Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Authors,

Thank you for the opportunity to review this manuscript. The topic is relevant and the study provides useful descriptive information in Kazakhstan, a context for which published evidence remains limited. The manuscript is well structured; however I have several comments.

Introduction

The introduction provides a useful overview of nursing reforms and evidence-based practice in Kazakhstan. However, the knowledge gap could be stated more clearly, particularly regarding the importance of assessing guideline and checklist use in the context of ongoing nursing reforms. In addition, I recommend to distinguish more explicitly between guideline use and checklist use, as these represent different aspects of evidence-based practice.

Methods

The use of convenience sampling should be discussed in greater depth, as participation may have been influenced by organizational engagement with nursing reforms and documentation practices. Although the authors appropriately acknowledge that the sample is not nationally representative, the potential impact of the unknown regional distribution and workplace settings on the findings deserves further discussion.

In addition, the absence of a “not applicable” response option represents an important limitation. Given that many guidelines and checklists are only relevant to specific specialties, some low percentages may reflect non-applicability rather than low implementation.

Finally, please indicate whether the reporting of this cross-sectional study followed any recognized reporting guideline (e.g., STROBE). Cconsider providing the corresponding checklist as supplementary material.

Results

The presentation of the results is clear and transparent.

Because clinical applicability varies considerably across specialties, readers may easily interpret some low percentages as poor adherence. I suggest including an additional sentence in the Results tables or table footnotes reminding readers that these proportions should not be interpreted as implementation rates among eligible nurses.

Discussion

The discussion should be more cautious when interpreting the observed variability as evidence of a gap between policy reforms and nursing practice, since implementation barriers were not directly assessed.

Alternative explanations, such as differences in specialty areas, workplace settings, or availability of tools, should be discussed.

In addition, organizational support, training, and electronic documentation systems are proposed as potential explanations and solutions, but these factors were not measured in the present study.

Strengths and Limitations

I would encourage the authors to expand the limitations section by discussing: potential non-response bias, given that the denominator of invited nurses is unknown; the possibility of over-reporting due to social desirability bias, particularly because guideline use and documentation practices were self-reported rather than objectively verified; the absence of information on nursing specialty and workplace setting, which substantially limits interpretation of several checklist-related findings.

Conclusions

I would slightly soften the statement that the variability suggests challenges in integrating evidence-based nursing into routine care. The findings indicate variability in self-reported use, but the study design does not allow identification of the underlying causes.

References and Reporting

Please review formatting consistency according to the journal style.

I hope this helps

Author Response

Thank you for your careful reading of our manuscript and for your constructive comments, which have helped us to improve it. We have revised the manuscript accordingly; all changes are highlighted in yellow in the revised version. Our point-by-point responses follow.

Comment 1 (Introduction): The knowledge gap could be stated more clearly, particularly regarding the importance of assessing guideline and checklist use in the context of ongoing nursing reforms. In addition, I recommend to distinguish more explicitly between guideline use and checklist use.
Response: Thank you. We added a passage at the end of the second paragraph of the Introduction that distinguishes clinical nursing guidelines (recommendations that inform care decisions) from documentation checklists (structured forms for recording assessments and interventions) and explains that the two were assessed separately. The final paragraph of the Introduction was rewritten to state the gap more precisely: it specifies what has already been studied in Kazakhstan, including our previous analysis of the same survey [14], what is new in the present article, and why baseline data on the use of these tools matter for the ongoing nursing reform.

Comment 2 (Methods: convenience sampling): The use of convenience sampling should be discussed in greater depth, as participation may have been influenced by organizational engagement with nursing reforms and documentation practices… the potential impact of the unknown regional distribution and workplace settings on the findings deserves further discussion.
Response: We agree. Section 2.1 now explains that, because the invitation was addressed to heads of primary health care organizations, primary care nurses were probably over-represented and inpatient, intensive care, and neonatal nurses under-represented, and that organizations more engaged with the reform and nurses more involved in documentation may have been more likely to participate, which could increase reported use. The consequences of the unknown regional and workplace distribution are discussed in a new paragraph of the Discussion and in the third and fourth limitations.

Comment 3 (Methods: “not applicable” option): The absence of a “not applicable” response option represents an important limitation… some low percentages may reflect non-applicability rather than low implementation.
Response: We agree. This is now a separate limitation (Section 5, fifth point), and the footnotes of Tables 2–4 state that an unticked item may reflect non-applicability rather than non-use.

Comment 4 (Reporting guideline): Please indicate whether the reporting of this cross-sectional study followed any recognized reporting guideline (e.g., STROBE). Consider providing the corresponding checklist as supplementary material.
Response: The manuscript is now reported according to the STROBE statement for cross-sectional studies. This is stated at the end of Section 2.3, and the completed checklist is provided as Supplementary File S4.

