‘More than Just a Personal Assistant’: A Qualitative Study Examining the Lived Experiences of Anaesthetic Nurses in Australia
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsDear editors and authors, thank you for the opportunity to review this manuscript. The study is devoted to an important and little-studied area. A phenomenological approach is appropriate here, and the results obtained may have implications for personnel policy, education, and clinic management.
The authors refer to both "phenomenology" and "Gadamer's hermeneutics." These are different philosophical traditions. Although hermeneutic phenomenology is legitimate, the article should clearly state which interpretative framework defines the analysis (for example, descriptive or interpretive phenomenology). Currently, the terms are mixed in the methodology section, without eliminating potential contradictions (for example, bracketing or merging horizons).
The lead researcher is an anesthesiologist nurse. Although reflexivity is mentioned, a more detailed description would be useful in the article, in particular, how her insider status influenced recruitment, questionnaires and interpretation of the topic. Did the participants assume that they had a common understanding? Have controversial assumptions been systematically documented?
31 participants is reasonable, but >50% are from Queensland and 77% are women. The authors acknowledge these as limitations, but the discussion is too generalized to "Australian anesthetic care." The paper should relax the requirements for national representativeness and instead present the results as illustrative or exploratory.
The article does not mention whether thematic saturation was discussed or whether it was achieved. Given the phenomenological purpose, this issue should be considered.
The sections of culture and leadership largely coincide. For example, "hierarchy" (3.1.1) and "restrictive leadership methods" (3.3.1) describe a similar power dynamic. The authors should either combine them or differentiate them more clearly (for example, culture = informal norms; leadership = formal managerial behavior).
In the personal attitude sub-topic, there is a risk of accusing nurse anesthesiologists of their own marginalization. Although it is important to communicate the opinions of participants, authors should be critical of this, taking into account systemic limitations (for example, acquired helplessness in a hierarchical environment). Currently, this is perceived as a victim's accusation.
During the discussion, Australia is often compared to the United States, Sweden, and the United Kingdom. These comparisons are useful, but sometimes unnecessary. For example, CRNAs in the United States have a different history of regulation and education. The document should clarify that the comparison does not imply direct equivalence of roles.
Section 4.1 lists four key priorities (career growth, education, leadership, legislation). Although they are reasonable, they are largely result-oriented. Qualitative data alone does not allow us to directly verify or justify these measures. The authors should reformulate them as suggestions stemming from the concerns of the participants, rather than as evidence-based recommendations.
The last sentence of the summary is vague. Specify exactly what the problems are (for example, hierarchy, lack of standardized training).
The authors state that they followed the recommendations of COREQ. The COREQ checklist should be provided as an additional file.
Recommendation: Major revisions required. The manuscript addresses a genuinely important topic and contains rich qualitative data. However, the phenomenological framing needs philosophical clarification, the thematic structure requires refinement to reduce overlap, and the discussion should avoid overgeneralising from a regionally concentrated sample. With careful revision, this paper would make a valuable contribution to perioperative nursing literature.
Author Response
Reviewer 1
Comment: Dear editors and authors, thank you for the opportunity to review this manuscript. The study is devoted to an important and little-studied area. A phenomenological approach is appropriate here, and the results obtained may have implications for personnel policy, education, and clinic management.
Response: Thank you for your kind words. We hope that we have addressed all feedback appropriately
Page number: n/a
Comment: The authors refer to both "phenomenology" and "Gadamer's hermeneutics." These are different philosophical traditions. Although hermeneutic phenomenology is legitimate, the article should clearly state which interpretative framework defines the analysis (for example, descriptive or interpretive phenomenology). Currently, the terms are mixed in the methodology section, without eliminating potential contradictions (for example, bracketing or merging horizons).
Response: We thank the reviewer for raising this point. The study employed reflexive thematic analysis within an interpretive (hermeneutic) phenomenological framework informed by Gadamer. We have revised the methodology section to explicitly articulate this positioning, clarify the distinction from descriptive phenomenology, and explain how thematic analysis functioned as an interpretive analytic method consistent with hermeneutic assumptions.
Page number: 4-5
Comment: The lead researcher is an anesthesiologist nurse. Although reflexivity is mentioned, a more detailed description would be useful in the article, in particular, how her insider status influenced recruitment, questionnaires and interpretation of the topic. Did the participants assume that they had a common understanding? Have controversial assumptions been systematically documented?
