{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T06:25:28Z","timestamp":1787293528051,"version":"build-2736575974"},"update-to":[{"DOI":"10.12688\/f1000research.186053.1","type":"new_version","label":"New version","source":"publisher","updated":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T00:00:00Z","timestamp":1786924800000}}],"reference-count":19,"publisher":"F1000 Research Ltd","license":[{"start":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T00:00:00Z","timestamp":1786924800000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["f1000research.com"],"crossmark-restriction":false},"short-container-title":["F1000Res"],"abstract":"\n Background Nursing innovation is essential for improving healthcare quality, patient safety, and organizational performance. Although transformational leadership and organizational culture have been associated with innovation, the mechanisms linking these organizational factors with nursing innovation remain insufficiently understood, particularly within integrated healthcare systems in Saudi Arabia. This study examined the relationships of transformational leadership and organizational culture with nursing innovation and investigated the mediating role of knowledge sharing among registered nurses in the Makkah Health Cluster, Saudi Arabia. Methods A quantitative analytical cross-sectional study was conducted among 531 registered nurses recruited using proportionate stratified random sampling from six hospitals within the Makkah Health Cluster. Data were collected using standardized self-administered questionnaires assessing transformational leadership, organizational culture, knowledge sharing, and nursing innovation. Partial Least Squares Structural Equation Modelling (PLS-SEM) was used to evaluate the measurement and structural models and examine direct and indirect relationships among the study constructs. Results Transformational leadership was positively associated with nursing innovation (\u03b2\u00a0=\u00a00.313,\n p<\/ns5:italic>\n \u00a0<\u00a00.001) and knowledge sharing (\u03b2\u00a0=\u00a00.573,\n p<\/ns5:italic>\n \u00a0<\u00a00.001). Organizational culture was also positively associated with nursing innovation (\u03b2\u00a0=\u00a00.249,\n p<\/ns5:italic>\n \u00a0<\u00a00.001) and knowledge sharing (\u03b2\u00a0=\u00a00.340,\n p<\/ns5:italic>\n \u00a0<\u00a00.001). Knowledge sharing was positively associated with nursing innovation (\u03b2\u00a0=\u00a00.345,\n p<\/ns5:italic>\n \u00a0<\u00a00.001). Knowledge sharing demonstrated complementary partial mediation in the relationships between transformational leadership and nursing innovation (indirect \u03b2\u00a0=\u00a00.198,\n p<\/ns5:italic>\n \u00a0<\u00a00.001) and between organizational culture and nursing innovation (indirect \u03b2\u00a0=\u00a00.117,\n p<\/ns5:italic>\n \u00a0<\u00a00.001). The model explained 63.1% of the variance in knowledge sharing and 62.0% of the variance in nursing innovation. Conclusions Transformational leadership, organizational culture, and knowledge sharing were significantly associated with nursing innovation, with knowledge sharing representing a complementary pathway linking leadership and organizational culture with innovative nursing behaviour. Healthcare organizations may benefit from integrating leadership development, supportive organizational cultures, and knowledge-sharing strategies to create conditions conducive to nursing innovation and continuous quality improvement within the context of Saudi healthcare transformation.\n <\/ns5:p>","DOI":"10.12688\/f1000research.186053.2","type":"journal-article","created":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T12:39:09Z","timestamp":1786970349000},"page":"1173","update-policy":"https:\/\/doi.org\/10.12688\/f1000research.crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["The Mediating Role of Knowledge Sharing in the Relationship Between Transformational Leadership, Organizational Culture, and Nursing Innovation in the Makkah Health Cluster"],"prefix":"10.12688","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-9590-3270","authenticated-orcid":false,"given":"Khadija Lafi","family":"Aljarary","sequence":"first","affiliation":[{"name":"Faculty of Nursing Petaling Jaya Selangor Lincoln University College"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Hafizah Che","family":"Hassan","sequence":"additional","affiliation":[{"name":"Faculty of Nursing Petaling Jaya Selangor Lincoln University College"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"2560","published-online":{"date-parts":[[2026,8,17]]},"reference":[{"key":"ref1","doi-asserted-by":"publisher","DOI":"10.5281\/zenodo.21144008","article-title":"Questionnaire for \u201cThe Mediating Role of Knowledge Sharing in the Relationship Between Transformational Leadership, Organizational Culture, and Nursing Innovation in the Makkah Health Cluster\u201d [Data set].","volume":"15","author":"K Aljarary","year":"2026","journal-title":"Zenodo."},{"key":"ref2","doi-asserted-by":"publisher","first-page":"208-214","DOI":"10.1177\/1355819620978436","article-title":"Understanding adaptive teamwork in health care: Progress and future directions.","volume":"26","author":"J Anderson","year":"2020","journal-title":"J. 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Public Health."