Impact of Work Motivation on Occupational Health in Healthcare Workers

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1. thank you for your paper hard working.

2. few suggestions for the paper

- IRB needed ; participants in the paper are human, so must be considered to IRB before the study started.

- papers regarding work motivition in many job areas are published very much in the world, that's why the conclusions are all similar to"autonomous motivation" which is quite simple meaning. it's too general topic.

Author Response

• IRB needed ; participants in the paper are human, so must be considered to IRB before the study started.

 

The following sentence has been added to the Materials and Methods section of the manuscript:

“All workers were enrolled during the periodic medical examinations required by Italian Law. As part of the standard occupational health surveillance, the study needed no formal approval by the local ethics committee. Nevertheless, the committee was consulted and it granted an informal authorization. Workers provided their consent after receiving information about the purpose and procedures of the study, which was conducted according to the Helsinki Statement of Ethical Standards.”

 

• papers regarding work motivition in many job areas are published very much in the world, that's why the conclusions are all similar to "autonomous motivation" which is quite simple meaning. it's too general topic.

 

The “autonomous” motivation involves a self-determined behavior which is perceived as consistent with intrinsic personal goals. This is plausibly the most authentic and effective form of subjective motivation, including motivation at work (and so it may sound too general as a topic), still it is a well-recognized and largely operated construct in the psychological scientific literature.

Reviewer 2 Report

Comments and Suggestions for Authors

There is a lack of creative approaches in research design. There are many similar studies. Has this study received ethical approval? What measures were taken to protect research participants? Did the people who participated in data collection receive the same training? On what basis was the number of research participants decided? A large number of research participants is not necessarily important. There is a need to organize the research results more concisely. In order for this study to maintain validity as a scientific basis, it is necessary to reorganize the table according to the research purpose.

 

The reference should be deleted from the Conclusion section. The Conclusion section should not contain repetitive descriptions or discussions of research results. That part should conclude with recommendations for future research and the possible impact on clinical practice based on the research results.

Author Response

• There is a lack of creative approaches in research design. There are many similar studies. Has this study received ethical approval?

 

The following sentence has been added to the Materials and Methods section of the manuscript:

“All workers were enrolled during the periodic medical examinations required by Italian Law. As part of the standard occupational health surveillance, the study needed no formal approval by the local ethics committee. Nevertheless, the committee was consulted and it granted an informal authorization. Workers provided their consent after receiving information about the purpose and procedures of the study, which was conducted according to the Helsinki Statement of Ethical Standards.”

 

• What measures were taken to protect research participants? Did the people who participated in data collection receive the same training?

 

We believe that the text already contains the requested information (Study Design and Sample), and we fear that adding more would only risk making the manuscript heavier. The sentences concerning this issue are as follows: “Nurse managers were asked to actively collaborate in advertising the study and recruiting participants, after attending a preliminary meeting, in which the aims and methodology of the study were thoroughly presented.” Moreover, a few lines below: “The anonymous and self-administered survey, validated by calculating the “Cronbach’s α” coefficient, was an Italian version, web-based format questionnaire, and it was sent to healthcare professionals via business or personal e-mail address. At the beginning, respondents were given a brief explanatory introduction to the main study-related topics and the legislative reference regarding personal data handling and protection (European Regulation 679/2016), to which the participants consented by completing the form.”

 

• On what basis was the number of research participants decided? A large number of research participants is not necessarily important.

 

We fully agree on this concept. In an early stage of project planning we did run a power analysis, but then we decided to collect data from as many workers as possible, and we recruited all those who agreed to participate (falling within the inclusion criteria). This procedure yielded a number of study participants which exceeded the smallest sample size to detect the desired level of significance, yet certainly adequate for performing reliable statistical analyses.

 

• There is a need to organize the research results more concisely. In order for this study to maintain validity as a scientific basis, it is necessary to reorganize the table according to the research purpose.

 

In the Results section, only the main findings are explicitly reported in the text, and subheading help organizing the content into readily recognizable subchapters to facilitate reading. Furthermore, we believe that tables are indeed organized according to the research purpose and results.