Response: Thank you for this valuable comment. In response, we have added a new subsection, “Reflexivity and Researcher Positionality” (Section 2.6), to more explicitly describe how the lead researcher’s insider status influenced recruitment, interview conduct, and interpretation. This section outlines how shared professional identity facilitated trust and engagement during recruitment, how assumptions of common understanding were actively managed during interviews through clarification and probing, and how reflexive journaling and peer debriefing were used to systematically document and examine assumptions and interpretive tensions throughout the study.
Page number: 6-7
Comment: 31 participants is reasonable, but >50% are from Queensland and 77% are women. The authors acknowledge these as limitations, but the discussion is too general to apply to "Australian anesthetic care." The paper should relax the requirements for national representativeness and instead present the results as illustrative or exploratory.
Response: We thank the reviewer for this constructive comment. In response, we have revised the manuscript to relax claims of national representativeness and to frame the findings explicitly as exploratory and illustrative. The Abstract, Discussion, and Limitations sections have been amended to clarify that the study provides in‑depth insight into the experiences of participating anaesthetic nurses rather than claiming to represent Australian anaesthetic care nationally.
Page number: Throughout the document
Comment: The article does not mention whether thematic saturation was discussed or achieved. Given the phenomenological purpose, this issue warrants consideration.
Response: Thank you for this comment. The Methods section has been revised to explicitly address data saturation, with reference to informational sufficiency as described in qualitative and interpretive research.
Page number: 3
Comment: The sections of culture and leadership largely coincide. For example, "hierarchy" (3.1.1) and "restrictive leadership methods" (3.3.1) describe a similar power dynamic. The authors should either combine them or differentiate them more clearly (for example, culture = informal norms; leadership = formal managerial behavior).
Response: Thank you, we have additional changes to each section (in the 3.1 and 3.3 section introductions) to differentiate them more clearly. We thank the reviewer for the suggestions.
Page number: 8 and 13
Comment: In the personal attitude sub-topic, there is a risk of accusing nurse anesthesiologists of their own marginalization. Although it is important to communicate the opinions of participants, authors should be critical of this, taking into account systemic limitations (for example, acquired helplessness in a hierarchical environment). Currently, this is perceived as a victim's accusation.
Response: Thank you for raising this important point. We wish to clarify that in the Results section we are reporting participants’ descriptions of their lived experiences and perceptions, without applying interpretive labels or attributing responsibility for marginalisation. The manuscript does not characterise participants as “victims,” nor does it assert that nurses are responsible for their own marginalisation; rather, it presents participant accounts as they were expressed during interviews. To avoid any unintended implication of endorsement, we have refined the wording in the Results section to more clearly attribute these views to participants and to emphasise the range and context of perspectives reported. Broader critical interpretation of these accounts in relation to systemic and hierarchical influences is addressed in the Discussion section.
Page number: Section 3.2.5 Personal attitude
Comment: During the discussion, Australia is often compared to the United States, Sweden, and the United Kingdom. These comparisons are useful, but sometimes unnecessary. For example, CRNAs in the United States have a different history of regulation and education. The document should clarify that the comparison does not imply direct equivalence of roles.
Response: Thank you, we have now made clarification and revision to enable the reader to understand that although there are differences between countries there are shared experiences among the perioperative nursing cohorts.
Page number: 12 and 14
Comment: Section 4.1 lists four key priorities (career growth, education, leadership, legislation). Although they are reasonable, they are largely result-oriented. Qualitative data alone does not allow us to directly verify or justify these measures. The authors should reformulate them as suggestions stemming from the concerns of the participants, rather than as evidence-based recommendations.
Response: We thank the reviewer for this important insight and suggestion. We have revised to reposition the four priorities as nurse‑informed suggestions arising from the concerns and experiences expressed in the data, rather than as evidence‑based or prescriptive recommendations. The revised text now explicitly frames these priorities as illustrative areas for consideration and future inquiry, consistent with the interpretive and hermeneutic orientation of the study.
Page number: 18
Comment: The last sentence of the summary is vague. Specify exactly what the problems are (for example, hierarchy, lack of standardized training).
Response: Thank you for this comment. We have revised the final sentence of the summary to explicitly specify the key problems identified in the study, including hierarchical power structures, lack of standardised education and training, limited career pathways, leadership challenges, and insufficient professional standards.
