Review Reports - ‘The Bird Fights Its Way Out of the Egg’: A Phenomenological Study of Nurses’ Lived Experiences of Self-Care in South Korea’s Closed Psychiatric Wards

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Editor,

Thank you for the opportunity to review this manuscript. I congratulate the authors on the relevance of the topic and the overall quality of the manuscript. I offer the following suggestions to further enhance the quality of the paper.

Abstract: The section is well organised, explicitly presenting the background, objectives, methods, main results, and conclusions. I recommend making the study’s contributions more explicit, particularly regarding the ways in which self-care may contribute beyond the instrumental or behavioural approaches that dominate the existing literature.

Introduction: This section is solid and well structured, drawing on recent literature. Nevertheless, it is somewhat lengthy and contains some conceptual repetition, particularly regarding the centrality of dignity, care ethics, and the scarcity of qualitative studies on self-care. The gap in the literature that motivates the study should be articulated in a more explicit and direct manner.

Materials and Methods: This is a rigorous section, with the phenomenological design well justified and appropriate to the study’s aims. However, a brief reflection on gender distribution and potential institutional differences among the included hospitals would be useful, even if these aspects were not central to the analysis. Regarding data analysis, the application of Colaizzi’s method is appropriate and well structured, although the section would benefit from more concrete examples of the interpretive process, particularly illustrating the transition from significant statements to formulated meanings.

Results: This is the strongest section of the manuscript, offering a rich and in-depth description of the participants’ lived experiences. Nonetheless, I encourage the authors to revisit this section, as some narrative redundancy is present.

Discussion: There is a good engagement between the findings and the existing literature. However, in some passages the discussion tends toward a descriptive reiteration of results rather than a critical analytical confrontation. It is also recommended that the conceptual contribution of the study be made more explicit, clarifying how the findings reconceptualise self-care as a relational ethical practice, particularly within restrictive psychiatric contexts.

Implications and Limitations: The implications and limitations of the study are relevant and well aligned with the findings, highlighting the need for organisational support, spaces for ethical reflection, and a broader understanding of self-care in psychiatric nursing.

Conclusions: The conclusions provide a synthesis of the main findings and their implications for clinical practice. However, the theoretical and practical contributions to psychiatric nursing and care ethics should be articulated more clearly.

Overall, this is a manuscript of high scientific quality, characterised by strong methodological rigour and conceptual depth, with clear potential to make a significant contribution to psychiatric nursing research and practice.

Author Response

Detailed Responses to Reviewer 1

Reviewer 1

Thank you for the thoughtful and constructive comments, which have greatly contributed to improving the quality and clarity of our manuscript. We have carefully revised the manuscript in accordance with your suggestions, with all revisions marked in red font.

Point 1: Abstract: The section is well organised, explicitly presenting the background, objectives, methods, main results, and conclusions. I recommend making the study’s contributions more explicit, particularly regarding the ways in which self-care may contribute beyond the instrumental or behavioural approaches that dominate the existing literature.

Response 1: We have revised the Abstract to make the study’s contribution more explicit by framing self-care beyond behavioural strategies and emphasising its ethical and relational dimensions. These revisions have been made in the Abstract (page 1, lines 30-33).

Point 2: Introduction: This section is solid and well structured, drawing on recent literature. Nevertheless, it is somewhat lengthy and contains some conceptual repetition, particularly regarding the centrality of dignity, care ethics, and the scarcity of qualitative studies on self-care. The gap in the literature that motivates the study should be articulated in a more explicit and direct manner.

Response 2: We have shortened the Introduction, reduced conceptual repetition, and articulated the literature gap more explicitly. These revisions have been made in Section 1. Introduction (page 2, lines 54-58, 63-70, 79–84; pages 2-3, lines 87-92).

Point 3: Materials and Methods: This is a rigorous section, with the phenomenological design well justified and appropriate to the study’s aims. However, a brief reflection on gender distribution and potential institutional differences among the included hospitals would be useful, even if these aspects were not central to the analysis. Regarding data analysis, the application of Colaizzi’s method is appropriate and well structured, although the section would benefit from more concrete examples of the interpretive process, particularly illustrating the transition from significant statements to formulated meanings.

Response 3: We have expanded Section 2.1. Participants to describe sample characteristics and to acknowledge contextual factors that may shape nurses’ experiences. We clarified that participants were purposively recruited as experienced nurses (≥3 years in closed psychiatric wards) from four closed psychiatric hospitals across three provinces, providing institutional and regional variation. We also reported the gender distribution and noted that, while the sample broadly reflects the gender composition of nursing in South Korea, male nurses were included. Although gender and institutional differences were not examined as analytic categories, core experiential patterns (e.g., “struggle” and “ethical self-care”) were evident across participants. In addition, to increase analytic transparency, we have added an illustrative example of Colaizzi’s interpretive process, demonstrating the progression from significant statements to formulated meanings and theme development. These revisions have been made in Section 2.1. Participants (page 3, lines 112–114) and Table 2. Illustrative example of Colaizzi’s analytic process (significant statements to formulated meanings) (pages 4-5, lines 167-168).

