Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol

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Research into doctors’ and nurses’ working conditions indicates the important role of 'solidarity' to their working experience. There is limited understanding of formal (trade unions, industrial action) and informal (peer-support, camaraderie) solidarity in shaping doctors’ and nurses’ working experience. This study aims to conceptualise both forms of solidarity as perceived by doctors and nurses to understand its potential on their working experience. This qualitative evidence synthesis (QES) protocol is reported following PRISMA-P recommendations. A search strategy has been developed using controlled vocabulary and free terms (MEDLINE, CINAHL, Scopus Embase, PubMed databases), following the Peer Review of Electronic Search Strategies (PRESS) process. English language articles will be included if they report primary, conceptually rich and contextually thick qualitative data, exploring the perceptions of informal and formal solidarity as experienced by qualified doctors and/or nurses. Its influence on the working experience, as reported by included studies, will be explored. Initial title and abstract screening, followed by full-text screening of included articles, will be completed independently by two reviewers. A grey literature search will be employed, including a targeted, domain-specific Google search of doctor and nurse national unions within ten countries with highest union density, and websites of intergovernmental organisations/agencies. Piloted data extraction forms will be used to extract study characteristics and qualitative data. The CASP (Critical Appraisals Skills Programme) tool will be used to assess the quality of included studies by two reviewers, independently. Confidence in cumulative findings will be assessed using GRADE-CERQual guidelines. The QES will be reported using eMERGe guidelines and will follow the Noblit and Hare meta-ethnography approach. Registration Number: This protocol has been registered via the PROSPERO database, the International Prospective Register of Systematic Reviews. The protocol can be found on the register under the following number: CRD420251150676. Available from: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251150676. PROSPERO Registration: CRD420251150676" } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://hrbopenresearch.org/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://hrbopenresearch.org/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://hrbopenresearch.org/articles/8-128/v1", "name": "Conceptualising doctors’ and nurses’ experience of formal and informal..." } } ] } Home Browse Conceptualising doctors’ and nurses’ experience of formal and informal... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Dumana M, Ó Riain S and Byrne JP. Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :128 ( https://doi.org/10.12688/hrbopenres.14294.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol [version 1; peer review: 1 approved, 1 approved with reservations] Maja Dumana https://orcid.org/0009-0002-9049-873X 1 , Seán Ó Riain 2 , John Paul Byrne https://orcid.org/0000-0002-9961-8710 3 Maja Dumana https://orcid.org/0009-0002-9049-873X 1 , Seán Ó Riain 2 , John Paul Byrne https://orcid.org/0000-0002-9961-8710 3 PUBLISHED 05 Dec 2025 Author details Author details 1 SPHeRE PhD Programme; Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences, Dublin, Leinster, Ireland 2 Sociology; Centre for European and Eurasian Studies; Social Sciences Institute, Maynooth University, Maynooth, County Kildare, Ireland 3 Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences, Dublin, Leinster, Ireland Maja Dumana Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Seán Ó Riain Roles: Conceptualization, Methodology, Resources, Supervision John Paul Byrne Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS Abstract Negative healthcare professional experiences of work can undermine health system stability by contributing to shortages, burnout and poor retention. Research into doctors’ and nurses’ working conditions indicates the important role of 'solidarity' to their working experience. There is limited understanding of formal (trade unions, industrial action) and informal (peer-support, camaraderie) solidarity in shaping doctors’ and nurses’ working experience. This study aims to conceptualise both forms of solidarity as perceived by doctors and nurses to understand its potential on their working experience. This qualitative evidence synthesis (QES) protocol is reported following PRISMA-P recommendations. A search strategy has been developed using controlled vocabulary and free terms (MEDLINE, CINAHL, Scopus Embase, PubMed databases), following the Peer Review of Electronic Search Strategies (PRESS) process. English language articles will be included if they report primary, conceptually rich and contextually thick qualitative data, exploring the perceptions of informal and formal solidarity as experienced by qualified doctors and/or nurses. Its influence on the working experience, as reported by included studies, will be explored. Initial title and abstract screening, followed by full-text screening of included articles, will be completed independently by two reviewers. A grey literature search will be employed, including a targeted, domain-specific Google search of doctor and nurse national unions within ten countries with highest union density, and websites of intergovernmental organisations/agencies. Piloted data extraction forms will be used to extract study characteristics and qualitative data. The CASP (Critical Appraisals Skills Programme) tool will be used to assess the quality of included studies by two reviewers, independently. Confidence in cumulative findings will be assessed using GRADE-CERQual guidelines. The QES will be reported using eMERGe guidelines and will follow the Noblit and Hare meta-ethnography approach. Registration Number: This protocol has been registered via the PROSPERO database, the International Prospective Register of Systematic Reviews. The protocol can be found on the register under the following number: CRD420251150676. Available from: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251150676 . PROSPERO Registration: CRD420251150676 READ ALL READ LESS Keywords Solidarity, solidarities, informal solidarity, formal solidarity, collective representation, trade unions, industrial relations, camaraderie, peer-support, experiences of work, shared experiences, doctors, nurses, qualitative evidence synthesis, QES, protocol Corresponding Author(s) Maja Dumana ( [email protected] ) Close Corresponding author: Maja Dumana Competing interests: No competing interests were disclosed. Grant information: Health Research Board [SPHeRE-2022-1 ] The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Copyright: © 2025 Dumana M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Dumana M, Ó Riain S and Byrne JP. Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :128 ( https://doi.org/10.12688/hrbopenres.14294.1 ) First published: 05 Dec 2025, 8 :128 ( https://doi.org/10.12688/hrbopenres.14294.1 ) Latest published: 10 Mar 2026, 8 :128 ( https://doi.org/10.12688/hrbopenres.14294.2 )  There is a newer version of this article available. Suppress this message for one day. 2.Introduction Introduction & background Healthcare workforce retention is a global population health challenge. As argued by the World Health Organization (WHO), there is ‘no health without a workforce’, highlighting the need for research exploring frontline healthcare staff workplace experiences 1 . Negative healthcare professional (HCP) experiences of work can undermine health system stability by influencing healthcare access, patient care quality and continuity – perpetuating the workforce crisis 2 . This crisis (comprising of a labour and mental health crisis) exists internationally, and is reflected in staff shortages, burnout and poor retention 3 . Increased workplace pressure faced by HCPs from the demands of ageing populations, and the coronavirus (COVID-19) pandemic especially, have highlighted the importance of ‘solidarity’ in shaping their working experience 4 , 5 . Recently, the COVID-19 pandemic has highlighted two key points of relevance to health research: the exacerbation of the unfavourable working conditions (extensive working hours and unreasonable shift patterns, resource shortages, pressure, stress, unsafe staffing) faced by HCPs, as well as the role of solidarity in the management of these conditions 4 – 6 . Solidarities in work have been broadly described as a collective sense of representation, shared vision and purpose that develop within work environments. Beck and Brook 7 define solidarity, broadly, as a phenomenon of ‘fellow-feeling’, which develops informally in the workplace as a collective sense of togetherness and mutually shared experiences and understanding. Solidarity (especially informal) refers to peer support or camaraderie – organic and mutually beneficial interpersonal support between colleagues with a shared sense of identity 5 , 7 – 10 , an example being illustrated by Korczynski’s communities of coping 11 , where two or more healthcare practitioners support one another in the workplace. Solidarities can also be formal – traditionally, as labour mobilisation or trade unions, commonly involving union membership of organised workers with similar material interests, ideas, or a sense of (in)justice 7 . With respect to formal solidarity, appropriate management of labour relations via engagement of healthcare workers’ trade unions and professional representative bodies has a documented influence on addressing and safeguarding workers’ wellbeing 3 , 12 . Trade unions, e.g., the Irish Nurses and Midwives Union (INMO) and the Irish Medical Organisation (IMO) representing Irish nurses and doctors, respectively, act as key stakeholders of formal, collective representation. Having the power to negotiate reform recommendations for more sustainable working contracts, conditions and pay through industrial action, workers’ unions shape the industrial and labour relations landscape, and thus, the experience of work for doctors and nurses 12 , 13 . In the Irish context, Byrne et al . 