Trust in the Leader, Organizational Commitment, and Nurses’ Intention to Leave—Insights from a Nationwide Study Using Structural Equation Modeling

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors start from the awareness that approximately a third of nurses intend to change jobs (both Italian and international data). They are well aware of the multifactorial dimension of the phenomenon, but decide to focus on the phenomenon of trust in the leader, which is presented as the element of originality in the literature of this work (p. 3). The data collection methodology (consider paragraph 2.4) is very good, which makes the authors' conclusion solid and well supported. A further advantage, in my opinion, is that the focus on trust in the leader is not a phenomenon that can be immediately understood and analyzed: other factors are in fact those that can most easily be taken into consideration (for example: burnout, shifts, salaries) . This research therefore offers the advantage of highlighting a decidedly important aspect, which however is not considered in the literature.

The work is usefully divided into five hypotheses.

The distinction between nurses working in the public and private sectors is very interesting, but perhaps it could be explored further (also with a note that implements the considerations). Other aspects (marginal for this research but which, with notes, could be implemented) that could be considered are: 1) the intention to change place of work but continuing to work as a nurse; 2) the intention to change place of work to continue working as a nurse abroad.

My overall opinion of this work is highly positive.

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The article does not provide new information, but rather it emphasizes what is already known. Although, as the authors point out, in Italy there does not seem to be a study that provides evidence of the importance of trust with the leader in the commitment and satisfaction of nurses in their jobs. 

The abstract makes clear the objective of the work, it would be missing to indicate the strengths of this. Appropriate keywords, instead of leaving the acronym SEM, put: Structural Equation Modeling

The manuscript is presented in a well-structured way.

The introduction is very repetitive in the general ideas, it can be improved.

In point 2.4 they indicate 3 categories for sex, however, in Table 1 only 1 of them appears (female). Nothing is indicated about the other two.

They do not distinguish between nurses with a permanent position and those who are working on a temporary basis, which may lead to higher turnover. The turnover of nurses in public health is not so much due to a lack of trust and commitment to the organization, but rather to the lack of long and stable contracts. Demotivation is due to job insecurity. There is a great difference in the jobs held by nurses in public and private centers and this reality should be taken into account by the authors. 

They say that they included nurses with two months of seniority in the position, but I think that this is not enough time to generate the necessary trust with the leader or with the institution. Refusing to participate is not an exclusion criterion, since they will not have signed the IC, it is obvious.

The authors have used scales appropriate to the objective of the work.

They do not delve into the causes of lack of commitment or lack of trust with the leader, for example. It is obvious that if there is distrust and a nurse does not identify with the company where she works, it produces little commitment. As the authors indicate, they do not delve into the specific aspects of managerial leadership style, which would have been very interesting. I think they lack analysis of the problems with leaders, competencies and years of experience. They discuss aspects that they have not studied and would have been interesting such as the behaviors that shape trust or the qualities of a good manager.

The quotes are adequate. Likewise the tables and graphs are appropriate.

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Reviewer 3 Report

Comments and Suggestions for Authors

The authors tested a model to examine the impact of trust in nursing leaders on nurses’ intention to leave as mediated by organizational commitment using a sample of nurses employed in various healthcare sectors across Italy. As the authors have argued, understanding factors that impact nursing turnover is critical given the global nursing shortage that has been exaggerated since the pandemic. The paper is well-written with sound logical reasoning for each set of relationships between variables in the study model. The explanation of the study design and methods was clear. The sample size was justified via a power analysis and was sufficient to conduct the CFA and SEM analyses. The response rate of 92% was impressive as often nurses are too busy to participate in surveys. Your success strategies would be useful to include. The data analysis and results were described in sufficient detail. The discussion was balanced and included strategies for nurse managers and organizations to build trust, commitment and thereby mitigate nurses’ intentions to leave. Suggestions for future research were thoughtful and the limitations noted were reasonable. Overall, this report was a pleasure to read.

In the interest of enhancing the quality of the report further, the following comments and suggestions are offered for consideration.

 

Abstract – final sentence – reference is made to well-being. Suggest removing this as the study did not include an examination of this variable.

Page2, line 62 – Suggest replacing ‘Consequently’ with ‘Alternatively’

Page 3 – The introduction was thorough but suggest adding in some discussion about the concept of commitment and the reason this variable was selected. I think the discussion should be proportionate for each study variable. As well, it would be useful to mention why ‘age’ was used in the study model.

Page 4, line 170 – You have stated that nurses and nurse managers were invited to participate in the study. The inclusion of nurse managers is confusing as the focus seems to be on direct care nurses. Later, in the results section, there is no mention of how many nurse managers were in the sample which would be useful information.

Page 5, line 217-26 – The explanation of the survey instrument to measure trust was useful but it might help to add a statement to show the link between the conceptual definition of trust (p. 2) and the operational definition you have provided (to support how they are aligned).

Page 6, line248 – You have stated that the Cronbach alphas were within permissible ranges. It would be useful to include the range that was identified across all instruments e.g. 0.70-0.92 or whatever.

-line 253 – I find this sentence somewhat awkward. I think it would be easier to understand if the variable is mentioned first i.e., ‘We specified Trust in the leader as the independent variable, Organizational commitment as the mediator and Intention to leave as the dependent variable.’

-line 257 – suggest replacing ‘was’ with ‘the goodness of fit values were…’

-line 267 – It was stated that missing data for each variable was below 5% but on line 273, you note there was no missing data. This seems to be contradictory.

-line 282 – It would be helpful for interpreting the results if the range for each variable was also included e.g., trust in leader in the entire sample was 3.6 (SD=0.7, range 0-5). This could be added to Table 1 as well.

-Page 8, There is no discussion on the results related to age as a variable in the study model. It would also be useful to include the overall R² for the study model so that the reader can understand the overall amount of impact the study variables had in explaining intention to leave.

-Page 10, line 374 – You have stated that trustful relationships serve as a potent catalyst for nurse retention and ‘potentially outweighing workload and other factors’. Given the size of the beta coefficients, I don’t think that you can make this claim i.e., to outweigh the impact of workload (based on my experience studying nursing workload). Perhaps it would be more appropriate to state that trust could ‘potentially mitigate to some degree’ the impact of environmental factors such as workload.

-line 383 – Suggest replacing ‘thereby’ with ‘but also’. The discussion on the leader’s role in developing trust is thorough. My only suggestion would be to link it back to your conceptual definition of trust as well.

Page 12 – The title of the paper begins with ‘unveiling the nexus’. It would be helpful to mention this concept in the discussion or conclusion section so that this phrase in the title is more meaningful.

Author Response

Please see the attachment

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have responded to all the issues raised.