Point 4: Results: This is the strongest section of the manuscript, offering a rich and in-depth description of the participants’ lived experiences. Nonetheless, I encourage the authors to revisit this section, as some narrative redundancy is present.

Response 4: We have revised the Results to reduce narrative redundancy while preserving the richness of participants’ accounts. These revisions have been made in Section 3. Results (pages 6-7, lines 205-214; page 7, lines 254-257; page 8, lines 295-298; page 9, lines 336-337; page 10, lines 361-363).

Point 5: Discussion: There is a good engagement between the findings and the existing literature. However, in some passages the discussion tends toward a descriptive reiteration of results rather than a critical analytical confrontation. It is also recommended that the conceptual contribution of the study be made more explicit, clarifying how the findings reconceptualise self-care as a relational ethical practice, particularly within restrictive psychiatric contexts.

Response 5: We have revised the Discussion to reduce descriptive reiteration and to make the study’s conceptual contribution more explicit by highlighting how the findings reconceptualise self-care as a relational and ethically grounded practice within restrictive psychiatric contexts. These revisions have been made in Section 4. Discussion (page 11, lines 434–440; page 12, lines 476-478, 488-495; page 13, lines 501-505, 522-524).

Point 6: Implications and Limitations: The implications and limitations of the study are relevant and well aligned with the findings, highlighting the need for organisational support, spaces for ethical reflection, and a broader understanding of self-care in psychiatric nursing.

Response 6: We have further refined the Implications and Limitations to emphasise organisational support, spaces for ethical reflection, and a broader conceptualisation of self-care in psychiatric nursing. These revisions have been made in Section 5. Implications (page 14, lines 547-553, 561-568, 572-576).

Point 7: Conclusions: The conclusions provide a synthesis of the main findings and their implications for clinical practice. However, the theoretical and practical contributions to psychiatric nursing and care ethics should be articulated more clearly.

Response 7: We have revised the Conclusions to more clearly articulate the study’s contributions to psychiatric nursing and care ethics and to clarify the practical implications for clinical practice and organisational support in closed psychiatric wards. These revisions have been made in Section 6. Conclusions (page 15, lines 597-602, 606-608).

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review this manuscript. The title is distinctive and appropriately reflects the study’s scope, and the topic is timely in addressing an underexplored issue among nurses working in closed psychiatric environments, where such experiences are often unspoken.

Minor concerns:

The abstract is well written and accurately reflects the study. Given that the data were collected in 2018–2019, the authors may wish to briefly clarify the timing of the study and the rationale for the current submission, either in the abstract or manuscript, to support transparency.
Method: Authors may consider explicitly stating the phenomenological orientation (e.g. descriptive phenomenology) to further clarify the methodological stance and consider briefly elaborating on researcher positionality to strengthen reflexivity. In addition to that, the authors state that data saturation was reached at the eighth interview. A brief description of how saturation was assessed would further enhance transparency.
Given the time gap between data collection and manuscript submission, the authors may consider briefly clarifying the timing of data analysis.
There appears to be a minor inconsistency in table numbering (e.g. participant characteristics and thematic summary both referred to as Table 1). The authors may wish to revise this for clarity (ref line 170-171).
The participant quotations are powerful and illustrative. In a few subsections, the authors may consider adding an additional brief quotation to further reinforce the analytic interpretation.
Given the time gap between data collection and publication, the authors may consider briefly reiterating why the findings remain relevant, supported by recent literature cited in the Discussion.
The theoretical integration is strong, and a clearer emphasis on practical implications for practice or policy may further enhance accessibility for a wider readership.
The Discussion effectively covers individual and relational self-care, and a clearer focus on organisational responsibility could enhance its applied relevance.
Conclusion section: the authors may consider adding one brief forward-looking statement related to practice, education, or future research, and may also consider briefly reaffirming the ongoing relevance of the findings, despite the earlier data collection period.

Author Response

Detailed Responses to Reviewer 2

Reviewer 2

Point 1: The abstract is well written and accurately reflects the study. Given that the data were collected in 2018–2019, the authors may wish to briefly clarify the timing of the study and the rationale for the current submission, either in the abstract or manuscript, to support transparency.

Response 1: We have added a brief statement in the Methods section clarifying the timing of data collection (2018–2019) and the rationale for the timing of submission to support transparency. These revisions have been made in Section 2.4. Data Analysis (page 4, lines 158-164).