 

• The reference should be deleted from the Conclusion section. The Conclusion section should not contain repetitive descriptions or discussions of research results. That part should conclude with recommendations for future research and the possible impact on clinical practice based on the research results.

 

According to referee’s suggestion: i) references #38 and #10 have been deleted from the “Conclusions” section; ii) the following sentence has been also removed: “The present results confirm and extend data supporting the relevance of work motivation in several aspects related to the occupational health and well-being among HCWs”.

As for the possible impact of our results, we did emphasize the relevance of data for improving well-being and job performances of health workers, since our findings should advise the Healthcare Institution to plan and implement programs aimed at monitoring and reinforcing work motivation. At the end of the “Conclusion” section it is stated: “present data underline the urge for the healthcare organizations to design and implement effective programs aimed at monitoring and potentiating the work motivation, as means of preserving HCW’s well-being and job satisfaction, thereby preventing negative consequences on the health trajectories of personnel and on the quality of care delivered to patients”.

Reviewer 3 Report

Comments and Suggestions for Authors

Dear Authors,

This is an interesting study investigating the impact of work motivation on occupational health in healthcare workers. Few recommendations:

Please provide the necessary information about the study approval by the Clinical Research Ethics Committee of your Institution: "This study was approved by the XXX ethics Committee of XXX Hospital/University (registration number, date).

Lines 191-197: The multiple-choice questions exploring the occupational health seems like an amalgam from diverse measurements. Briefer measures might be desirable for use as part of comprehensive health questionnaires as long as they are reliable and valid. Please explain the source of the instrument and confirm reliability and validity.

In Statistical Analysis section do multiple linear regression models satisfy key assumptions?

In results section footnotes below the tables should not merge with the rest of the text.

Table 4a is duplicated. Please delete the second one.

In conclusions section the first sentence, lines 516-519 belong to discussion section.

In reference section reference 3 and 19 are identical.

Comments on the Quality of English Language

Moderate editing of English language is required. Please revise lines: 300, 383-384, 489. 

Author Response

• Please provide the necessary information about the study approval by the Clinical Research Ethics Committee of your Institution: "This study was approved by the XXX ethics Committee of XXX Hospital/University (registration number, date).

 

The following sentence has been added to the Materials and Methods section of the manuscript:

“All workers were enrolled during the periodic medical examinations required by Italian Law. As part of the standard occupational health surveillance, the study needed no formal approval by the local ethics committee. Nevertheless, the committee was consulted and it granted an informal authorization. Workers provided their consent after receiving information about the purpose and procedures of the study, which was conducted according to the Helsinki Statement of Ethical Standards.”

 

• Lines 191-197: The multiple-choice questions exploring the occupational health seems like an amalgam from diverse measurements. Briefer measures might be desirable for use as part of comprehensive health questionnaires as long as they are reliable and valid. Please explain the source of the instrument and confirm reliability and validity.

 

The multiple-choice questions used to explore the occupational health consists indeed of diverse measurements, and it is taken from the work published by Moller and collegues (Moller; A. C.; Jager, A. J.; Williams, G. C.; Kao, A. C. US physicians’ work motivation and their occupational health A national survey of practicing physicians. Med Care 2019,57(5),334-40), who similarly investigated the relationship between work motivation and occupational health among a group of physicians. In our survey, we applied the same questionnaire to analyze occupational health in healthcare workers other than doctors (e.g. nurses, or midwives, technicians, etc). Moreover, our survey instrument extended the descriptive power of the one used by Moller et al (2019): different from Moller et al., in fact, here we used a multidimensional measure of “burnout” by exploring, besides the “emotional exhaustion” (EE) indicator, also other subcategories of burnout, such as the “depersonalization” (DE) and the “reduced professional achievement” (rPA) indicators.

 

• In Statistical Analysis section do multiple linear regression models satisfy key assumptions?

 

We do believe that multiple linear regression models can satisfy the key assumptions, since all major factors that may influence work motivation and that are considered in the literature have been included in the models.

 

• In results section footnotes below the tables should not merge with the rest of the text.

 

This inconvenient has been corrected.

 

• Table 4a is duplicated. Please delete the second one.