Comment 5 (Results): I suggest including an additional sentence in the Results tables or table footnotes reminding readers that these proportions should not be interpreted as implementation rates among eligible nurses.
Response: The footnotes of Tables 2, 3, and 4 now state that the proportions should not be interpreted as implementation rates among nurses for whom each tool is clinically applicable, and that “not ticked” does not indicate non-adherence. A similar sentence was added to the Results text preceding Table 4.

Comment 6 (Discussion: caution): The discussion should be more cautious when interpreting the observed variability as evidence of a gap between policy reforms and nursing practice, since implementation barriers were not directly assessed.
Response: We revised the relevant paragraph. It now states that, because implementation barriers were not assessed, the data cannot show whether the variability reflects a gap between reform and practice or other explanations. We also added a sentence noting that the barriers described in systematic reviews were not assessed in our survey.

Comment 7 (Discussion: alternative explanations): Alternative explanations, such as differences in specialty areas, workplace settings, or availability of tools, should be discussed.
Response: A new paragraph in the Discussion presents alternative explanations: differences in clinical applicability by specialty, recruitment through primary health care organizations, differences in the availability of tools between organizations, and different interpretations of “use” by respondents.

Comment 8 (Discussion: unmeasured factors): Organizational support, training, and electronic documentation systems are proposed as potential explanations and solutions, but these factors were not measured in the present study.
Response: The last paragraph of the Discussion was rewritten. These factors are now presented explicitly as working hypotheses from the international literature, not measured in our survey, to be tested in future studies. The Highlights and the Abstract were revised accordingly.

Comment 9 (Strengths and Limitations): I would encourage the authors to expand the limitations section by discussing: potential non-response bias…; the possibility of over-reporting due to social desirability bias…; the absence of information on nursing specialty and workplace setting.
Response: The Limitations section was expanded to cover all three points: non-response bias that cannot be assessed because the number of invited nurses is unknown (also added to Section 2.1); possible over-reporting due to social desirability, because use was self-reported and not verified against records; and the absence of specialty and workplace data, which prevents description of the sample and identification of the nurses for whom each tool is applicable.

Comment 10 (Conclusions): I would slightly soften the statement that the variability suggests challenges in integrating evidence-based nursing into routine care.
Response: This statement was removed. The Conclusions now state that the study design does not allow the causes of the variability to be identified and that the data should not be interpreted as national-level estimates.

Comment 11 (References): Please review formatting consistency according to the journal style.
Response: The reference list was reformatted according to the MDPI style (numbering, italic journal names and volumes, bold years), and full author lists were given for references 2 and 6.

We hope that the revised manuscript addresses your comments satisfactorily.

Sincerely,
Sarsenbayeva Maira and Shnara Svetlanova, on behalf of all authors

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript addresses a relevant topic for evidence-based nursing practice and provides useful descriptive data from a large sample of nurses in Kazakhstan. The study is generally well structured, and the authors appropriately acknowledge several methodological limitations.
Before publication, some clarifications and revisions are recommended. In particular, the authors should ensure consistency between the methods, questionnaire, and tables; clarify the interpretation of self-reported use and whole-sample denominators for clinically specific tools; and maintain a clear distinction between observed findings and hypotheses regarding implementation barriers. The presentation of the sample characteristics and supplementary analyses should also be checked for consistency. 
These revisions would improve the manuscript's methodological transparency, readability, and interpretability while preserving the value of the descriptive findings.

Comments for author File: Comments.pdf

Comments on the Quality of English Language

A final linguistic review in scientific English is recommended, with particular attention to terminological consistency across clinical guidelines, nursing documentation checklists, reported use, and implementation. Furthermore, the formatting of the tables should be standardized.

Author Response

Thank you for your positive assessment of our manuscript and for your detailed and constructive suggestions, which have helped us to improve it. We have revised the manuscript accordingly; all changes are highlighted in yellow in the revised version. Our point-by-point responses follow.

Comment 1: It is recommended to verify the consistency between the values presented in the highlights and those reported in the tables, while always distinguishing between clinical guidelines and documentary checklists. For instance, fall prevention is listed at 34.3% for clinical guidelines and 34.5% for checklists.
Response: Thank you. The Highlights now report clinical guidelines and documentation checklists in separate points, and all values were checked against Tables 2–4. The fall prevention guideline (34.3%, Table 2) and the “Preventing injuries and falls” checklist (34.5%, Table 3) are now named explicitly, using the same names as in the tables. The same distinction was made in the Abstract.

Comment 2: The authors should clarify the specific novelty of this research in relation to existing literature, as well as their own previous publication based on the same dataset, while tempering the claim that the topic is entirely unexplored.
Response: The final paragraph of the Introduction now states what was reported in our previous publication [14] (13 of the 29 checklists and standard operating procedures) and what is new in the present article: the use of clinical nursing guidelines (item 24, not reported previously) and the remaining 16 checklists, with confidence intervals and explicit denominators. The statement that little is known was replaced by a description of the limited existing evidence, including studies on advanced practice nursing in Kazakhstan [16,17].

