planning, guide staff training, and support institutional and national strategies for promoting sustainability in healthcare.

(Page 13-14; Lines 490-505) “The psychometric robustness of the Italian NEAT supports its use not only as a research instrument but also as a practical tool in nursing education and policy development. For instance, subscales such as NAS I, which focuses on awareness of sustainability concepts, and NPEB I, which measures engagement in professional ecological behaviors, can be particularly valuable for identifying knowledge gaps and behavioral trends among nursing students and professionals [8]. These insights can inform the design of targeted educational interventions, such as integrating sustainability modules into nursing curricula or simulation-based training focused on eco-conscious clinical decision-making. In academic settings, the NEAT could be administered at different stages of nursing education to monitor progress and evaluate the impact of environmental health content [40]. In clinical contexts, it could serve as a component of continuing professional development, informing staff training programs aimed at reducing the environmental footprint of healthcare practices. At a broader level, the NEAT may also contribute to national or institutional sustainability strategies by offering a standardized method to assess and monitor nurses' awareness and engagement with environmental issues over time.

Theoretical models are not re-examined on the basis of findings.

Reflect on briefly how findings support or oppose the Integrated Change Model and EWT-E Wheel.

Thank you for this suggestion. We have included a brief sentence to relocate the findings against the theoretical models.

(Page 13, Lines 463-466) “Overall, the findings align with the Integrated Change Model and the EWT-E Wheel [16,19], as the structure and correlations among NEAT subscales reflect the expected links between awareness, motivation, and ecological behaviors across key environmental domains.”

Quality of English Language: The English is fine and does not require any improvement.

Thank you for your positive feedback regarding the quality of the English language. We are glad to know it meets the required standards.

The paper presents a solid and well-executed study; however, several areas require improvement to enhance its clarity and scientific rigor. The abstract should be condensed and more focused on key results and implications. Including specific metrics—such as Cronbach’s α values and model fit indices—would strengthen the credibility of the findings.

Thank you for your valuable feedback. We revised the abstract to make it more concise and focused on the key results and implications. Additionally, we included specific metrics, such as Cronbach’s α values and model fit indices, to enhance the clarity and scientific rigor of the study.

Additionally, the discussion of factor loadings and item performance is largely confined to the supplementary materials. Bringing key points into the main text would improve accessibility and interpretation.

The manuscript should also address why certain subscales (e.g., NAS II, NPEB II) demonstrated weaker fit in the Italian context—potentially exploring cultural norms or differences in healthcare practices as contributing factors

Thank you for your suggestion. As another reviewer has underlined this need, we have chosen to include three specific tables (Tables 2, 3, 4) into the main text to show factor loadings.

Concerning the point about discussing weaker fit indexes from the NAS II and NPEB II subscales, we have provided an interpretation of these findings.

 (Page 12-13, Lines 443-454) “While the CFA supported the overall structure identified in previous validation studies [18,20], two subscales (NAS II and NPEB II) showed moderate fit indexes. This may suggest that certain items within these subscales did not perform as strongly in the Italian context. A possible explanation could cultural and systemic differences in how Italian nurses and nursing students perceive the environmental impact of healthcare, particularly regarding institutional-level environmental practices (NAS II) or challenges in carrying out professional ecological behaviors (NPEB II). In particular, organizational structures, policy environments, and interprofessional dynamics in Italian healthcare may differ from those in the contexts where the original NEAT was developed and validated. Further research should explore whether refinement of these subscales or cultural adaptation of specific items may enhance model fit and conceptual relevance.”

The limitations section is understated and should be expanded to acknowledge the use of convenience sampling, the relatively young mean age of participants, and the absence of a test–retest reliability assessment.

Thank you for raising this point. We have amended the limitations section following your suggestions.