14 and Creese et al . 15 , 16 highlight how doctors’ experiences of work are shaped by informal peer support in a situation of a perceived ‘lack of voice’. However, there is limited research available regarding informal solidarity in frontline healthcare work (with two studies specifically related to the pandemic only, taking a psychological perspective) 5 , 8 , and limited evidence coherency of how informal solidarity shapes doctors’ and nurses’ experience of their work. As with informal solidarity, there is a lack of coherency as to the perceived influence trade unions and other collective forms of representation have on the experience of work from the viewpoint of doctors and nurses 3 , 12 . Following the consultation of the ‘RETREAT’ criteria developed by Booth et al . 17 , we identified qualitative evidence synthesis as the best methodology to explore this topic and address this evidence gap. Doctors and, in particular, nurses, were chosen due to historically high unionisation rates 18 , 19 and a tendency for these HCP unions to be single-profession(al) unions. The COVID-19 pandemic has highlighted the importance of solidarity for both professions 4 , 5 . Aim This QES aims to conceptualise how doctors and nurses experience both formal and informal solidarity in work. Findings of this review can inform strategies for improving health system sustainability by addressing the workforce crisis, leveraging the priorities of the World Health Organization’s (WHO) ‘Framework for action on the health and care workforce in the WHO European Region 2023–2030’, which is to safeguard the wellbeing of staff 1 . Additionally, a better understanding of working experiences of frontline health workers has the potential to influence workforce policy and improve retention. Research questions 1. What are doctors’ and nurses’ experience of formal and informal solidarity 2. How do these solidarities influence doctors’ and nurses’ experience of work. 3. Methods The SPIDER 20 (Sample, Phenomenon of Interest, Design, Evaluation, Research Type) framework informed the review question, search terms and inclusion and exclusion criteria, which are outlined in Table 1 below. See also the ‘Study Design ’ section, ‘ Step 1: Getting Started ’. Table 1. Research question as defined and formulated using the SPIDER framework 20 . Each aspect of the question is mapped on to and explained in the context of each element of SPIDER, while providing a summary of study search strategy inclusion and exclusion criteria (see ‘Study Design’ below). S ample Doctors and nurses of any grade/register (including intern but excluding undergraduate student or not fully qualified groups ) or specialty, working in any healthcare setting (hospital, community, public or private etc.). Doctors and nurses can be either active union members or non-members and be actively practicing or retired. Doctors and nurses who have exited the system but have healthcare work experience will also be included. Patient peer-support groups, or support groups for various morbidities/diseases (either communicable or non-communicable) will be excluded. Articles exploring the experiences of other allied HCPs only will be excluded . Articles where data specifically related to the perceptions and experiences of nurses and doctors can be extracted will be included. P henomenon of I nterest Solidarity comprising: a. Formal collective representation (e.g., trade unions, unionisation & union membership - representative bodies) of doctors and nurses, most frequently involving a contractual, paid subscription to access services such as legal support/advice, organised collective bargaining, safeguarding of interests and well-being, adequate renumeration etc., via negotiation with an employer 22 , 23 . b. Informal solidarity (e.g., peer support, shared experiences, camaraderie), defined as voluntary, mutual(ly beneficial), organic, interpersonal support and camaraderie between peers/colleagues who have a shared sense of experience, justice, purpose, and identity 5 , 7 – 10 . This can involve peer-to-peer support through institutionally organised programmes. To meet inclusion criteria, studies must specifically address either a or b above in depth, i.e., literature must include contextually thick and conceptually rich qualitative data, assessed using a QES assessment tool developed for this purpose 24 . D esign Qualitative evidence synthesis of primary, qualitative data studies using: - focus groups - interviews - fieldwork observations and notes - diaries and other qualitative data Included literature types: - articles published in peer-reviewed journals - ‘grey’ literature (reports and websites of international, representative agencies/bodies) Ethnographic studies , including digital book chapters with thick/rich qualitative data Excluded research designs and literature types: - Quantitative primary studies - Reviews (qualitative or quantitative, of any nature, including systematic reviews), - Mixed-methods studies (meta-ethnography being applicable to qualitative studies exclusively ) - Grey literature in the form of expert opinions, editorials, news articles, commentaries, abstracts in proceedings, theses, dissertations. - Ethnographic books (hard copies only, due to possible access restrictions and specificity to research question) - Full-text studies not written in the English language E valuation Experiences and perceptions R esearch Type Original qualitative research articles using designs noted above. Full-text, English language only (for the sake of preserving context/accurate interpretation of qualitative data). Study design This QES will employ Noblit and Hare’s 21 7-step meta-ethnography, a systematic approach to the synthesis of findings of relevant qualitative studies, translating them into one another. This provides novel interpretations, adding to the body of knowledge surrounding the phenomenon of interest; in this case, solidarity in healthcare work. The 7 steps (or ‘'phases’', as described by Noblit and Hare) include: 1. Getting started – identifying a novel research question or ‘intellectual interest’ which could be answered using qualitative methods (see ‘3. METHODS’ section and Table 1 ). 2. Deciding what is relevant – identifying articles, literature, and data which meet researcher-established criteria to answer the research question (described in ‘3. METHODS’). 3. Reading the studies – taking time to analyse and interpret the data selected in Step 2 above (see ‘3. METHODS - Search Strategy’) 4. Determining relatability across selected studies – finding similarities, but also differences, across concepts, themes and author interpretations which complement or refute each other throughout the selected studies (‘3. METHODS – Data Extraction Process and Analysis & Data Synthesis’). 5. Translating studies into one another – analysing the data of each selected study, through line-by-line coding (creating ‘first-line constructs’), followed by the grouping of this coding into descriptive codes, based on the similarities and differences in themes and concepts present in the data (‘ Data Synthesis ’). 6. Translation synthesis – generating analytical themes based on descriptive themes, as understood and interpreted by the researcher, with the help of existing theoretical frameworks to further the body of evidence related to the research question. This is also known as reciprocal translation and generates ‘second-order constructs’. Translation can also be refutational, should some constructs or concepts be conflicting (‘ Data Synthesis ’). 