Comment 3: The authors are advised to clearly state that the estimated sample size is purely theoretical… that the confidence intervals reflect only sampling variability… and to provide an adequate justification for the use of the unusual 99.99% confidence level.
Response: Section 2.1 now states that the sample size calculation is theoretical, assumes simple random sampling, and does not compensate for selection bias; that the 95% confidence intervals reflect random sampling variability only and do not account for systematic error from the non-probabilistic sample; and that the 99.99% confidence level was a deliberately conservative planning choice used only to set a larger minimum sample, because many items were to be estimated and participation could not be predicted. All estimates in the article are reported with 95% confidence intervals. These points are repeated in the Limitations.

Comment 4: Please verify and standardize the numbering and wording of the items across the methods section, the appended questionnaire, and the tables. Additionally, please clarify which sociodemographic variables were actually included in Table 1.
Response: The numbering and wording were harmonized with File S1: item 13 is now described throughout (Section 2.2, Section 2.3, Results, Limitations, and Table S1) as “whether they conduct nursing consultations with patients”. Section 2.2 now states that Table 1 presents sex, age, position, and qualification category; that education level and work experience were collected but are not shown, because they were reported for the same sample previously [14]; that item 7 (name of the medical organization) is summarized in the text; and that item 8 (pilot site) is not analyzed in this article.

Comment 5: It is suggested that the number and characteristics of the subjects involved in the pilot test be reported… alternatively, it should be specified that these steps were intended solely to assess the readability of the items, rather than to serve as a formal validation.
Response: The number and characteristics of the pilot participants were not formally recorded. Section 2.2 now states this and specifies that the expert review and pilot test were intended solely to assess the clarity and readability of the items and did not constitute a formal validation. The absence of internal consistency and other validity testing is acknowledged in Section 2.2 and as a limitation in Section 5.

Comment 6: The formatting style for estimates should be standardized across all tables; the names of the checklist items must be aligned…; the nature of the ICD codes should be clarified…; it is essential to explicitly state that the denominator is N = 2,263, and to clarify that a “No” response simply indicates that an item was not checked…
Response: All tables now use the same format, n (% [95% CI]), with a “Not ticked, n (%)” column; Table 2 was reformatted accordingly. Checklist names in the text now match those in the tables. Column headings and footnotes of Tables 3 and 4 distinguish ICD-10 diagnosis codes, external-cause codes, and Z codes for contact with health services from ICD-9-CM procedure codes. All footnotes state the denominator (N = 2,263), explain that “not ticked” means only that the item was not selected and does not represent a clinical failure, and advise particular caution for setting-specific tools such as care after a tracheostomy and gastric tube insertion in neonates.

Comment 7: It is essential to clarify that these are working hypotheses, to be explored further in future research, rather than etiological factors confirmed by the results of this analysis.
Response: Training, organizational support, digitalization, and workflow integration are now described explicitly as working hypotheses that were not measured in this study (Discussion, last paragraph). A new paragraph discusses alternative explanations for the observed variability.

Comment 8: Explicitly state that the findings reflect only the situation at the time of data collection… and clarify that regulatory and employment developments occurring after 2022 serve solely to contextualize the significance of the study.
Response: Both points were added to the relevant Discussion paragraph: the findings describe reported use only in December 2021–February 2022 and do not allow conclusions about later trends, and the post-2022 developments are presented solely as context and as justification for further field research, not as evidence of current use. This is also stated in the Limitations.

Comment 9: Make even more explicit the implications of the lack of structured information regarding region, care setting, and specialty.
Response: The Limitations now state explicitly that the lack of these variables prevents description of the sample distribution and comparison with the national nursing workforce, and makes it impossible to determine for which respondents a given tool was applicable, so non-applicability cannot be distinguished from non-use.

Comment 10: It is recommended that these proposals be framed as guidance for future research, and that it be reiterated that the collected data should not be interpreted as epidemiological or national-level estimates.
Response: The Conclusions were revised: proposals on training, leadership, and electronic documentation are now framed as directions for future research, and we state that the data should not be interpreted as epidemiological or national-level estimates.

Comment 11: The discussion references sources 29 and 30… yet the bibliography provided in the manuscript ends with reference 26.
Response: Thank you for noticing this error. The citations were corrected to [25] (Ministry of Health press release, 2025) and [26] (WHO Central Asian Strategic Directions 2025–2030). All in-text citations now correspond to the reference list.

We hope that the revised manuscript addresses your comments satisfactorily.

Sincerely,
Sarsenbayeva Maira and Shnara Svetlanova, on behalf of all authors

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors The authors have satisfactorily addressed all of my comments. I believe the manuscript has improved considerably, and I have no further concerns.

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

Dear authors,
Thank you for your prompt, accurate, and well-structured response. You have satisfactorily addressed all the comments and questions raised; the revisions made to the text, tables, and references have significantly improved the clarity, methodological rigor, and overall quality of the manuscript.
I have no further observations.