Point 2: Method: Authors may consider explicitly stating the phenomenological orientation (e.g. descriptive phenomenology) to further clarify the methodological stance and consider briefly elaborating on researcher positionality to strengthen reflexivity. In addition to that, the authors state that data saturation was reached at the eighth interview. A brief description of how saturation was assessed would further enhance transparency.

Response 2: We have revised the Methods section to explicitly state our phenomenological orientation as descriptive phenomenology, consistent with our use of Colaizzi’s analytic approach. We have also added a brief statement on researcher positionality/reflexivity (researchers’ backgrounds, relationship to the topic, and steps taken to support reflexive awareness during data collection and analysis). In addition, we have elaborated on how data saturation was assessed by describing our iterative monitoring of emerging meanings/themes after each interview and the team-based confirmation that no substantively new themes were identified by the eighth interview. These revisions have been made in Section 2.3. Data Collection (page 3, lines 120-124; page 4, lines 138-141), Section 2.4. Data Aanalysis (page 4, lines 144-149, 156-164), and Section 2.5. Trustworthiness section (page 5, lines 171-186).

Point 3: Given the time gap between data collection and manuscript submission, the authors may consider briefly clarifying the timing of data analysis.

Response 3: We have added a brief statement in the Methods section clarifying the timing of data analysis, including the period of preliminary analysis and the completion of the final analytic synthesis, to support transparency. These revisions have been made in Section 2.4. Data Analysis (page 4, lines 158-164).

Point 4: There appears to be a minor inconsistency in table numbering (e.g. participant characteristics and thematic summary both referred to as Table 1). The authors may wish to revise this for clarity (ref line 170-171).

Response 4: We have corrected the table numbering inconsistency by renumbering the thematic summary table from Table 1 to Table 3 and updating the corresponding in-text citation accordingly. These revisions have been made in the table caption and related in-text reference (page 5, lines 202-203).

Point 5: The participant quotations are powerful and illustrative. In a few subsections, the authors may consider adding an additional brief quotation to further reinforce the analytic interpretation.

Response 5: We have added additional brief participant quotations to further reinforce the analytic interpretation in Sections 3.1.4, 3.2.2, and 3.3.3. These revisions have been made in Section 3. Results (page 7, lines 246-251; page 8, lines 275-281; page 9, lines 324-334).

Point 6: Given the time gap between data collection and publication, the authors may consider briefly reiterating why the findings remain relevant, supported by recent literature cited in the Discussion.

Response 6: We have revised the Discussion to briefly reiterate why the findings remain relevant despite the time gap between data collection and publication, and we have supported this statement with recent literature on locked/acute mental health settings. We have also added a brief note in the Limitations section acknowledging the timing of data collection and reiterating the continued relevance of the findings. These revisions have been made in Section 4 Discussion (page 12, lines 451-456, 460-463, 488-495) and Section 5.2. Limitations (page 14, lines 579-581).

Point 7: The theoretical integration is strong, and a clearer emphasis on practical implications for practice or policy may further enhance accessibility for a wider readership.

Response 7: We have revised Section 5.1 Implications to more clearly emphasise practical implications for practice and policy, including actionable organisational and leadership strategies (e.g., protected reflective dialogue and ethics debriefings, confidential emotional support pathways, training that integrates therapeutic communication with safety routines, and structured forums for ethical reflection). These revisions have been made in Section 4. Discussion (pages 11-12, lines 445-451; page 12, lines 493-495) and Section 5.1. Implications (page 14, lines 547-553, lines 561-576).

Point 8: The Discussion effectively covers individual and relational self-care, and a clearer focus on organisational responsibility could enhance its applied relevance.

Response 8: We have strengthened the Discussion by more explicitly emphasising organisational responsibility for supporting nurses’ self-care in closed psychiatric wards. Specifically, we clarified that psychosocial burden and moral distress are structurally produced within restrictive ward conditions and therefore require organisational and system-level supports (e.g., protected reflective dialogue, structured post-incident debriefings, interdisciplinary ethics reflection rounds, and confidential support pathways), rather than relying primarily on individual coping. These revisions have been made in Section 4. Discussion (pages 11-12, lines 443-451; page 12, lines 488-495) and Section 5.1. Implications (page 14, lines 561-576).

Point 9: Conclusion section: the authors may consider adding one brief forward-looking statement related to practice, education, or future research, and may also consider briefly reaffirming the ongoing relevance of the findings, despite the earlier data collection period.

Response 9: We have revised the Conclusions to (1) briefly reaffirm the ongoing relevance of the findings despite the 2018–2019 data collection period, noting that the core structural and ethical conditions of closed psychiatric wards remain salient, and (2) add a concise forward-looking statement highlighting implications for practice and education (and the need for future research on organisational caregiver-support interventions). These revisions have been made in Section 6 Conclusions (page 15, lines 597-604, 606-608).

Author Response File: Author Response.pdf