7. Synthesis expression – achieved by discussing and reporting the synthesised, translated interpretations from Steps 4 to 6 (‘third-order constructs’) as a systematic review of included qualitative literature, while following appropriate reporting guidelines such as eMERGe 21 , 25 (‘3. METHODS – Dissemination' and ‘4. CONCLUSION’). The protocol for this QES is reported using the PRISMA-P protocol checklist and guidelines 26 . The final synthesis and analysis will be reported in line with the ‘Improving reporting of meta-ethnography (eMERGe)’ guidelines 25 . Eligibility criteria Inclusion/exclusion criteria of study types, properties and study participants/population sampled are set out in the SPIDER framework 20 of Table 1 and addresses ‘Step 2: Deciding what is relevant’ of the 7-step Noblit and Hare meta-ethnography approach 21 . An English language filter will not be applied, due to the risk of excluding articles with non-English titles which include an English language translation. However, studies for which there is no available full-text English language translation will be manually removed during title/abstract screening - the rationale being the importance of context in qualitative studies, which may be impacted by translation. There will be no publication year restrictions applied to the search, the justification being that solidarity is a traditional concept in the social sciences and the likelihood of studies from the 70s and 80s in industrial relations being potentially relevant to our conceptualisation and research question. Search strategy The search strategy was devised, using the PRESS Peer-Review process, to address ‘ Step 2: Deciding what is relevant ’ of the Noblit and Hare 7-step meta-ethnography approach 21 . An independent, expert health librarian affiliated with the 1 st Author’s host institution was consulted to develop the search strategy and search strings for each relevant database. An initial search was developed with the help of the host institution librarian ('searcher'). A second, independent, university librarian ('reviewer') affiliated with the 2 nd Author’s host institution produced a PRESS Peer-Review 27 of the initial search, to finalise the search string, strategy, and increase rigour and transparency throughout the QES. Upon meeting and discussing with both librarians, any amendments advised as part of the PRESS peer-review were clarified and implemented across the search strategy and search strings for all databases used. The finalised search strings and strategy used for the purpose of this review, as well as the PRESS peer-review form completed by both librarians, is available under the ‘Extended Data’ section. The PRESS peer-review proved to be a very beneficial exercise, both in formalising the search strategy, as well as increasing the rigour and transparency of study search methodology. Additionally, both librarians offered invaluable amendments and suggestions for a more precise database search by pointing to some minor omissions and errors. Preliminary search terms were developed to reflect the research question, using both keywords and controlled vocabulary of MeSH terms. MeSH terms were used for term refinement. The final search string will be translated and applied to MEDLINE (Ovid; doctor focus), CINAHL (Cochrane; nurse focus), Scopus (Elsevier; a multidisciplinary database, with coverage of social sciences and humanities research), and Embase (Ovid/Elsevier). PROSPERO will be searched for similar, prospective reviews. Article authors may be contacted for clarifications. Search results will be subject to initial title and abstract screening carried out independently by two reviewers and selected based on relevance and meeting inclusion criteria outlined above. Disagreements and conflicts will be resolved by consulting a third reviewer. Grey literature search strategy. A two-step, grey literature search will be carried out via a targeted, domain specific Google search using the following keywords: “nurse”, “doctor”, “physician”, “midwife”, “frontline worker”, “union”, “experience”, “solidarity”, “peer support”, “employee morale”, “workplace support”, “strike”, “collective organisation”, “camaraderie” of: a) doctor and nurse-specific unions in the ten countries with the highest union density as per OECD data 28 : Iceland, Sweden, Denmark, Finland, Norway, Belgium, Italy, Luxembourg, Canada, Ireland. It is hoped that countries where union density and activity is highest will have published reports on union-member experiences. b) the websites of the following intergovernmental organisations and agencies will also be searched: Eurofound, WHO, OECD (Organisation for Economic Co-operation and Development), ILO (International Labour Organization) for key data relevant to the research question and inclusion criteria. The reference list of all included documents will be screened for additional studies using forward and backward citation (citation chasing via ‘Citationchaser’), supplemented by hand-searching reference lists where necessary 29 . Screening/data management & selection process. Following the search, all identified citations will be collated and imported into Zotero. After deduplication, citations will be uploaded into Covidence. The title and abstracts will be screened independently by two reviewers against the inclusion criteria outlined in Table 1 . The senior author will review the first 100 titles/abstracts as part of a pilot test. Disagreements will be resolved by consulting a third reviewer. Remaining articles will be subject to independent, full-text screening by two reviewers - disagreements will be resolved by consulting a third reviewer ( Steps 2 and 3 of the meta-ethnography approach) 21 . Data extraction process and analysis For the purpose of collecting both descriptive characteristics of studies included in this review, as well as qualitative data reported in each, data extraction forms will be drafted, piloted, and finalised. Data will be extracted using said preconceived extraction forms and the qualitative data (such as interview or focus group quotes/statements, observational notes and author analysis) generated from each included study will be imported into the latest NVivo software available to the 1 st Author, for further synthesis and analysis. This will be done independently by MD, with review from JPB – disagreements, should they arise, will be resolved by consulting SOR. This will address Steps 3 and 4 of the 7-step meta-ethnography process 21 . Data items. Data items collected will reflect the requirements proposed in data extraction forms. This will include: - Sample demographics and sample size. - Country of origin of each study. - Year of publication. - Author name(s). - Qualitative data generated and the authors’ interpretation of this data. This could include sections/paragraphs or transcripts, or direct study participant quotes interpretations, and analyses from grey literature. Data synthesis Meta-ethnography as described in the 7-step process developed by Noblit and Hare will be used to analyse the data, through line-by-line (first-order constructs) coding ( Step 4 of the process), followed by first-order grouping into descriptive codes (second-order constructs, including any contradictory findings, addressing Step 5 of the process), to generate analytical themes (third-order, using any existing conceptual or theoretical frameworks in this specific research field) 21 . In essence, this is a method of interpreting interpretations of interpretations to synthesise common or conflicting findings through analytical themes. Analytical themes will be translated into the results of individual studies, which adds cohesiveness to pre-existing knowledge, and can summarise how knowledge from one existing study can relate to another ( Step 6 ) 21 . Outcomes & prioritisation. In line with the research question and qualitative nature of this review, primary data will include doctors’ and nurses’ experiences and perceptions of formal and informal solidarity. Secondary data (which will be inductive) will explore the impact of this solidarity experience, e.g., staff expressions of engagement, intention to leave current post or system, workplace satisfaction, doctors’/nurses’ satisfaction with the representativeness of trade unions/consequences of industrial action, and the perceived ability of informal and formal solidarity to enforce/promote/enable workplace wellbeing and voice concerns. Risk of bias in individual studies, meta bias(es) Studies will be independently assessed for risk of bias (in both study methodology and outcomes reporting) by MD and JPB (with input from SOR should discrepancies arise) using the ’Critical Appraisal Skills Programme (CASP) Qualitative Studies Checklist’ 30 . Studies will not be excluded or included based on quality, but as previously stated, based on the richness and thickness of qualitative data. Contextual thickness and conceptual richness will be determined using a QES assessment tool developed by Ames et al . 24 . Confidence in cumulative evidence To assess the overall level of confidence to be placed in the overall findings of this review, and to increase reporting transparency, the (GRADE-CERQual) approach 31 will be applied to the cumulative evidence synthesis. Confidence in the cumulative evidence will be graded, assessed independently by each author and will be discussed by the research team. Reflexivity To ensure an unbiased approach, especially during the data analysis and the presentation of study findings, the research team will reflect on individual preconceptions and past experiences which could interfere with the validity of this study. The 1 st Author (MD) has a background in microbiology and public health, with some experience in the administrative aspect of healthcare management and teaching, but little experience in sociology or industrial relations. Two of the remaining authors (JPB and SOR) have an extensive background in sociology, with experience in the field of healthcare management. JPB’s previous work has largely focused on the working conditions and experiences of frontline healthcare workers (especially doctors). All authors have carried out research in both an Irish and an international context. However, none of the authors are qualified doctors, nurses, or any other allied healthcare professionals. The research team will reflect on any possible preconceptions at each stage of producing this review, which may affect the interpretation of data and research results. Dissemination of information It is hoped that this review will be published in a relevant peer-reviewed journal. The published review and its findings will be incorporated as part of the 1 st Author’s PhD research and disseminated at relevant conferences, PhD research showcases (internal and external to the 1 st Author’s host institution) and presented to policymakers and stakeholders of interest as relevant (‘ Step 7: Synthesis Expression ’) 21 . 