}],"container-title":["F1000Research"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/f1000research.com\/articles\/15-1173\/v2\/xml","content-type":"application\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/f1000research.com\/articles\/15-1173\/v2\/pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/f1000research.com\/articles\/15-1173\/v2\/iparadigms","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,21]],"date-time":"2026-08-21T05:54:09Z","timestamp":1787291649000},"score":1,"resource":{"primary":{"URL":"https:\/\/f1000research.com\/articles\/15-1173\/v2"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,17]]},"references-count":19,"URL":"https:\/\/doi.org\/10.12688\/f1000research.186053.2","relation":{"has-version":[{"id-type":"doi","id":"10.12688\/f1000research.186053.1","asserted-by":"subject"}],"has-review":[{"id-type":"doi","id":"10.5256\/f1000research.207970.r512816","asserted-by":"subject"},{"id-type":"doi","id":"10.5256\/f1000research.207970.r512816","asserted-by":"object"}]},"ISSN":["2046-1402"],"issn-type":[{"value":"2046-1402","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,17]]},"assertion":[{"value":"Indexed","URL":"https:\/\/f1000research.com\/articles\/15-1173\/v2#article-reports","order":0,"name":"referee-status","label":"Referee status","group":{"name":"current-referee-status","label":"Current Referee Status"}},{"value":"10.5256\/f1000research.205353.r506481, Suryanti Suryanti, Universitas Dian Nuswantoro, Semarang, 31 Jul 2026, version 1, 1 approved, 1 approved with reservations","URL":"https:\/\/f1000research.com\/articles\/15-1173\/v1#referee-response-506481","order":0,"name":"referee-response-506481","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.205353.r506489, Benny Hutahayan, University of Brawijaya, Malang, East Java, 03 Aug 2026, version 1, 1 approved, 1 approved with reservations","URL":"https:\/\/f1000research.com\/articles\/15-1173\/v1#referee-response-506489","order":1,"name":"referee-response-506489","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"Khadija Lafi Aljarary<\/b>; \nPosted: 03 Aug 2026<\/i>; We sincerely thank the reviewer for the careful and constructive evaluation of our manuscript. We greatly appreciate the detailed comments and recommendations, which have helped us substantially strengthen the theoretical foundation, methodological transparency, statistical reporting, and interpretation of the study. We have carefully revised the manuscript in response to each comment. Our point-by-point responses are provided below.  Comment 1: The introduction is generally well-structured and addresses relevant topics. However, the research gaps are still presented in general terms and need to be strengthened through a critical synthesis of previous empirical research. Response: Thank you for this important observation. We have substantially revised the Introduction to provide a more critical synthesis of previous empirical evidence and to articulate the research gap more explicitly. The revised Introduction now clarifies that previous studies have frequently examined transformational leadership, organizational culture, knowledge sharing, and innovation separately, whereas evidence integrating these constructs within a unified model remains comparatively limited. We have also strengthened the contextual gap concerning nursing innovation within integrated healthcare systems in Saudi Arabia. These revisions provide a clearer empirical and contextual rationale for the present study. Comment 2: The manuscript currently lacks a dedicated \u201cLiterature Review and Hypothesis Development\u201d section. The authors should add this section to strengthen the theoretical foundation of the study and systematically explain how each hypothesis is developed. This section should provide a critical synthesis of previous studies, clarify the definitions and relationships among the variables, identify the relevant research gaps, and present theoretical arguments that clearly lead to the formulation of each hypothesis. The literature should not merely be summarized descriptively but should be integrated to establish the conceptual logic underlying the proposed research model. Response: We greatly appreciate this recommendation and have addressed it extensively. A new section entitled \u201cTheoretical Background and Hypothesis Development\u201d has been added to the revised manuscript. This section systematically addresses the relationships between: (1) transformational leadership and nursing innovation; (2) transformational leadership and knowledge sharing; (3) organizational culture and nursing innovation; (4) organizational culture and knowledge sharing; and (5) knowledge sharing and nursing innovation. Rather than merely summarizing previous studies, the new section critically integrates empirical evidence with the Knowledge-Based View (KBV), Social Exchange Theory (SET), and Organizational Learning Theory (OLT). Each subsection clarifies the relevant constructs and their proposed relationships, discusses previous empirical evidence and remaining gaps, and develops the theoretical rationale leading to the corresponding hypothesis. We believe this addition has substantially strengthened the conceptual foundation of the proposed model. Comment 3: The stratified random sampling procedure needs to be explained in greater detail. The authors should specify the strata used, the proportional allocation method, and the procedure for randomly selecting respondents within each hospital or clinical department. Response: Thank you for this helpful suggestion. The Participants and sampling subsection has been expanded to provide a more detailed description of the sampling procedure. The revised manuscript now specifies that a proportionate stratified random sampling technique was employed to ensure representation across participating hospitals and major clinical departments. These constituted the sampling strata, and the number of nurses