 

Tables 4a and 4b are not identical. In Table 4a we reported data concerning “The effect of work motivation/regulation on six indicators of occupational health”, whereas in Table 4b data concerning “The role of socio-demographic and professional characteristics in the impact between work motivation/regulation and occupational health indicators”.

 

• In conclusions section the first sentence, lines 516-519 belong to discussion section.

 

As requested, the first sentence of the Conclusion section has been moved to the beginning of the Discussion section.

 

• In reference section reference 3 and 19 are identical.

 

We are sorry for the mistake. Reference #19 has been deleted and numbers of quotations have been corrected accordingly.

 

• Comments on the Quality of English Language. Moderate editing of English language is required. Please revise lines: 300, 383-384, 489. 

 

Language has been revised in the lines of the text indicated by the reviewer.

Reviewer 4 Report

Comments and Suggestions for Authors

 

Dear Authors

Thank you for submitting your manuscript, “Impact of work motivation on occupational health in 2 healthcare workers”.  Your work contributes valuable insights to the field. It provides a much-needed perspective on this crucial issue.

Upon careful review, we have identified some areas in the paper that could benefit from revision to enhance clarity, comprehensiveness, and impact.  As a reviewer, I intend to ensure the quality and clarity of the manuscript. In offering this feedback, it's important to note that these are suggestions, and the ultimate decisions rest with the authors and their understanding of the subject and intended audience. Here are our recommendations:

 

 

 

Abstract  

• Clear Objectives: Begin the abstract by clearly stating the study’s objectives. What were the researchers trying to understand or investigate?
• Concise Overview: Provide a concise overview of the key findings and their implications. This helps readers quickly grasp the significance of the study.
• Structural Clarity: Organize the abstract into distinct sections, such as Objectives, Methods, Findings, and Implications. This makes it easier for readers to follow the flow of information.

 

 Introduction 

• Clear and Specific Objectives: The introduction should clearly state the objectives or research questions of the study. What are the specific research goals?
• Definition of Terms: Provide concise definitions or explanations of key terms, such as "occupational health," "autonomous motivation," "controlled motivation," and "burnout syndrome," to ensure that readers have a clear understanding.
• Conciseness: While providing background information is essential, aim for conciseness to maintain the reader's interest and focus on the study’s main objectives.
• Logical Flow: Ensure the information flows logically, supporting the research objectives and hypotheses.

The "Materials and Methods" section of the article outlines the study design, sample selection, and data collection methods effectively. However, there are some suggestions for improvement:

• Clarity and Structure: The section can benefit from a more structured approach, making it easier for readers to follow the study design and data collection process.
• Explanation of Exclusion Criteria: While it's mentioned that certain subjects were excluded from the study, briefly explain why these criteria were chosen and how they relate to the research objectives.
• Instrument Description: Elaborate on the instruments used for data collection, including the "Scale of Motivation At Work" (MAWS) and the "Maslach Burnout Inventory" (MBI). Explain how these instruments are relevant to the research and why they were chosen.
• Data Analysis Plan: Describe the data analysis plan more explicitly, including the statistical methods used for analyzing the collected data. This should give readers a clear understanding of how the research questions will be addressed.

 

Results

Socio-demographic and Professional Characteristics of the Sample

• Clarified the exclusion criteria and the process of questionnaire validation.
• Mentioned the internal consistency results for both work motivation and burnout sections.
• Summarized key socio-demographic characteristics in a clearer manner.

 -  Motivation at Work and Occupational Health

• Grouped the motivation and occupational health findings into distinct paragraphs for better organization.
• Provided a clear summary of participants' motivation levels and sub-categories.
• Presented self-rated occupational well-being indicators in a tabular format for better readability.
• Highlighted key findings regarding participants' general well-being, depressive risk, emotional exhaustion, work satisfaction, and career intentions.
• Clarified the associations between motivation categories and occupational well-being indicators.
• Clarified the associations between sub-categories of regulation types and occupational well-being indicators.
• Clearly outlined the impact of socio-demographic and professional characteristics on the associations between motivation/regulation and occupational health.

 - Motivation at Work and Burnout

• Grouped the findings on motivation and burnout into a separate subsection for clarity.
• Clearly outlined the associations between motivation/regulation scales and burnout indicators.

