Dear Dr. Abere,

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1: Yes

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2. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

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3. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: No

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Reviewer #1: Thank you for the opportunity to review this manuscript titled "Work autonomy and its associated factors among nurses working in South Gondar zone public hospitals, Amhara regional state, Northcentral Ethiopia."

Overall assessment:

The topic is relevant and helps fill a gap in the literature about professional autonomy in nursing within low-resource settings. The manuscript is generally well-organized and presents a clear research goal supported by appropriate methods. However, some areas need revision to enhance clarity and strength.

Strengths:

- Using a census-based sampling in a specific population improves the completeness of the dataset.

- The statistical approach, particularly multivariable logistic regression with proper adjustment and testing, is appropriate.

- The conclusions align with the results.

Concerns and suggestions:

1. Language and grammar:

The language used in the manuscript is clear, but several grammatical and structural issues diminish clarity (for example, “Nurse professionals who were bothered by a lack of material” – awkward phrasing). Consider professional editing to improve readability.

2. Measurement of autonomy:

The way 'autonomy' is measured with 5 Likert-type items is suitable, but dividing it into two categories (good vs. poor based on the mean) might oversimplify complex perceptions. The authors should consider discussing the limitations of using a binary outcome more thoroughly in the discussion section.

3. Limitations:

Although the limitations are discussed, I recommend emphasizing the cross-sectional design's inability to infer causality and adding a brief comment on potential self-report bias in measuring autonomy.

4. Ethics and Data Availability:

The ethics approval and consent are clearly outlined. Data availability also adheres to PLOS ONE policy.

5. Contextualization:

The introduction and discussion could benefit from better integration of relevant global literature, especially outside of sub-Saharan Africa, to expand the discussion of autonomy across healthcare systems.

Recommendation:

Minor revision — once language issues and clarification around autonomy measurement are addressed, the paper will be suitable for publication.

I appreciate the authors’ efforts and believe the paper makes a meaningful contribution to the discussion on nursing workforce development.

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Reviewer #1: No

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Dear Dr. Abere,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by the Jan 04 2026 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: https://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Philipos Petros Gile, MA

Academic Editor

PLOS ONE

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If the reviewer comments include a recommendation to cite specific previously published works, please review and evaluate these publications to determine whether they are relevant and should be cited. There is no requirement to cite these works unless the editor has indicated otherwise.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #1: Yes

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Thank you for your thorough revision of the manuscript and your detailed point-by-point responses. The revised version demonstrates substantial improvements across all key areas.

Reviewer #2: Authors research on “Work autonomy and its associated factors among nurses working in South Gondar zone public hospitals, Amhara regional state, Northcentral Ethiopia: institution-based cross-sectional study” is interesting and valuable area of research for work productivity and mental and psychological health for both the nurses and the patients they cared for. I have a few comments authors need to address before the paper is accepted for publication.

Comments

Methods section

1.The papers would be benefited if qualitative study is included as it would allow for deeper understanding of the barriers to nurses' autonomy, making a mixed methods approach the most effective way to investigate this issue.

2. What is the relevance of stating this unless otherwise the authors believe it has something related with nurses autonomy “It is bordered to the east by the South and North Wollo zones, to the west by Lake Tana and the Bahirdar Liyu zone, to the north by Central Gondar, to the northeast by the Waghimra zone, and to the south by the East and West Gojjam zones. According to data from the South Gondar Zone Administrative Health Bureau, the population of South Gondar is 2,609,823, with 50.1% women and 49.9% men. The majority of the population lives in rural areas, with around 80-85% residing in rural districts and engaging in agriculture. Urbanization is growing, particularly around key towns like Debre Tabor, which is the administrative center of South Gondar, and other urban centers such as Woreta”. The methods need to be sharper and targeted to the goal of the study.

3.While the repeated use of 'data was' may not be a major issue, such minor grammatical errors can distract readers. It would be much better if authors review the paper for grammar throughout.

4.The authors included all nurses in the study area, noting that the study population was smaller than the intended sample size. However, they did not specify the estimated sample size before making this claim. There appears to be a significant inconsistency regarding the study population, sample size, and study design. If the authors were unable to reach their estimated sample size, it is unclear why they did not include nurses working outside hospitals, such as those in health centres within the zone. The use of a census in their methodology need to be clear such as is the census about all nurses in the zone or only those working in hospitals? It appears that a non-random sampling approach was used, focusing only on nurses working in hospitals, while many nurse professionals in the zone work in health centres and were not included. If authors are about to include nurses working in hospital, they need to answer why nurses working in health centres are excluded in the method section.

5.How authors define nurse? It would be clearer who is considered nurse in this study and who is included.

Registered diploma nurse, BSc nurse, mental health nurse, nurses with advanced training like Perioperative Anaesthesia Nurse and so on. This is very important particularly their work autonomy might be affected by their level of training and scope that authors may consider adjusting in their regression analysis. Perhaps authors need clearly state this in the method section.

6.Do the authors assess whether the type of job nurses aimed for affects their work autonomy? What percentage of the study participants are working as nurses by choice versus not by choice? This is a sensitive variable that may be better explored through qualitative research and should be examined further for discussion and recommendations.

7.What does the mean score refers? Was it the mean score of each item for all participants or scores from the 5 items are summed or averaged first to get an overall autonomy score for each nurse. Then calculate the mean averaged score of the participant. This needs to be clearer in the method section.

Results section

8.This needs to be entirely presented in the methods section “Using logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (CIs), factors related to work autonomy at public hospitals in the South Gonder Zone, Northcentral Ethiopia, were identified. First, the relationship between each independent variable and the result variable was evaluated using bivariable logistic regression. Twelve variables with a p-value below 0.25 were selected as candidates for multivariable logistic regression analysis. Variables with a p-value less than 0.05 in the multivariable logistic regression analysis were considered statistically significant.”

Discussion

9.There is contradicting results discussed for example authors said “Nurses who reported being bothered by a lack of material during work had 1.8 times higher odds of having good work autonomy (AOR 1.8, 95% CI 1.1–3.0)” while down in the discussion they stated that “findings from this study showed that being bothered by a lack of materials during work is associated with having a lower level of autonomy than their counterparts”. Authors needed to be clearer and careful of interpreting the findings.

10. The result showed 53.5 % of nurses had good work autonomy (above the mean score). However, the authors should also consider the reverse perspective, as 46.5% of nurses report poor work autonomy, a substantial proportion that warrants further investigation and needs to be discussed.

I would be happy to review this paper after authors revise it according to the comments.

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Reviewer #1: No

Reviewer #2: No

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Work autonomy and its associated factors among nurses working in South Gondar zone public hospitals, Amhara regional state, Northcentral Ethiopia: institution-based cross-sectional study

PONE-D-25-21650R2

Dear Author,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

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Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions??>

Reviewer #2: Partly

**********

3. Has the statistical analysis been performed appropriately and rigorously? -->?>

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available??>

The PLOS Data policy

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English??>

Reviewer #2: No

**********

Reviewer #2: The methods section needs further work to make the manuscript tight enough for the scientific audience.

**********

what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy

Reviewer #2: No

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