allocated to each stratum was determined proportionally according to its relative representation within the nursing workforce. Within each stratum, eligible nurses were selected from the available nursing staff lists using random selection procedures. These additions improve the transparency and reproducibility of the sampling methodology. Comment 4: The number of nurses invited, the number who responded, the number of responses excluded, and the final response rate should be reported. Response: We agree and have added complete participant-flow information to the Sample size and participant flow subsection. A total of 800 registered nurses were invited to participate. Of these, 565 nurses submitted the questionnaire, yielding an overall response rate of 70.6%. Following eligibility verification and data screening, 34 questionnaires were excluded because they were incomplete or did not meet the predefined eligibility criteria. Consequently, 531 complete and valid questionnaires were retained for the final analysis, representing a usable response rate of 66.4% of the invited sample. Comment 5: The sample size calculation has not been presented transparently. Response: Thank you for highlighting this issue. The Sample size and participant flow subsection has been revised to provide a transparent description of sample-size determination. The minimum required sample was estimated using Cochran's formula with finite population correction based on the target population of 4,425 registered nurses. Assuming a 95% confidence level, a 5% margin of error, and a population proportion of 0.50, the minimum required sample was approximately 354 participants. In addition, an \na priori<\/i> statistical power analysis using G*Power version 3.1 was included to assess the adequacy of the sample for the proposed structural relationships. Assuming a medium effect size (f² = 0.15), \u03b1 = 0.05, statistical power of 0.95, and a maximum of three predictors for an endogenous construct, the estimated minimum sample was 119 participants. The final analytical sample of 531 registered nurses therefore exceeded both sample-size requirements. Comment 6: The sources of each measurement instrument need to be clearly cited. Currently, the sources of the scales for organizational culture, knowledge sharing, and nursing innovation have not been explained. Response: Thank you for identifying this omission. We have revised the Study variables and measurements subsection to clearly identify the source of each measurement instrument. Transformational leadership was assessed using a 16-item questionnaire adapted from the Multifactor Leadership Questionnaire developed by Bass and Avolio. Organizational culture was measured using a 10-item scale adapted from Cameron and Quinn (2011), knowledge sharing using a 10-item instrument adapted from Bock et al. (2005), and nursing innovation using a 10-item instrument adapted from Scott and Bruce (1994). The revised manuscript now presents these sources alongside the description of each construct, thereby improving the transparency of the measurement procedures. Comment 7: The authors need to explain in greater detail the relationships among the variables studied, findings that are still inconsistent or incomplete, and how the proposed model can contribute to the existing literature. Response: We appreciate this important suggestion. Both the newly added Theoretical Background and Hypothesis Development section and the Discussion have been substantially expanded to address this issue. The revised manuscript now critically examines the relationships among transformational leadership, organizational culture, knowledge sharing, and nursing innovation rather than discussing these constructs independently. We have further clarified the limitations and incompleteness of existing evidence regarding the organizational processes through which leadership and organizational culture are associated with innovative nursing behaviour. Particular attention is now given to knowledge sharing as a complementary pathway linking transformational leadership and organizational culture with nursing innovation. The revised Discussion also explains the theoretical contribution of integrating KBV, SET, and OLT within a single conceptual framework and highlights the contextual contribution of examining these relationships within the Makkah Health Cluster. Comment 8: The authors need to conduct a Common Method Bias (CMB) test using Harman\u2019s single-factor test because your data are cross-sectional. Response: Thank you for highlighting the potential influence of common method variance in cross-sectional questionnaire-based research. We agree that this represents an important methodological consideration. In revising the manuscript, we have carefully aligned the analytical procedures described in the Methods with the analyses reported in the Results and have avoided extending the statistical interpretation beyond the analyses consistently available from the study. Potential common method variance arising from the use of self-administered measures for all study constructs is now explicitly acknowledged in the Strengths and limitations section. In addition, interpretations throughout the revised manuscript have been carefully moderated to emphasize statistical associations rather than causal relationships. We appreciate this observation and have incorporated it into both the interpretation and limitations of the study. Comment 9: The author must present the full factor loadings for each item (these must be listed in detail, not just as a range). Response: We fully agree and have revised the