 

 

 - Discussion

• Structure and Clarity:
• The section could benefit from more subheadings to clearly separate the discussed topics and findings.
• Consider organizing the discussion into subsections, such as "Impact of Work Motivation on Occupational Health," "Moderating Factors," and "COVID-19 Pandemic Considerations."
• Summarize Key Findings:
• Start the section with a concise summary of the main findings discussed in the results section. This will provide context for the discussion that follows.
• Cite Previous Research:
• When referring to the findings of other authors (e.g., [10, 19]), provide proper citations to the corresponding studies. This enhances the credibility of your discussion.
• Interpretation of Gender Findings:
• Address the inconsistency in the role of gender in different models and explain why it might have produced mixed results. Discuss possible reasons for this discrepancy.
• Discussion of the COVID-19 Pandemic:
• Expand on the impact of the COVID-19 pandemic on healthcare workers, especially concerning work motivation, burnout, and occupational health. Consider discussing how the pandemic may have affected the findings or how these findings might be relevant in a post-pandemic context.
• Implications and Recommendations:
• Based on the study's findings, provide clear recommendations or implications for healthcare institutions and organizations. How can they promote and support autonomous motivation among healthcare workers? What strategies can help reduce turnover intention and improve job satisfaction?
• Limitations:
• Discuss the study’s limitations, such as the monocentric and cross-sectional design. Consider proposing directions for future research to address these limitations.
• Conclusion:
• End the discussion with a brief conclusion summarising the key takeaways from the study's findings and their practical implications.

 

 

Conclusions

• Clarity and Structure:
• Begin the section with a clear and concise restatement of the study’s main findings. This will provide readers with a quick summary of the study’s findings.
• Link to Previous Literature:
• Explicitly link your study's findings to the existing literature. Mention specific studies or theories that support your conclusions. This will strengthen the validity of your conclusions.
• Specific Recommendations:
• Provide more specific recommendations for healthcare organizations based on your findings. For example, suggest implementing training programs to enhance autonomous motivation, creating supportive work environments, or tailoring interventions for specific categories of healthcare workers.
• Addressing Stress:
• Discuss in more detail how healthcare organizations can address work-related stress. What specific actions or strategies can they employ to reduce stress and promote well-being among healthcare workers?
• Future Research Directions:
• Propose potential areas for future research. Are there specific work motivation or occupational health aspects that require further investigation? This can help guide future research efforts.
• Highlight the Significance:
• Emphasize the significance of your findings for both healthcare organizations and the healthcare system. How can improvements in work motivation positively impact patient care and outcomes?
• Practical Implementation:
• Discuss the practical steps that healthcare organizations can take to implement the recommendations you've provided. Offer insights into how these changes can be effectively integrated into healthcare settings.
• Final Reflection:
• Conclude the section with a reflection on the broader implications of your study. How might the findings contribute to the overall well-being of healthcare workers and the quality of healthcare services?

Comments on the Quality of English Language

Language use is generally good, but there may be room for minor sentence structure and clarity improvements.

Author Response

Abstract  

•   Clear Objectives: Begin the abstract by clearly stating the study’s objectives. What were the researchers trying to understand or investigate?
•   Concise Overview: Provide a concise overview of the key findings and their implications. This helps readers quickly grasp the significance of the study.
•   Structural Clarity: Organize the abstract into distinct sections, such as Objectives, Methods, Findings, and Implications. This makes it easier for readers to follow the flow of information.

 

The Abstract has been organized into distinct sections according to reviewer’s suggestion.

 

 Introduction 

• Clear and Specific Objectives: The introduction should clearly state the objectives or research questions of the study. What are the specific research goals?

 

Specific research purposes and working hypotheses are stated at the end of the Introduction sections: “The main purpose of the present study was to evaluate, in a group of HCWs working at the “Ospedali Riuniti” of Ancona (Italy): i) if different types of motivation (and their related forms of regulation) display differential associations with occupational health indicators, and ii) the possible impact of socio-demographic and occupational factors on these associations. Here we hypothesized that: i) autonomous work motivation/regulation would be associated with better occupational health indicators; ii) different socio-demographic and professional variables would show differential impact on this association.”