(Page 14, Lines 506-537) “This study has some limitations. The inclusion of participants from a restricted area in North-West of Italy may limit the generalizability of our findings, particularly given regional differences in healthcare provisions and resources. Additionally, the inclusion of both nurses and nursing students could have influenced the results, as participants may have been either more closely engaged with clinical practice or more familiar with knowledge acquired during undergraduate education. Moreover, the inclusion of nursing students likely contributed to the relatively young mean age of the participants. With regard to the representativeness of the sample, the participating nurses were drawn from a variety of clinical settings, ensuring diversity in terms of working environments. However, they shared a relatively homogeneous educational background. Similarly, the nursing students had completed internships across different care contexts, which contributed to capturing diverse perspectives on environmental awareness in healthcare. The decision to analyze students and nurses as a single group was guided by the aim of validating a tool that can be used in both educational and clinical contexts to assess environmental awareness and support sustainability-related policies in nursing. Furthermore, this study used a convenience sampling approach, which may introduce selection bias and limit the generalizability of the findings. Participants were recruited from specific academic and clinical settings, and may not fully represent the broader population of Italian nurses and nursing students. As a result, the sample may be skewed toward individuals with a particular interest in sustainability or those more available to participate in research. While the diversity of clinical contexts adds some variability, caution is warranted when extrapolating the results to the entire nursing workforce. Future studies employing probabilistic sampling methods could help to strengthen the external validity of the NEAT's psychometric properties. Finally, a test–retest reliability assessment should be conducted to evaluate the instrument’s stability over time. The lack of longitudinal data in the present study represents a methodological limitation, as temporal stability is an essential component of construct validation. Future research should assess the NEAT’s reliability over time to confirm its consistency and usefulness for repeated measurement in educational or clinical interventions. However, we followed the COSMIN guidelines and included a substantial multidisciplinary sample to assess content validity. Despite the mixed composition, our sample adhered to the rule of thumb of five to ten participants per item in the Italian NEAT subscales.”

Finally, the authors are encouraged to include a paragraph detailing practical applications of the Italian NEAT, such as its integration into nursing curricula, staff training programs, or broader national strategies for promoting sustainable healthcare.

Thank you for your suggestion. We have included a paragraph with some examples of practical application of the Italian NEAT.

(Page 16-17, Lines 490-505) “The psychometric robustness of the Italian NEAT supports its use not only as a research instrument but also as a practical tool in nursing education and policy development. For instance, subscales such as NAS I, which focuses on awareness of sustainability concepts, and NPEB I, which measures engagement in professional ecological behaviors, can be particularly valuable for identifying knowledge gaps and behavioral trends among nursing students and professionals [8]. These insights can inform the design of targeted educational interventions, such as integrating sustainability modules into nursing curricula or simulation-based training focused on eco-conscious clinical decision-making. In academic settings, the NEAT could be administered at different stages of nursing education to monitor progress and evaluate the impact of environmental health content [40]. In clinical contexts, it could serve as a component of continuing professional development, informing staff training programs aimed at reducing the environmental footprint of healthcare practices. At a broader level, the NEAT may also contribute to national or institutional sustainability strategies by offering a standardized method to assess and monitor nurses' awareness and engagement with environmental issues over time.”

Quality of English Language: The English is fine and does not require any improvement.

Thank you for your positive feedback regarding the quality of the English language. We are glad to know it meets the required standards.

Thank you for allowing me the ability to review your manuscript. This is a very interesting study and timely as well. I have outlined a few suggestions below to help with the improvement of communication and clarity.

Thank you for your thoughtful review and positive comments on the relevance of our study. We appreciate your suggestions and have carefully addressed them to improve the clarity and communication of the manuscript.

The introduction can be improved by providing more information on the Italian context and why it is needed in this area now. More detail and justification are needed to help support.

This study would benefit from adding research questions or objectives to achieve. This would also help with the organization of the discussion and conclusions.

Thank you for your suggestion.

We have provided a sentence in which we have described more information about the Italian context and need for developing an instrument.

(Page 2; Lines 60-65) “In Italy, this topic remains relatively understudied; one recent qualitative study reported that nurses expressed concerns about environmental exposures and emphasized the need for targeted training on environmental disease types, exposure pathways, preventive measures, health promotion, and environmental impact [9]. These findings highlight the need for validated instruments that can effectively assess these concepts in the Italian setting.”

There is no literature review added to this manuscript. Any particular reason why? A background is always helpful to support the research being conducted. This manuscript would benefit from a section devoted to a review of previous literature on the subject.