measurement-model reporting accordingly. Table 3 now presents the outer loading for every individual indicator rather than reporting only the range of loadings. The revised table includes all 16 transformational leadership indicators and all 10 indicators for each of organizational culture, knowledge sharing, and nursing innovation. In addition, Cronbach's alpha, rho_A, composite reliability (rho_C), and average variance extracted (AVE) are reported for each construct. All outer loadings exceeded 0.70, and the revised table therefore provides a more transparent assessment of indicator reliability, internal consistency reliability, and convergent validity. Comment 10: Discriminant validity has not been tested transparently. To test discriminant validity, you need to conduct the HTMT and Fornell-Larcker tests. You must present the HTMT and Fornell-Larcker results in detail (An additional table is needed to present this information.) Response: Thank you for this valuable recommendation. We have strengthened the assessment and reporting of discriminant validity in the revised manuscript. Specifically, the Fornell\u2013Larcker criterion is now presented in detail in a dedicated table (Table 4). The square root of the AVE for each construct exceeded its correlations with the other constructs, supporting adequate discriminant validity among the study constructs. We also appreciate the reviewer's recommendation regarding HTMT. In the revised manuscript, discriminant-validity reporting has been aligned with the analytical results available for the study, and the interpretation has therefore been confined to the Fornell\u2013Larcker criterion. The corresponding Methods and Results sections have been revised accordingly to ensure consistency between the analytical procedures described and the findings reported. Comment 11: I did not find the SRMR, NFI, or PLS-Predict (Q2) values; you need to include them. Response: Thank you for this helpful recommendation. We have substantially expanded the assessment of the structural model in the revised manuscript. Specifically, the revised Results now report R², adjusted R², effect sizes (f²), Q²_predict, RMSE, and MAE. The model explained 63.1% of the variance in knowledge sharing (R² = 0.631) and 62.0% of the variance in nursing innovation (R² = 0.620). Predictive assessment further yielded positive Q²_predict values of 0.629 for knowledge sharing and 0.573 for nursing innovation, with the corresponding RMSE and MAE values reported in Table 5. We appreciate the reviewer's recommendation regarding SRMR and NFI. The revised manuscript reports the model-evaluation indices consistently available from the study analysis, and the Methods and Results have been carefully aligned to ensure consistency between the analytical procedures and the model-evaluation statistics reported. Comment 12: Table 4 would be more complete if it included confidence intervals. Response: Thank you for this helpful suggestion. We agree that confidence intervals can provide additional information regarding the precision of structural estimates. In revising the statistical reporting, we have expanded the direct-effects table to provide the standardized path coefficient (\u03b2), standard deviation, t-statistic, p-value, and hypothesis decision for each structural relationship. The mediation analysis has likewise been expanded to report the specific indirect coefficients, t-statistics, p-values, mediation classification, and hypothesis decisions. The revised statistical reporting has been kept consistent with the bootstrapping results available from the study analysis. The corresponding Methods and Results sections have also been aligned to ensure consistency between the statistical procedures described and the parameters reported. We sincerely thank the reviewer again for the detailed and constructive assessment of our manuscript. In response to these comments, we have made substantial revisions throughout the manuscript, including strengthening the Introduction and research gap; adding a dedicated Theoretical Background and Hypothesis Development section; providing more detailed sampling, participant-flow, and sample-size information; clarifying the sources of the measurement instruments; reporting complete indicator loadings; adding a dedicated Fornell\u2013Larcker discriminant-validity table; expanding the structural and predictive model assessment; strengthening the mediation analysis; and substantially revising the Discussion and interpretation of the findings. We believe that these revisions have considerably improved the theoretical clarity, methodological transparency, statistical reporting, and overall interpretability of the manuscript. We sincerely appreciate the reviewer's thoughtful guidance and the opportunity to improve our work.","URL":"https:\/\/f1000research.com\/articles\/15-1173\/v2#referee-comment-16838","order":2,"name":"referee-comment-16838","label":"Referee Comment","group":{"name":"article-reports","label":"Article Reports"}},{"value":"10.5256\/f1000research.207970.r512816, Nia Desriva, Institut Kesehatan dan Teknologi Al Insyirah, Riau, 21 Aug 2026, version 2, indexed","URL":"https:\/\/f1000research.com\/articles\/15-1173\/v2#referee-response-512816","order":3,"name":"referee-response-512816","label":"Referee Report","group":{"name":"article-reports","label":"Article Reports"}},{"value":"The author(s) declared that no grants were involved in supporting this work","order":4,"name":"grant-information","label":"Grant Information"},{"value":"This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.","order":0,"name":"copyright-info","label":"Copyright"}]}}