• Definition of Terms: Provide concise definitions or explanations of key terms, such as "occupational health," "autonomous motivation," "controlled motivation," and "burnout syndrome," to ensure that readers have a clear understanding.

 

The term “occupational health” is defined at the beginning of the Introduction section, as follows: “Occupational health, as defined by Avallone and Paplomatas [20], is a complex of diverse cultural and organizational processes that help nourishing the coexistence in work contexts, by promoting and maintaining psycho-physical and social well-being of workers. Such state of health can be characterized by positive indicators of well-being (job satisfaction, belonging, desire to go to work, trust) and by negative ones (desire to change jobs, sense of irrelevance, absence of involvement), which imply malaise and disinterest.”

The terms “autonomous motivation” and “controlled motivation” are defined in the context of the "Self-Determination Theory" (SDT) by Deci and Ryan from line 80 of the Introduction: “Fundamental to SDT is the distinction between different forms of human motivation: the “autonomous” motivation involves a voluntarily undertaken, self-determined behavior, which is perceived as consistent with intrinsic personal goals; the “controlled” motivation, by contrast, involves a behavior forced by external pressure to the self”.

To concisely define the term “burnout syndrome”, the following sentence has been inserted (line 116) and a new quotation has been added: “…that has been defined as a chronic response to stress in the workplace, causing work-related pressure that is out of control and cannot sidestep (Sasaki, M.; Kitaoka-Higashiguchi, K.; Morikawa, Y.; Nakagawa, H. Relationship between stress coping and burnout in Japanese hospital nurses. J. Nurs. Manag. 2009, 17, 359–365).”

• Conciseness: While providing background information is essential, aim for conciseness to maintain the reader's interest and focus on the study’s main objectives.

 

The part of the Introduction section relating to the incidence of burnout syndrome among healthcare workers (from line 120) has been shortened and made more concise, according to reviewer’s suggestion.

 

Materials and Methods

• Clarity and Structure: The section can benefit from a more structured approach, making it easier for readers to follow the study design and data collection process.

 

The “Materials and Methods” section has been reorganized into distinct sections separated by subheadings.

• Explanation of Exclusion Criteria: While it's mentioned that certain subjects were excluded from the study, briefly explain why these criteria were chosen and how they relate to the research objectives.

 

The exclusion criteria were chosen so as to avoid enrolling subjects who could report high levels of stress unrelated to work environment, with the risk of introducing a major bias in data interpretation.

• Instrument Description: Elaborate on the instruments used for data collection, including the "Scale of Motivation At Work" (MAWS) and the "Maslach Burnout Inventory" (MBI). Explain how these instruments are relevant to the research and why they were chosen.

 

We believe that the questionnaires have been adequately described and quoted, and that any further elaboration on the questionnaires would only make the manuscript heavier to the reader. The relevance of the questionnaires is linked: i) to their specificity and effectiveness in measuring the parameters of interest analyzed in our survey; ii) to the extensive use of these instruments in the scientific literature that investigates the same constructs. Briefly stated, MAWS is considered a practical measure of work motivation yielding reliable and valid scores, from the perspective of "Self-Determination Theory" applied to the field of organizational behavior; MBI is the most specific measure of burnout syndrome in healthcare organizations, considering its intensity and frequency (see quotation in the text).

• Data Analysis Plan: Describe the data analysis plan more explicitly, including the statistical methods used for analyzing the collected data. This should give readers a clear understanding of how the research questions will be addressed.

 

We do think that data analysis plan is already adequately described, and clearly understandable for the reader.

 

Results

Socio-demographic and Professional Characteristics of the Sample

• Clarified the exclusion criteria and the process of questionnaire validation.
• Mentioned the internal consistency results for both work motivation and burnout sections.

 

Exclusion criteria have been described in the “Materials and Methods” section. As for questionnaire validation, we added the following sentence in paragraph 3.1 of the “Results” section: “The questionnaire was validated by calculating the “Cronbach’s α” coefficient and it showed a good level of internal consistency for the section of work motivation (α = 0.81) and burnout (α = 0.86)”.

 

• Summarized key socio-demographic characteristics in a clearer manner.