Thank you for raising this point. As proposed by other reviewers, a paragraph has been added to the introduction.

(Page 2, Lines 72-86) “The COVID-19 pandemic further highlighted the urgent need for structured assessments of nurses’ environmental awareness, as level of awareness remained low despite a significant increase in waste production. This gap reinforces the importance of evaluating nurses’ ecological consciousness to inform effective sustainability initiatives and reduce the climate footprint of healthcare systems [5]. Recent literature further emphasize that climate-related competencies among nurses and nursing students are increasingly recognized as critical to sustainable healthcare delivery. For instance, nursing students have shown high levels of environmental awareness and literacy, underlining the importance of integrating environmental health content into both nursing curricula and ongoing professional training. At the same time, HCPs report recognizing the relevance of climate change but feeling inadequately informed or equipped to address it in clinical practice, often due to time constraints, limited information, and insufficient training materials. Together, these findings underscore a global need for targeted interventions and validated instruments to assess and enhance environmental awareness and climate literacy within the nursing profession.”

Please provide more information on NEAT. More information on background, creators, new versions, other studies that used it, and why it is appropriate for this study.

Thank you for your suggestion. More information about the NEAT were provided in the introduction.

(Page 3, Lines 103-118) “Originally developed and tested by Schenk et al. (2015), the questionnaire is grounded in two complementary theoretical frameworks: the Integrated Change Model and the EWT-E Wheel. The Integrated Change Model proposes that behavior change is influenced by awareness, motivation, and perceived ability to act, highlighting the importance of understanding beliefs and attitudes as precursors to ecological behaviors [16]. This framework supports the NEAT’s focus on both awareness and behavioral domains. In parallel, the EWT-E Wheel provides a practical lens for categorizing environmental impacts within healthcare, organized into four domains: energy, waste, toxicants, and engagement [12]. These domains are reflected in the NEAT’s subscales, which assess nurses’ awareness of how daily clinical practices intersect with resource consumption, pollution, and opportunities for sustainability engagement. Together, these models provide a solid theoretical foundation for the NEAT and support its application in evaluating nurses’ environmental awareness. The NEAT questionnaire serves as an essential tool for assessing and comparing nurses' environmental consciousness across different settings. Except for the validation conducted in Spanish [14], an assessment of the psychometric properties of the instrument has never been carried out in languages other than English [15].”

A table could be of benefit to highlight the five phases mentioned in the methods.

Thank you for your suggestion. We have included a specific table to highlight the five phases (Table 1).

How were emails obtained?

The nurses’ email addresses were obtained from the mailing list of those employed by ASL Città di Torino, while the email addresses of the nursing students were provided by the coordinators of the Bachelor’s Degree in Nursing program. This information has been included in the manuscript.

(Page 5, Lines 240-242) “Email addresses for nurses were obtained from the ASL Città di Torino mailing list, while those of nursing students were provided by the program coordinators.”

Did the nursing students need to have some experience to be a part of the study? I do believe that is an important criterion.

Thank you for your question. As specified at the end of the first paragraph of the Methods section (Page 3, Line 131-134), only nursing students with prior clinical experience were eligible for inclusion in the study. Furthermore, the previous experience of nursing students has now been discussed in the limitations section.

(Page 14, Lines 506-517) “This study has some limitations. The inclusion of participants from a restricted area in North-West of Italy may limit the generalizability of our findings, particularly given regional differences in healthcare provisions and resources. Additionally, the inclusion of both nurses and nursing students could have influenced the results, as participants may have been either more closely engaged with clinical practice or more familiar with knowledge acquired during undergraduate education. Moreover, the inclusion of nursing students likely contributed to the relatively young mean age of the participants. With regard to the representativeness of the sample, the participating nurses were drawn from a variety of clinical settings, ensuring diversity in terms of working environments. However, they shared a relatively homogeneous educational background. Similarly, the nursing students had completed internships across different care contexts, which contributed to capturing diverse perspectives on environmental awareness in healthcare.”

Discussions and conclusions are superficial. What is the so what of the study. What are the implications? More is needed here to wrap up the study.

Thank you for this helpful suggestion. We have revised the discussion to better highlight the practical implications of the study.