4. Discussion COVID-19 highlighted a number of key points: there is no healthcare without a health workforce 1 , already strained working conditions and staff wellbeing were exacerbated by the pandemic experience, and solidarity was a key influence on the experience of healthcare delivery 5 , 6 , 8 – 10 . The findings of this QES can inform strategies for improving health workforce sustainability by leveraging the priorities of the WHO’s 'Framework for action on the health and care workforce in the WHO European Region 2023–2030’ to safeguard the wellbeing of health workforce staff 3 . A better understanding of the working experiences of frontline health workers, and the role of solidarity on this experience, has the potential to inform health workforce retention strategies and policies. 5. Limitations, final considerations Limitations This review will examine the experiences of qualified doctors and nurses only – undergraduate student doctors and nurses, and other allied healthcare professionals (be they students or fully qualified professionals) will not be considered. Therefore, this review will not capture the phenomena of solidarity, formal or informal, as perceived by other types of HCPs, or future frontline health workers. Due to the current political, social, and industrial relations landscape, views of those who practice in countries where trade union membership is considered unprofessional, taboo, or perceived to have consequences for one’s employment security (e.g. USA currently – especially in terms of the possibility of newly emerging research being limited, Belarus, Hungary, Turkiye) may not be captured fully despite this study aiming to capture an international perspective. Research emerging from countries where union density tends to be high (for example, Nordic and Benelux countries), may be overrepresented in this review. Additionally, articles not published in the English language are excluded, which, despite all efforts to include international literature, does not fully encapsulate the international perspective of doctors and nurses surrounding the concept of solidarity in the workplace. Although meta-ethnography is a powerful evidence synthesis tool for qualitative research, it often necessitates an exclusion of mixed-methods and quantitative studies such as research which utilises questionnaires or surveys with an explanatory or open-text element. Therefore, “thinner” qualitative data and quantitative data fall outside the scope of this review. However, this is partially justified with the primary aim of meta-ethnography being the synthesis of valuable rich and thick qualitative data only, which tends to be reported on and generated more transparently and rigorously in a fully qualitative study, as opposed to being an adjunct of a primarily quantitative study (which oftentimes yields ‘thin’ qualitative data). Study status On publication of this protocol, the review has commenced with the initial title and abstract screening phase. Data availability Underlying data No data associated with this article. Extended data PORSPERO Registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251150676 . The following extended data is available for this protocol under the Open Science Framework and the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication): https://doi.org/10.17605/OSF.IO/DGMK4 32 . Preliminary Search Strategy.docx (Provisional search string, exploring relevant MeSH terms prior to peer-review by a second, independent librarian.) PRESS Peer-Review Form.docx (Fully completed search string and search strategy peer-review document completed by librarian one and two.) Finalised Search Strategy.docx (Full, peer-reviewed search string applied as part of the search strategy, applied to databases PubMed, MEDLINE, CINAHL, Scopus and Embase) Protocol reporting guidelines PRISMA-P 2015 Checklist 26 for ‘Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol’ is available as extended data as ‘PRISMA-P Checklist’.docx under the Open Science Framework and the terms of the Creative Commons Zero “No rights reserved” data waiver (CC0 1.0 Public domain dedication): https://doi.org/10.17605/OSF.IO/DGMK4 32 . Acknowledgements The authors would like to acknowledge the kind help and patience of both Mr Killian Walsh (Information Specialist and Librarian, RCSI) and Mr Ciarán Quinn (Research Support Librarian, MU) in producing the preliminary search string and strategy, completing the PRESS Peer-Review, and finalising the search string/strategy applied for use in the QES review. The authors would also like to thank Dr Barbara Clyne (Senior Lecturer, RCSI) who reviewed this protocol. Faculty Opinions recommended References 1. Campbell J, Dussault G, Pozo-Martin F, et al. : A universal truth: no health without a workforce. Geneva: Global Health Workforce Alliance and World Health Organization, 2013. Reference Source 2. Bodenheimer T, Sinsky C: From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014; 12 (6): 573–576. PubMed Abstract | Publisher Full Text | Free Full Text 3. Azzopardi-Muscat N, Zapata T, Kluge H: Moving from health workforce crisis to health workforce success: the time to act is now. Lancet Reg Health Eur. 2023; 35 : 100765. PubMed Abstract | Publisher Full Text | Free Full Text 4. World Health Organization: Health and care workforce in Europe: time to Act. Copenhagen: WHO Regional Office for Europe, 2022. Reference Source 5. Kinsella EL, Muldoon OT, Lemon S, et al. : In it together?: Exploring solidarity with frontline workers in the United Kingdom and Ireland during COVID-19. Br J Soc Psychol. 2023; 62 (1): 241–263. PubMed Abstract | Publisher Full Text | Free Full Text 6. Byrne JP, Humphries N, McMurray R, et al. : COVID-19 and healthcare worker mental well-being: comparative case studies on interventions in six countries in the WHO European Region. Health Policy. 2023; 135 : 104863. PubMed Abstract | Publisher Full Text | Free Full Text 7. Beck V, Brook P: Solidarities in and through work in an age of extremes. Work Employ Soc. 2020; 34 (1): 3–17. Publisher Full Text 8. Sumner RC, Kinsella EL: Solidarity appraisal, meaning, and markers of welfare in frontline workers in the UK and Ireland during the Covid-19 pandemic. SSM Ment Health. 2022; 2 : 100099. PubMed Abstract | Publisher Full Text | Free Full Text 9. 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PubMed Abstract | Publisher Full Text 18. Guillaume C, Kirton G: ‘Walking a fine line’: union perspectives on partnership in nursing and midwifery workplaces. Econ Ind Democracy. 2022; 44 (3): 893–909. Publisher Full Text 19. Dube A, Kaplan E, Thompson O: Nurse unions and patient outcomes. ILR Review. 2016; 69 (4): 803–833. Publisher Full Text 20. Cooke A, Smith D, Booth A: Beyond PICO: the SPIDER tool for qualitative evidence synthesis. Qual Health Res. 2012; 22 (10): 1435–1443. PubMed Abstract | Publisher Full Text 21. Noblit GW, Hare RD: Meta-ethnography: synthesizing qualitative studies. SAGE Publications, Inc., 1988. Reference Source 22. Irish Nurses and Midwives Organisation: INMO rule book 2024. North Brunswick Street, Dublin: Irish Nurses and Midwives Organisation, 2024. Reference Source 23. Irish Medical Organisation: IMO constitution and rules. Dublin: Irish Medical Organisation, 2018. Reference Source 24. 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[dataset], OECD; Better Policies for Better Lives, 2025; [cited 28 October 2025]. Reference Source 29. Haddaway NR, Grainger MJ, Gray CT: Citationchaser: a tool for transparent and efficient forward and backward citation chasing in systematic searching. Res Synth Methods. 2022; 13 (4): 533–545. PubMed Abstract | Publisher Full Text 30. Critical Appraisal Skills Programme: CASP qualitative checklist. 2024; [cited 28 October 2024]. Reference Source 31. Lewin S, Glenton C, Munthe-Kaas H, et al. : Using qualitative evidence in decision making for health and social interventions: an approach to assess confidence in findings from qualitative evidence syntheses (GRADE-CERQual). PLoS Med. 2015; 12 (10): e1001895. PubMed Abstract | Publisher Full Text | Free Full Text 32. Dumana M: Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: a meta-ethnography protocol. Extended data. 2025. http://www.doi.org/10.17605/OSF.IO/DGMK4 Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 05 Dec 2025 ADD YOUR COMMENT Comment Author details Author details 1 SPHeRE PhD Programme; Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences, Dublin, Leinster, Ireland 2 Sociology; Centre for European and Eurasian Studies; Social Sciences Institute, Maynooth University, Maynooth, County Kildare, Ireland 3 Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences, Dublin, Leinster, Ireland Maja Dumana Roles: Conceptualization, Data Curation, Formal Analysis, Investigation, Methodology, Project Administration, Resources, Validation, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Seán Ó Riain Roles: Conceptualization, Methodology, Resources, Supervision John Paul Byrne Roles: Conceptualization, Funding Acquisition, Methodology, Project Administration, Resources, Supervision, Validation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information Health Research Board [SPHeRE-2022-1 ] The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Article Versions (2) version 2 Revised Published: 10 Mar 2026, 8:128 https://doi.org/10.12688/hrbopenres.14294.2 version 1 Published: 05 Dec 2025, 8:128 https://doi.org/10.12688/hrbopenres.14294.1 Copyright © 2025 Dumana M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics VIEWS $counts.viewCount downloads Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Dumana M, Ó Riain S and Byrne JP. Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :128 ( https://doi.org/10.12688/hrbopenres.14294.1 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 1 VERSION 1 PUBLISHED 05 Dec 2025 Views 0 Cite How to cite this report: Doran B. Reviewer Report For: Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :128 ( https://doi.org/10.21956/hrbopenres.15731.r52942 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-128/v1#referee-response-52942 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 29 Jan 2026 Brenna Doran , University of California San Francisco, San Francisco, Canada Approved with Reservations VIEWS 0 https://doi.org/10.21956/hrbopenres.15731.r52942 Article Summary This protocol outlines a Qualitative Evidence Synthesis (QES) designed to conceptualize formal and informal "solidarity" among qualified doctors and nurses. The study focuses on how these solidarities influence the working experience and potentially address health system instability ... Continue reading READ ALL Article Summary This protocol outlines a Qualitative Evidence Synthesis (QES) designed to conceptualize formal and informal "solidarity" among qualified doctors and nurses. The study focuses on how these solidarities influence the working experience and potentially address health system instability and workforce retention issues. The methodology follows the Noblit and Hare seven-step meta-ethnography approach, utilizing a search strategy refined by the PRESS process across major databases (MEDLINE, CINAHL, Scopus, Embase, and PubMed). The authors plan to utilize the SPIDER framework for criteria definition, CASP for quality appraisal, and GRADE-CERQual for assessing confidence in the cumulative findings. Overall Strengths: The manuscript addresses a timely and significant topic—healthcare workforce retention and the role of solidarity. The use of the PRESS process and professional librarians makes the search strategy highly transparent and reproducible. Using Noblit and Hare’s meta-ethnography and the SPIDER framework provides a solid academic structure for the study. Is the rationale for, and objectives of, the study clearly described? Answer: Partly While the manuscript identifies a significant gap regarding healthcare workforce retention, the rationale would benefit from further strengthening. For primary research terms such as “negative experiences” and “solidarity,” recommend using the definitions from the studies being referenced unless the intent is to provide a novel definition. If a novel definition is intended, this must be clearly communicated. Recommend ensuring the use of international references aligns with the stated local focus and application of the findings. Recommend stating if the goal of "conceptualizing" solidarity is to create a brand-new theory or to refine an existing one. Recommend including terms like "Medical Sociology" or "Industrial Relations" to improve the study's discoverability. The phrase "negative experiences" is broad. Recommend adding context regarding the root causes of these experiences and the role of the work environment. Recommend defining the "workplace crisis" more clearly (e.g., chronic staff shortages, increased patient mortality) and supporting it with appropriate citations. Ref 2 primarily identifies burnout as the issue. Recommend clarifying if burnout is the primary focus and ensuring the terminology used in the paper aligns with the cited references. Ref 2 is from 2014 and is based on a US study. Depending on the intended scope, recommend adding more current studies and references that reflect the appropriate geographical and historical scope to demonstrate the chronic nature of the issue. The paper states the crisis exists internationally; however, Reference 3 appears to be an opinion article focused on Europe that cites other studies. Recommend citing the original research studies and including a broader international lens to support the "labour and mental health crisis" claim. As "solidarity" is a primary variable, recommend clearly defining it and explaining how it relates to the specific problem being addressed. The current text provides multiple definitions; recommend specifying which one the reader is to follow. There is a heavy reliance on references from Ireland. If the Irish context is unique or superior in its research on solidarity, recommend providing that context. There is a disconnect between the global scope (WHO) and the specific geographical scope (10 OECD countries). If the research is limited to these 10 countries, recommend reconsidering the references in the introduction to support that specific scope. The specific problem and research question require greater clarity. Recommend explaining why a lack of knowledge regarding solidarity is a problem. For example: The workforce crisis harms retention → Solidarity may be the "glue" that prevents quitting → We do not know if staff perceive unions or peer support as effective → Therefore, this study is needed to inform policy. Recommend further elaborating on the tensions between informal solidarity, formal solidarity, and the role of the union, as these remain unclear. Regarding the use of the RETREAT methodology, it is unclear if there are enough primary studies to synthesize. Recommend addressing this concern, which is reinforced by the absence of robust references in the section outlining the research problem. To strengthen the introduction, recommend considering the following: Define the “so what” of the problem (e.g., “we don't know if solidarity is enough to stop doctors and nurses from leaving”). Explicitly state the objective around the third paragraph using a phrase like: "The objective of this Qualitative Evidence Synthesis is to..." State the research question clearly (e.g., "How do doctors and nurses perceive the influence of both informal peer support and formal union representation on their decision to remain in the workforce?"). Streamline the definitions of solidarity to focus on why the study is necessary. Is the study design appropriate for the research question? Answer: Partly This section outlines the steps of the meta-ethnography method without clearly explaining how it will be applied to this specific study. Recommend adding a justification for why these specific steps are the most appropriate tools to address the "solidarity" problem. The author describes the seven steps of Noblit and Hare in a general sense, but the section lacks a clear "audit trail." Specifically, how will the author ensure that ‘third-order' interpretations remain grounded in the original contexts of the international studies. Example (1 st order: The raw quotes from the doctors/nurses in the original studies, 2nd order: The original researchers' interpretations of those quotes, and 3 rd order the new synthesis of those interpretations.) This will also help the reader understand how the author will address a potential limited size of original research papers. Providing this detail will also help the reader understand how the author will address the potential issue of a limited number of original research papers. There is a heavy use of circular referencing (e.g., multiple references to Section 3 and Table 1). While referencing is appropriate, recommend streamlining these mentions to avoid repetitive citations. The author states that an English filter will not be applied to avoid excluding translated articles, yet also states that studies without English full-text will be manually removed. Recommend clarifying this contradiction; excluding non-English studies may result in missing key international research. Are sufficient details of the methods provided to allow replication by others? Answer: Partly The historical scope (dating back to 1970) appears broader than the background and research problem, which focus on COVID-19 and modern aging populations. If historical studies are to be included, recommend adding an explanation of how contexts from the 1970s forward remain relevant to the current healthcare environment and modern union relationships. Regarding the sample, recommend clarifying the specific criteria for "doctor" and "nurse" from an international perspective (e.g., education and licensure). For example, in the US, "doctor" can refer to many terminal degrees (MD, DNP, PhD); recommend specifying if the study is limited to physicians (MD/DO) and how allied health professionals with similar degrees will be handled. Recommend clarifying the definition