Page number: 18
Comment: The authors state that they followed the recommendations of COREQ. The COREQ checklist should be provided as an additional file.
Response: We apologise, this was omitted to be uploaded with the original submission. We have now included this with the revision.
Page number: n/a
Comment: Recommendation: Major revisions required. The manuscript addresses a genuinely important topic and contains rich qualitative data. However, the phenomenological framing needs philosophical clarification, the thematic structure requires refinement to reduce overlap, and the discussion should avoid overgeneralising from a regionally concentrated sample. With careful revision, this paper would make a valuable contribution to perioperative nursing literature.
Response: Thank you for your supportive guidance, we hope that we have addressed all feedback appropriately.
Page number: n/a
Reviewer 2 Report
Comments and Suggestions for AuthorsDear Authors,
Thank you for the opportunity to review this manuscript. Please find below my comments and suggestions.
In lines 59–61, the authors state that there is a lack of studies and that these studies identified a lack of consistency in the training of anaesthetic nurses in Australia. However, reference [7] does not appear to make this explicit claim and therefore does not seem to be an appropriate source to support it. I would suggest that the authors include the specific studies they are referring to and analyse them individually to justify this statement.
I also believe the authors should clarify how this study contributes to the education and clinical practice of anaesthetic nurses.
The recruitment approach used may introduce selection bias and limit representativeness, as it is likely to include more motivated or professionally connected participants. This issue should be discussed in the study limitations.
The process used to determine data saturation should be described in greater detail to ensure it is not subjective and to allow for replication of the study.
The absence of audio recording in some interviews may affect the quality of the data, as field notes cannot fully replace verbatim transcripts. This should also be acknowledged in the limitations.
The authors should justify why a pilot test with only three participants is considered sufficient to ensure face and content validity of the interview questions.
Key concepts such as “reflexivity,” “reflexive practice,” and “reflexive writing” should be explained more clearly, including what they involve and how they were implemented.
In the results section, I observed repetition of similar ideas across different subsections, such as nurses feeling undervalued and subordinate or experiencing a lack of adequate training. This should be addressed by integrating and streamlining key categories.
The findings should be better prioritised to highlight the most relevant themes.
It would also be valuable to relate demographic characteristics to the study findings to explore potential influences.
The discussion does not sufficiently explore the relationships between different findings. For example, the authors could examine how medical hierarchy may influence both training gaps and nursing leadership. Rather than presenting results in isolated sections, the findings could be more effectively integrated into an overall explanatory model.
The limitations section should also include selection bias related to the sampling method, potential interpretation bias due to multiple researchers, and recording bias due to the lack of audio recording in some interviews.
The conclusions should synthesise the findings rather than repeat content already presented in earlier sections.
The recommendations should be more specific, clearly identifying which interventions would be most beneficial based on the results.
A qualitative study cannot establish causal relationships. Therefore, while this study may suggest that strengthening anaesthetic nursing could benefit patients, this cannot be stated definitively.
Kind regards.
Author Response
Editor comments:
Comment: Needing higher resolution image and English editing
Response: Thank you for the comment, we have included a higher resolution image and have revised the English language where appropriate.
Page number: Page 6
Reviewer 2
Comment: Thank you for the opportunity to review this manuscript. Please find below my comments and suggestions.
Response: Thank you for your support. We hope that we have addressed all feedback appropriately
Page number: n/a
Comment: In lines 59–61, the authors state that there is a lack of studies and that these studies identified a lack of consistency in the training of anaesthetic nurses in Australia. However, reference [7] does not appear to make this explicit claim and therefore does not seem to be an appropriate source to support it. I would suggest that the authors include the specific studies they are referring to and analyse them individually to justify this statement.
Response: Thank you for this comment. We agree that the original wording required clearer justification. To address this, we have now cited and discussed the specific studies underpinning this statement. These comprise of the two ONLY Australian studies that explicitly identify variability and a lack of standardisation in the education and preparation of anaesthetic nurses. Each of these studies is now referenced and briefly analysed individually to support our claim. We note that this conclusion was also informed by a comprehensive scoping review conducted by the authors; however, as this review is currently under peer review, it cannot be cited at this time. To ensure transparency and accuracy, we have therefore relied solely on the published literature available and revised the wording accordingly to ensure it is fully supported by the cited sources.
Page number: 2, lines 60-63
Comment: I also believe the authors should clarify how this study contributes to the education and clinical practice of anaesthetic nurses.