We have amended the conclusions. (Page 14-15, Lines 540-558) “This study adapted and psychometrically validated an Italian version of the NEAT, supporting its use in the Italian context. The instrument demonstrated satisfactory validity and reliability, confirming its potential for assessing environmental awareness among both nursing students and professionals. By capturing both cognitive and behavioral dimensions of sustainability, the NEAT represents a valuable resource for evaluating educational needs and monitoring the impact of interventions aimed at promoting environmentally responsible practices in healthcare.

The findings have important implications for nursing education and policy. The NEAT can be used in academic settings to guide curriculum development and in clinical contexts to inform professional training and sustainability initiatives. Furthermore, the instrument provides a foundation for future research exploring the factors that influence environmental awareness in nursing and its relationship to practice change.

While the use of a convenience sample limits generalizability, the inclusion of a diverse population across educational and clinical settings enhances the ecological relevance of the findings. Future studies should consider broader and more representative samples to further validate the tool and support its international application.

In conclusion, the Italian NEAT is a theoretically grounded and psychometrically sound instrument that can contribute to building sustainability competencies among nurses, paving the path toward achieving environmentally responsible healthcare.”

Quality of English Language: The English is fine and does not require any improvement.

Thank you for your positive feedback regarding the quality of the English language. We are glad to know it meets the required standards.

Thank you for taking the time to address my comments. The manuscript is improved, yet there were some areas not addressed.

Thank you for your thoughtful review and positive comments on the relevance of our study. We appreciate your suggestions and have carefully addressed them to improve the clarity and communication of the manuscript.

This study would benefit from adding research questions or objectives to achieve. This would also help with the organization of the discussion and conclusions.

We thank the reviewer for this suggestion. While psychometric validation studies do not typically follow a hypothesis-testing framework—given their exploratory or confirmatory nature and emphasis on evaluating measurement properties rather than testing directional assumptions (DeVellis, 2016 - Scale Development: Theory and Applications; Boateng et al., 2018 - Best practices for developing and validating scales for health, social, and behavioral research. Frontiers in Public Health; COSMIN guidelines)—we acknowledge that clearly stated objectives or guiding questions can enhance the structure and interpretability of the study. Therefore, in response to the reviewer’s comment, we have added a set of research questions at the end of the Introduction to clarify the study’s aims and support the organization of the discussion and conclusions.

(Page 3, Lines 129-136) “To guide this process, the following questions were considered:

-                Does the Italian version of the NEAT demonstrate adequate content and face validity, as evaluated by expert judgment and pilot testing?

-                Does the factor structure of the Italian NEAT reflect the dimensionality identified in previous validation studies?

-                Does the Italian NEAT show satisfactory reliability, as measured by internal consistency across its subscales?

-                Do the correlations among subscales support its construct validity in the Italian context?”

There is no literature review added to this manuscript. Any particular reason why? A background is always helpful to support the research being conducted. This manuscript would benefit from a section devoted to a review of previous literature on the subject.

We thank the reviewer for this comment. While we did not include a separate “Literature Review” section, we intentionally integrated a thorough review of relevant literature into the Introduction, in line with standard conventions for psychometric validation studies. This background section comprises over 1,000 words and includes 21 references, covering:

- the environmental impact of healthcare,

- nurses’ roles in sustainability,

- existing tools for assessing environmental awareness,

- theoretical frameworks underpinning the NEAT,

- recent international studies on climate literacy and education in nursing.

Given the breadth and depth of the content already presented, we believe this approach effectively supports the study rationale and aligns with the manuscript’s aims. We have, however, revisited the Introduction and made minor refinements to further emphasize the literature base and enhance coherence.

(Page 2, Lines 87-89) “Although recent literature emphasizes the need for assessing and enhancing climate literacy and environmental behaviors among nurses [5,12], few validated tools exist to support such evaluation efforts.”

(Page 3, Lines 119-121) “The NEAT questionnaire serves as an essential tool for assessing and comparing nurses' environmental consciousness across different settings and has been the subject of prior validation studies in English [20] and Spanish [18], highlighting its relevance for cross-cultural adaptation and broader international use.”