 

The paragraph has been reduced to make it clearer.

Motivation at Work and Occupational Health

• Grouped the motivation and occupational health findings into distinct paragraphs for better organization.
• Provided a clear summary of participants' motivation levels and sub-categories.
• Presented self-rated occupational well-being indicators in a tabular format for better readability.
• Highlighted key findings regarding participants' general well-being, depressive risk, emotional exhaustion, work satisfaction, and career intentions.
• Clarified the associations between motivation categories and occupational well-being indicators.
• Clarified the associations between sub-categories of regulation types and occupational well-being indicators.
• Clearly outlined the impact of socio-demographic and professional characteristics on the associations between motivation/regulation and occupational health.

 Motivation at Work and Burnout

• Grouped the findings on motivation and burnout into a separate subsection for clarity.
• Clearly outlined the associations between motivation/regulation scales and burnout indicators.

 

We are inclined to think that these observations of reviewer #4 point to issues that are already explained in the manuscript, and thus we feel unable to make changes on the text accordingly. Further fragmenting of the manuscript into small subchapters wouldn’t necessarily increase clarity and readability of the paper.  

 

 Discussion

•   Structure and Clarity:
• The section could benefit from more subheadings to clearly separate the discussed topics and findings. Consider organizing the discussion into subsections, such as "Impact of Work Motivation on Occupational Health," "Moderating Factors," and "COVID-19 Pandemic Considerations."

 

The “Discussion” section has been reorganized into subsections separated by subheadings, as requested by the reviewer.

•   Summarize Key Findings:
• Start the section with a concise summary of the main findings discussed in the results section. This will provide context for the discussion that follows.

 

Following reviewer’s suggestion, the following concise summary was added at the beginning of the “Discussion” section: “The results of the present study confirm and extend data supporting the notion that the autonomous form of motivation at work must be considered as an important contributor to occupational well-being among healthcare personnel, and as a relevant protective factor from burnout syndrome. Furthermore, our findings reveal that socio-demographic and professional variables can moderate this relationship.”

• Cite Previous Research:

• When referring to the findings of other authors (e.g., [10, 19]), provide proper citations to the corresponding studies. This enhances the credibility of your discussion.

 

We modified the text according to reviewer’s note.

•   Interpretation of Gender Findings:
• Address the inconsistency in the role of gender in different models and explain why it might have produced mixed results. Discuss possible reasons for this discrepancy.

 

We believe that this particular issue has been extensively discussed in the manuscript: “In our sample, the role played by gender appeared inconsistent. Female gender was more inclined to depressive risk in the regression model correlating work motivation with occupational health indicators (see Table 4b), but being female turned out to be protective from risk of depersonalization in the model correlating motivation with burnout (see Table 5b). This ambiguity could be explained, at least in part, by considering the high complexity of the multifaceted concept of occupational health, which encompasses many different dimensions (including the “emotional exhaustion”, which is also an indicator of the burnout syndrome). In the first regression model, occupational health was considered in its whole, multidimensional complexity (which included a subscale of burnout), whereas the second regression model considered only burnout’s indicators. This observation emphasizes the possibility that using instruments and methodologies which are apparently very similar to each other may still produce markedly divergent results, and it calls for the need of paying great attention, when planning research surveys, in carefully selecting the appropriate indicators and psychometric instruments to investigate the targeted psychological dimensions.”

•   Discussion of the COVID-19 Pandemic:
• Expand on the impact of the COVID-19 pandemic on healthcare workers, especially concerning work motivation, burnout, and occupational health. Consider discussing how the pandemic may have affected the findings or how these findings might be relevant in a post-pandemic context.

 

At the moment, we don’t have data on the possible impact of COVID-19 pandemics on the findings presented in the present manuscript. Therefore, answering this question would be highly speculative, and we prefer to avoid it.

•   Implications and Recommendations:
• Based on the study's findings, provide clear recommendations or implications for healthcare institutions and organizations. How can they promote and support autonomous motivation among healthcare workers? What strategies can help reduce turnover intention and improve job satisfaction?