Response: Thank you, we have revised the Introduction to explicitly clarify how the study contributes to anaesthetic nursing education and clinical practice, with a new paragraph outlining the relevance of the findings for educators, clinical leaders, and workforce planning.
Page number: 2
Comment: The recruitment approach used may introduce selection bias and limit representativeness, as it is likely to include more motivated or professionally connected participants. This issue should be discussed in the study limitations.
Response: We have revised the Study Limitations section to explicitly acknowledge potential selection bias arising from purposive and snowball sampling through professional networks, noting the likelihood that more professionally engaged or motivated anaesthetic nurses participated.
Page number: 18-19
Comment: The process used to determine data saturation should be described in greater detail to ensure it is not subjective and to allow for replication of the study.
Response: Thank you for this comment, the Methods section has been revised to provide greater detail on how informational sufficiency was determined. The manuscript now describes the iterative, team‑based process used to assess saturation during data collection, including regular analytic review and collaborative decision‑making.
Page number: 3-5
Comment: The absence of audio recording in some interviews may affect the quality of the data, as field notes cannot fully replace verbatim transcripts. This should also be acknowledged in the limitations.
Response: Thank you for highlighting this important issue. We agree that the absence of audio recording for a small number of interviews represents a methodological limitation, as field notes cannot fully substitute for verbatim transcripts. This limitation has now been explicitly acknowledged and discussed in the Study Limitations section of the manuscript to ensure transparency regarding its potential impact on data richness and nuance. As noted in the revised manuscript, a small number of participants expressed concern about potential professional repercussions and were only willing to participate on the condition that interviews were not audio‑recorded. Given the sensitivity of the topic and the ethical priority of protecting participant safety, confidentiality, and autonomy, these requests were accommodated to enable participation. While the absence of audio recordings may have reduced the depth of data captured in these interviews, this approach allowed the inclusion of perspectives that may otherwise have been excluded. Importantly, participants’ reluctance to be recorded reflects the broader power dynamics and perceived professional vulnerability that underpin the findings of this study and therefore reinforces rather than detracts from the interpretive value of the data.
Page number: 3 and 18
Comment: The authors should justify why a pilot test with only three participants is considered sufficient to ensure face and content validity of the interview questions.
Response: Thank you for this comment. The pilot interviews were conducted to establish face and content validity of the interview guide rather than to achieve data saturation. In qualitative interview research, pilot testing commonly involves a small number of participants (typically 2–5) and is considered sufficient when the aim is to assess question clarity, relevance, and alignment with the study aims. The three pilot participants were experienced anaesthetic nurses representative of the target population and provided focused feedback, which resulted in minor refinements to wording and sequencing. This approach is consistent with qualitative methodological guidance, which prioritises information adequacy and expert judgement over numerical thresholds for pilot testing. We have added additional commentary within the text to support the approach undertaken.
Page number: 4
Comment: Key concepts such as “reflexivity,” “reflexive practice,” and “reflexive writing” should be explained more clearly, including what they involve and how they were implemented.
Response: Thank you for this comment, this has now been addressed within the text based on this and reviewer one’s feedback.
Page number: 6
Comment: In the results section, I observed repetition of similar ideas across different subsections, such as nurses feeling undervalued and subordinate or experiencing a lack of adequate training. This should be addressed by integrating and streamlining key categories. The findings should be better prioritised to highlight the most relevant themes.
Response: Thank you for this comment, this has now been addressed within the text based on this and reviewer one’s feedback.
Page number: 7-14
Comment: It would also be valuable to relate demographic characteristics to the study findings to explore potential influences.
Response: Thank you for this suggestion. We agree that relating demographic characteristics to qualitative findings can be valuable in some contexts; however, in this study such analysis was not undertaken due to ethical considerations. Anaesthetic nursing represents a relatively small and specialised workforce in Australia and combining detailed demographic characteristics with experiential findings, particularly when participants are drawn from identifiable jurisdictions or roles, carries a heightened risk of participant identifiability. Protecting participant anonymity was a key ethical priority, especially given the sensitive nature of the issues discussed.
Additionally, the study was designed as a phenomenological inquiry aimed at exploring shared meanings and lived experiences rather than comparing subgroups or examining demographic influences. Introducing demographic‑linked analyses would not align with the study’s methodological aims. For these reasons, demographic characteristics were reported descriptively only and were not analytically linked to specific findings.