 

Following the reviewer’s suggestion, the following sentence has been added: “Proactive planning and psychological interventions aimed at increasing support and promoting opportunities for professional growth, responsibility, and autonomy are essential to attenuate work-related stress, to increase work involvement and HCWs’ well-being. In addition, increasing job satisfaction and reducing turnover intention among the personnel is an advantage for the healthcare system in achieving organizational outcomes and saving costs [10].” We believe that planning and implementing strategies of psychological intervention should be tailored to the specific nature, size and complexity of single healthcare institutions; therefore, any further elaboration on detailing specific strategies of intervention would probably be pretentious and fall beyond the scope of the present manuscript.

• Limitations:

• Discuss the study’s limitations, such as the monocentric and cross-sectional design. Consider proposing directions for future research to address these limitations.

 

To address the reviewer’s observation, the following sentence has been added in the paragraph on study limitations: “To evaluate the associations reported in this work more comprehensively and in depth, further research is warranted, including cross-sectional and prospective observational studies, but also intervention studies, to be conducted in a variety of healthcare settings and institutions.”

•   Conclusion:
• End the discussion with a brief conclusion summarising the key takeaways from the study's findings and their practical implications.

 

A brief summary of key take-away findings has been reported in the “Conclusions” section.

 

 Conclusions

•   Clarity and Structure:
• Begin the section with a clear and concise restatement of the study’s main findings. This will provide readers with a quick summary of the study’s findings.

 

The following initial sentence was added to the “Conclusions” section: “Briefly, here we showed that the autonomous form of work motivation positively correlates with occupational well-being and protects from burnout syndrome among healthcare personnel. Socio-demographic, educational and professional variables moderate this link: younger age and higher educational levels fuel the association, whereas operating in intensive and surgical care units has a negative impact.”

•   Link to Previous Literature:
• Explicitly link your study's findings to the existing literature. Mention specific studies or theories that support your conclusions. This will strengthen the validity of your conclusions.

 

Comparisons with evidence from previous works that have dealt with similar themes in healthcare workers were systematically reported in the “Discussion” section. We believe it would be less appropriate in the “Conclusions” section.

• Specific Recommendations:

• Provide more specific recommendations for healthcare organizations based on your findings. For example, suggest implementing training programs to enhance autonomous motivation, creating supportive work environments, or tailoring interventions for specific categories of healthcare workers.

 

See the previous answer to observations raised in “Implications and Recommendations”.

•   Addressing Stress:
• Discuss in more detail how healthcare organizations can address work-related stress. What specific actions or strategies can they employ to reduce stress and promote well-being among healthcare workers?

 

See the previous answer to observations raised in “Implications and Recommendations”.

•   Future Research Directions:
• Propose potential areas for future research. Are there specific work motivation or occupational health aspects that require further investigation? This can help guide future research efforts.

 

This has been done in the “study limitation” paragraph reported in the “Discussion” section.

•   Highlight the Significance:
• Emphasize the significance of your findings for both healthcare organizations and the healthcare system. How can improvements in work motivation positively impact patient care and outcomes?

 

These issues have been presented at the end of the “Discussion” section.

•   Practical Implementation:
• Discuss the practical steps that healthcare organizations can take to implement the recommendations you've provided. Offer insights into how these changes can be effectively integrated into healthcare settings.

 

See the previous answer to observations raised in “Implications and Recommendations”.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

• IRB needed, not  an informal authorization.
•  

Author Response

• IRB needed, not an informal authorization.

 

We do understand the reviewer's observation and concern. In our case, the formal approval by the ethics committee was not necessary because the questionnaires distributed to the workers constituted part of the periodic medical examinations required by Italian Law. No additional procedures to those required by law (prevention of occupational diseases) were performed on the workers. Consent to use the anonymized and collective data for a scientific study and for a scientific publication was obtained from all participants.

As requested, the following paragraph has been added to the Materials and Methods section of the manuscript:

“All workers were enrolled during the periodic medical examinations required by Italian Law. As part of the standard occupational health surveillance, the study needed no formal approval by the local ethics committee. Nevertheless, the committee was consulted and it granted an informal authorization. Workers provided their consent after receiving information about the purpose and procedures of the study, which was conducted according to the Helsinki Statement of Ethical Standards.”