Page number: n/a
Comment: The discussion does not sufficiently explore the relationships between different findings. For example, the authors could examine how medical hierarchy may influence both training gaps and nursing leadership. Rather than presenting results in isolated sections, the findings could be more effectively integrated into an overall explanatory model.
Response: Thank you for this constructive suggestion. We have revised the Discussion to more explicitly integrate relationships across the findings, rather than presenting themes in isolation. In particular, the revised text examines how medical hierarchy operates as a central mechanism influencing workplace culture, educational gaps, leadership constraints, and institutional barriers. These interconnections are now synthesised into an overarching explanatory narrative that situates the findings as an interconnected system shaping anaesthetic nursing practice.
Page number:15-17
Comment: The limitations section should also include selection bias related to the sampling method, potential interpretation bias due to multiple researchers, and recording bias due to the lack of audio recording in some interviews.
Response: Thank you for this comment. The Limitations section has been revised to explicitly to address these challenges within the paper.
Page number: 18-19
Comment: The conclusions should synthesise the findings rather than repeat content already presented in earlier sections.
Response: Thank you for this comment and suggestion. The Conclusion has been rewritten to synthesise the findings rather than reiterate content presented earlier in the manuscript.
Page number: 19
Comment: The recommendations should be more specific, clearly identifying which interventions would be most beneficial based on the results.
Response: Thank you, the recommendations have been revised based on this and reviewer one’s feedback
Page number: 18
Comment: A qualitative study cannot establish causal relationships. Therefore, while this study may suggest that strengthening anaesthetic nursing could benefit patients, this cannot be stated definitively.
Response: Thank you for this comment. We agree that qualitative research cannot establish causal relationships. The Conclusion has therefore been revised to avoid definitive or causal claims and now frames potential patient benefits as suggestive and interpretive, rather than conclusive. The revised wording reflects that the findings indicate possible implications for patient care and workforce sustainability, while acknowledging that further empirical research is required to establish causal relationships.
Page number: 19
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsDear authors and editors, at the moment the manuscript is a well-executed, methodologically sound and practically significant study. The results of the study and the data obtained will be of interest not only to practitioners, but also to health policy makers and educational regulators. Weaknesses and limitations remain that do not reduce the publication potential, but require mention in the conclusion, namely, more than half of the participants are from Queensland, which reduces transferability for the whole of Australia (the authors admit this). The lack of an anesthesiologist's view is stated as a limitation and direction of future research. A small number of interviews without audio recordings, which may have led to a loss of accuracy in the wording, but the authors took detailed notes. I recommend that you accept the manuscript for publication.
Author Response
Comment:
Dear authors and editors, at the moment the manuscript is a well-executed, methodologically sound and practically significant study. The results of the study and the data obtained will be of interest not only to practitioners, but also to health policy makers and educational regulators. Weaknesses and limitations remain that do not reduce the publication potential, but require mention in the conclusion, namely, more than half of the participants are from Queensland, which reduces transferability for the whole of Australia (the authors admit this). The lack of an anesthesiologist's view is stated as a limitation and direction of future research. A small number of interviews without audio recordings, which may have led to a loss of accuracy in the wording, but the authors took detailed notes. I recommend that you accept the manuscript for publication.
Response:
We thank the reviewer for this helpful comment. The Conclusion has been revised to include a concise acknowledgement of key study limitations, without repeating the full limitations section. These brief additions ensure transparency while maintaining the appropriate scope and focus of the conclusion.
Comment:
English Language and Figures
Response:
Thank you for this reminder. We have carefully reviewed the manuscript to improve clarity, grammar, spelling, and consistency throughout. Minor language issues were corrected, including typographical errors, subject-verb agreement, pluralisation, punctuation, and word choice. We also addressed inconsistent hyphenation, terminology. Table and text consistency were reviewed and aligned where necessary. These revisions were editorial in nature and did not alter the meaning or interpretation of the findings but were undertaken to enhance readability and ensure the manuscript meets publication standards.
Reviewer 2 Report
Comments and Suggestions for AuthorsDear authors,
The manuscript has been sufficiently improved, and I have no further comments or suggestions.
Kind regards.
Author Response
Comment:
The manuscript has been sufficiently improved, and I have no further comments or suggestions.
Response:
Thank you for your contribution