of "experiences" in the context of the exclusion criteria for allied healthcare providers. Excluding frontline staff such as respiratory therapists, surgical technicians, and pharmacists may result in missing impactful studies, as "solidarity" is often a multi-disciplinary phenomenon. The exclusion of "patient peer-support groups" is noted; recommend providing a clear justification for why this specific group is being excluded from a study on workplace solidarity. High-quality healthcare studies often use mixed-method approaches to show both what is happening (quantitative) and why (qualitative). By excluding these entirely, the author may miss "thick and rich" qualitative data. Recommend the author justify why the qualitative components of mixed-methods studies are considered insufficient for this specific synthesis. Most current keywords focus on "strikes" and "unions." Recommend adding sociological terms like "professional identity," "occupational community," or "social capital" to find studies on informal support that the current industrial relations terms might miss. Since this is a social topic, consider searching databases like PsycINFO or SocINDEX. As Table One includes excluding non-english full-texts please clarify if the author will be searching for non-english terms. If search is limited to English Keywords, the ‘translation’ of the string (for grey searches) is purely technical rather than linguistic and needs to be specified. When two people test the first 100 articles, recommend using a math-based score (like Cohen’s Kappa) to prove both reviewers are truly aligned on the study criteria before proceeding. In a meta-ethnography, it is vital to distinguish between 1st-order constructs (participant quotes) and 2nd-order constructs (original author interpretations) during extraction. Recommend explicitly stating how the extraction form will separate these to ensure an organized translation process. The author mentions using a QES assessment tool (Ref 24) but does not explain when the quality appraisal occurs. Recommend clarifying the timing of this step (e.g., during full-text screening or after extraction) and at what point "thin" studies are discarded. The author defines 1st-order constructs as "line-by-line coding" and 2nd-order as "descriptive codes." Recommend clarifying whether the coding is being applied to the raw data or the original researchers' analysis. The author mentions that analytical themes will be "translated into the results of the individual studies." As Step 6 is typically the reverse—where individual studies are translated into one another to create themes—recommend confirming the order and ensuring the synthesis emerges from the studies. Regarding 3rd-order constructs, recommend naming the "existing conceptual or theoretical frameworks" being considered to ensure the interpretations have a strong theoretical grounding. The protocol mentions "refutational translation" but lacks an execution plan. Recommend detailing how the team will handle "disconfirming cases" (e.g., where formal solidarity undermines informal camaraderie) to avoid a homogenized result that ignores contextual tensions. It is unclear how the author will distinguish between the "experience" (primary data) and "impact" (secondary data) of solidarity, as these are often linked in narratives. Recommend justifying the prioritization of these data items, particularly given that "intention to leave" is a core problem identified in the introduction. Regarding the GRADE-CERQual approach, recommend clarifying how the four components (Methodological Limitations, Relevance, Coherence, and Adequacy) will be operationalized. Specifically, recommend defining "Adequacy"—whether it is based on the number of studies or the "thickness" of the data. Recommend specifying if the CERQual assessment will be performed independently by two reviewers to reduce subjective bias and increase confidence in the cumulative findings. The discussion focuses heavily on the COVID-19 pandemic and the WHO Framework. Recommend explicitly connecting the potential findings of this QES to specific policy levers beyond "wellbeing," such as how solidarity might practically influence retention strategies. The author acknowledges that countries where unionization is "taboo" may be underrepresented. Recommend clarifying if the search strategy will proactively look for "alternative" forms of solidarity in these regions to ensure the study is truly international as claimed. The limitation regarding the exclusion of "allied healthcare professionals" is noted. However, since the author justifies this by focusing on high unionization rates in nursing and medicine, recommend discussing how the exclusion of the "wider team" might limit the understanding of "informal solidarity" (camaraderie), which is often multi-disciplinary. The author justifies the exclusion of allied healthcare professionals by citing the high unionization rates of doctors and nurses. However, since the study aims to explore both unionized and non-unionized staff, this justification appears inconsistent. Furthermore, because "informal solidarity" (camaraderie) is inherently multi-disciplinary, excluding the "wider team" may result in a fragmented or incomplete understanding of how doctors and nurses experience workplace support. Recommend the author clarify this exclusion, especially since unionization structures and professional roles vary significantly across the ten countries included in the study. Is the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: My research and professional expertise focus on the operational challenges and psychological well-being of the infection prevention workforce, with specific emphasis on the following topics: Infection preventionist staffing and workload, Healthcare worker burnout and attrition, Professional resilience and leadership coaching, Retention factors in specialized healthcare roles, Infectious disease epidemiology and clinical microbiology, and Change management and patient safety advocacy. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Doran B. Reviewer Report For: Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :128 ( https://doi.org/10.21956/hrbopenres.15731.r52942 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-128/v1#referee-response-52942 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 10 Mar 2026 Maja Dumana , SPHeRE PhD Programme; Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences, Dublin, Ireland 10 Mar 2026 Author Response Thank you kindly for taking the time to publish your peer-review, it is much appreciated. Is the rationale for, and objectives of, the study clearly described? Thank you for ... Continue reading Thank you kindly for taking the time to publish your peer-review, it is much appreciated. Is the rationale for, and objectives of, the study clearly described? Thank you for this comment. We have now clarified what is meant by ‘’negative experiences’’ in the first paragraph of the ‘Introduction and background’ section. Additionally, we define solidarity – based on the references listed and discussed, in Table 1 (SPIDER). This definition also drives our search strategy. We have also clarified that the purpose of this study, in line with a meta-ethnography approach, is to produce a novel conceptualisation of the role of solidarity for doctors and nurses and their working experience. Thanks for this suggestion. In the final QES paper, we will ensure a balance between both national and international references. We refer to the Irish context in the background especially but make it clear that our search strategy and overall study scope is international literature. We have also described the ‘’healthcare workforce crisis’’ as an international phenomenon, with global evidence (WHO). We have also included evidence from countries other than Ireland, to expand the context. Thank you. As per the meta-ethnography approach, our primary goal is to develop a new theory of solidarity’s impact for doctors and nurses. This point has been clarified in the protocol aim. We really welcome this suggestion – we have added ‘’Medical Sociology’’ as a term to the protocol keywords. The term ‘’Industrial Relations’’ has already been included. Thank you, we have now clarified what is meant by ‘’negative experiences’’ (please refer to point 1 above). Thank you for this comment. References 3 and 4 provide core features defining the ‘’workforce crisis’’. These features have now been clarified in the ‘Introduction and background’ section. Thank you – we have reviewed the protocol to ensure there is no overemphasis on burnout, as it is not the sole focus of our research. Reference 2 uses burnout as one of many outcomes or issues facing healthcare staff, but focuses more on illustrating the importance of considering working lives, experiences and conditions in health systems research. Thank you very much for this suggestion. We have edited this section of the ‘Introduction and background’ to include more recent EU and UK references. We have highlighted the range of work stressors and conditions experiences by healthcare staff. Please also refer to point 7 above. Thank you. We have now expanded the citations to include various primary studies illustrating poor working conditions and mental health issues for doctors and nurses as evidence of the international crisis. Thank you. The guiding definition in our research is provided in Table 1. However, to improve clarity, we have added ‘’Please see Table 1 for specific definitions of solidarity which will guide this study.’’ in the ‘Background and introduction’’ section and the ‘Methods’ section. Thank you for this comment. To better describe an international context for the issue at heart, as well as solidarity for both doctors and nurses, more references have now been added (please see point 8 and 9). Regarding union bodies cited in the protocol, national (Irish) examples have been used for formal solidarity, as these are the most familiar to the research team. However, these bodies represent standard trade union ethos, membership and engage in activity common to many typical trade unions globally. To clarify, the study is not limited to these 10 countries, and it is made clear that this focus is part of the grey literature search only, (the main literature search has no geographical limits as stated).The countries were chosen as they have the highest general workforce unionisation rates (according to the OECD). This data may not have been picked up by the standard search otherwise. Thank you for this suggestion. We have now edited the problem and research question in the ‘Background and introduction’’ to read as follows: ‘’As established, negative work experiences have the potential to exacerbate the workforce crisis by undermining HCP retention, and contributing to burnout and shortages. Meanwhile research has shown that solidarity shapes the working experience of HCPs, particularly that of doctors and nurses, profoundly. However, there is no universal consensus on whether doctors and nurses perceive both informal solidarity or formal representation (mainly trade union support) as effective in mediating negative work experiences. It is worthwhile, therefore, to synthesise existing literature exploring these perceptions to better inform and support health workforce policies.’’ Thank you for this suggestion. We have now mentioned defining the relationship/tensions between formal and informal solidarity in the ‘Outcomes’ section. However, these tensions do remain unclear in the literature. To our knowledge, no review provides any context as to this relationship for doctors and nurses. This relationship is something that our QES has potential to contribute to. Additionally, this will be examined in a further study as part of my PhD project (qualitative, semi-structured interviews with union and non-union member doctors and nurses). Thank you. Additional studies have now been cited which highlight the problem. QES meta-ethnography is not concerned with a large number of studies, but rather, the richness and thickness the data of the included studies contributes to the overall synthesis. In fact, a large number of studies may interfere with accurate synthesis,and may warrant employing a sampling of studies to mitigate this ( Sattar et al., 2021 )(Reference 37 in the updated manuscript). Sources of data are being assessed using the QES meta-ethnography data richness and thickness tool (Ref 29 in the updated manuscript). Thank you. We have now stated that it is not clear how exactly solidarity shapes the working experience of doctors or nurses, and thus, warrants review. This has been done towards the end of the ‘Background and introduction’ section. The objective of the QES has been re-emphasised towards the very end of the ‘Background and introduction’ section. Our research question is stated in the ‘Aims - Research Question’ section. To model your suggestion, we have edited this section to read as only one coherent question. The definitions of solidarity have been defined in Table 1. Is the study design appropriate for the research question? The use of QES has been justified throughout the protocol. Each of the 7-steps of meta-ethnography are contextualised with respects to the study processes. Each relevant research step described as part of this study is referenced back to one of the seven meta-ethnography steps (e.g. ‘’Step 3 - ‘’Reading the studies’’ ‘’...’’ (see ‘3 - METHODS - ‘Search Strategy’)’’. In line with your suggestion, we have also strengthened our justification for addressing the research question with the use of meta-ethnography, as developed by Noblit and Hare, in the first paragraph of the ‘Study Design’ section (‘3.Methods’). Thanks for this comment. We have now clarified how data extraction and analysis will be managed to account for three orders of data. This has been clarified in the ‘Study Design’, ‘Data Extraction and Analysis’ and ‘Data Synthesis’ subsections of the ‘Methods’ section. Please refer back to my comments in point 15 above, as I feel like they may also be applicable to this suggestion. Thank you for this suggestion. We have amended some references to read, e.g. ‘’Please refer to the METHODS section, specifically...’’. We appreciate this suggestion. We have now better clarified this. Studies for which there is no English language translation will be excluded. However, to avoid excluding studies with non-English titles which are otherwise supplemented with an original English translation (provided by the authors/journal), no English language filter will be applied to the search. Studies not written in English (title or otherwise), without a full-text English translation from the authors of the study or the publishing journal, will be excluded manually. We have also already included a justification for this exclusion. Qualitative study findings, especially when discussing experiences and perceptions via e.g. direct study participant quotes, can easily lose context (linguistically, in this case), when accurate translation is not provided at the original source. We have also listed excluding studies not written in the English language as a limitation. Are sufficient details of the methods provided to allow replication by others? Thank you for this suggestion. We have now stated the following in the ‘Eligibility Criteria’ section. This reads as follows: ‘’Although previously cited studies describe solidarity which may be more recent (e.g. in the context of the COVID-19 pandemic), the relevance and impact of solidarity for both doctors and nurses is a historically relevant concept. Therefore, in order to broadly address the research question, to note any historical differences in sentiment towards solidarity, and to minimise the risk of excluding older, but highly relevant literature, no publication year restriction filter will be applied.’’ As mentioned above, solidarity is a historically intricate phenomenon which evolves throughout the year across professions and culture ( Wildt, 1999 ). We have now re-emphasised that the study is limited to medical, qualified (licensed) doctors (i.e. not doctorates, PhDs or similar) and nurses. We have also clarified that, in order to capture international spelling variants and titles, MeSH terms, other database specific vocabulary and appropriate terms and truncations (e.g. ‘’physician*’’) have already been used with respects to the search strategy. Thank you for the comment. We absolutely acknowledge and agree that solidarity is often a multi-disciplinary phenomenon. However, we justify the decision to exclude other allied HCPs mainly due to the fact that these professionals tend to hold membership in multi-profession union as opposed to mostly single-profession unions, such as doctors and nurses. Also, due to this being a PhD research project QES, including other allied healthcare professionals would stretch the scope and feasibility of the study. We also discuss this in the limitations section of the protocol. Future planned research as part of the PhD project will involve qualitative interviews with doctors and nurses discussing solidarity where its multi-disciplinary nature can be explained further. Thank you – we have made the rationale for this exclusion in Table 1. This exclusion is primarily to limit the number of irrelevant search result being returned. The exclusion of mixed-methods studies and quantitative studies has been justified in the protocol as follows: ‘’Although meta-ethnography is a powerful evidence synthesis tool for qualitative research, it often necessitates an exclusion of mixed-methods and quantitative studies such as research which utilises questionnaires or surveys with an explanatory or open-text element. Therefore, “thinner” qualitative data and quantitative data fall outside the scope of this review. However, this is partially justified with the primary aim of meta-ethnography being the synthesis of valuable rich and thick qualitative data only, which tends to be reported on and generated more transparently and rigorously in a fully qualitative study, as opposed to being an adjunct of a primarily quantitative study (which oftentimes yields ‘thin’ qualitative data (Ames et al., 2024 ; Noblit and Hare, 1988)’’ (Ref 28, 29 in the updated manuscript). The ‘Limitations’ section also lists this exclusion, which the research team deems necessary in order to follow the gold standard approach to conducting meta-ethnography. Thank you for this recommendation - ‘’social capital’’ in particular is a worthwhile term to matching our search criteria. However, the current search strategy once developed and piloted has captured articles exploring this topic or referencing this particular term. Terms such as ‘’community’’ have already been included in the search strategy. Terms similar to ‘’professional identity’’ and ‘’occupational community’’ have shown to generate a large number of irrelevant results when previously piloted, and are not specific enough for the purpose of addressing the research question Thank you for this suggestion. In order to explore this topic from a social sciences perspective, we have already included the database Scopus, which provides context from a social sciences and humanities perspective, the database focus being largely multi-disciplinary. Thank you – we have clarified that the author will not be searching for non-English terms. As already mentioned, truncations and terms such as ‘’physician*’’ have already been included in the search string.We have now stated that there will be no translation of search strings or search terms for neither search. Thanks for this suggestion. However, we will not use Cohen’s Kappa or other mathematical score to evaluate inter-rater reliability. As per Smith and McGannon (2017) , the use of inter-rater reliability is in conflict with qualitative methods: ‘’ Member checking and inter-rater reliability are shown to be ineffective for verification, trustworthiness, or reliability purposes.’’ Instead, two reviewers will review the first 100 titles/abstracts as part of a pilot test. The team will discuss any conflicts. Final disagreements will be resolved by a third reviewer. Thank you for this suggestion. We have now addressed this (please refer back to point 2 of the previous section of comments). Thank you. We have now clarified the stages at which the QES assessment tool developed by Ames et al. will be implemented in the ‘Screening/Data Management & Selection’ section of the protocol. We will also include a reasoning trail for all decisions made using the tool developed by Ames et al. (Ref 28 in the updated manuscript) for screening purposes as part of the full QES publication. Thank you for this suggestion. To clarify, we are applying coding (line-by-line coding, and creating descriptive codes) to both the raw data from participants and the original researcher’s analysis from primary studies. We have amended the protocol to reflect this. Thank you for this clarification, this has been amended. Individual study results (i.e. raw data, authors’ interpretations) will be translated into one another to create/synthesise novel themes, adding to the body of knowledge i.e. new interpretations of author’s interpretations of primary data. This has now been stated in the protocol. Thank you for this suggestion. We will keep this in mind at later stages as this will be an iterative process. Some potentially relevant theoretical frameworks have been proposed, including the Social Exchange Theory and Durkheim’s Sociological Foundations (mechanical and organic solidarity ) (Ref 35 and 36 in the updated manuscript). Thank you for this comment. We have now addressed this (please refer back to point 10 above and point 2 of the previous section of comments). Thank you for this suggestion. We have now clarified that there is no hierarchy (i.e. no primary or secondary data). This decision came from discussing with the research team. Experience and impact are equally important, related and not easy to differentiate. Additionally, our research question sets out to address both the experience and impact/influence of solidarity. The ‘’data’’ referred to here refers to outcomes. Additionally, please refer to point 2 from the previous section, and points 10, 12 and 15 from this section for a clarification on how data will be managed. Thank you for this suggestion. We have now elaborated on this approach in the ‘Confidence in Cumulative Evidence’ section. Please also refer to points 11 and 5 directly above, and point 15 of the previous section). We have amended this in the protocol to emphasise that this assessment will be carried out independently by MD and JPB, and will be discussed by the team. Thank you for this suggestion. This will be addressed more comprehensively in the full QES paper. However, we have amended the ‘Discussion’ section to add an explanation stating that representative bodies and organisation will be informed of key findings regarding how solidarity can encourage workforce retention, amplify employee voice and belonging, and address some elements of the workforce crisis. Thank you for this suggestion. The purpose of this point in the limitations section was ensure transparency and highlight we are aware of limitations. Specific regions will not be targeted for more covert forms of solidarity. As mentioned, in order to capture an international perspective, our search strategy has been designed using broad terms (e.g. ‘’doctor*’’ but also ‘’physician*’’) with appropriate truncations and database specific controlled vocabulary. Thank you for this comment. Please refer to my response in point 3 above, as there is some overlap. Focusing on specific professions (i.e. doctors and nurses) will offer our study clarity and feasibility. Additionally, qualitative interviews with doctors and nurses, which will take place as part of a different study under this PhD project, will aim to capture a multi-disciplinary experience. Thank you for this comment. Please refer to point 21 and point 3 above, as my responses are also relevant here. A profession specific focus will allow for the exploration of formal and informal solidarity within the same profession, which is not inconsistent in terms of what has been set out by the research question. Theorising connections between union rates of nurses and camaraderie for other allied healthcare professionals would not necessarily provide a coherent answer to the research question. The scope of this study also requires feasibility – hence, the focus on doctors and nurses. As addressed in point 12 of the previous section of comments, the 10 countries mentioned are related to the grey literature search only. Thank you kindly for taking the time to publish your peer-review, it is much appreciated. Is the rationale for, and objectives of, the study clearly described? Thank you for this comment. We have now clarified what is meant by ‘’negative experiences’’ in the first paragraph of the ‘Introduction and background’ section. Additionally, we define solidarity – based on the references listed and discussed, in Table 1 (SPIDER). This definition also drives our search strategy. We have also clarified that the purpose of this study, in line with a meta-ethnography approach, is to produce a novel conceptualisation of the role of solidarity for doctors and nurses and their working experience. Thanks for this suggestion. In the final QES paper, we will ensure a balance between both national and international references. We refer to the Irish context in the background especially but make it clear that our search strategy and overall study scope is international literature. We have also described the ‘’healthcare workforce crisis’’ as an international phenomenon, with global evidence (WHO). We have also included evidence from countries other than Ireland, to expand the context. Thank you. As per the meta-ethnography approach, our primary goal is to develop a new theory of solidarity’s impact for doctors and nurses. This point has been clarified in the protocol aim. We really welcome this suggestion – we have added ‘’Medical Sociology’’ as a term to the protocol keywords. The term ‘’Industrial Relations’’ has already been included. Thank you, we have now clarified what is meant by ‘’negative experiences’’ (please refer to point 1 above). Thank you for this comment. References 3 and 4 provide core features defining the ‘’workforce crisis’’. These features have now been clarified in the ‘Introduction and background’ section. Thank you – we have reviewed the protocol to ensure there is no overemphasis on burnout, as it is not the sole focus of our research. Reference 2 uses burnout as one of many outcomes or issues facing healthcare staff, but focuses more on illustrating the importance of considering working lives, experiences and conditions in health systems research. Thank you very much for this suggestion. We have edited this section of the ‘Introduction and background’ to include more recent EU and UK references. We have highlighted the range of work stressors and conditions experiences by healthcare staff. Please also refer to point 7 above. Thank you. We have now expanded the citations to include various primary studies illustrating poor working conditions and mental health issues for doctors and nurses as evidence of the international crisis. Thank you. The guiding definition in our research is provided in Table 1. However, to improve clarity, we have added ‘’Please see Table 1 for specific definitions of solidarity which will guide this study.’’ in the ‘Background and introduction’’ section and the ‘Methods’ section. Thank you for this comment. To better describe an international context for the issue at heart, as well as solidarity for both doctors and nurses, more references have now been added (please see point 8 and 9). Regarding union bodies cited in the protocol, national (Irish) examples have been used for formal solidarity, as these are the most familiar to the research team. However, these bodies represent standard trade union ethos, membership and engage in activity common to many typical trade unions globally. To clarify, the study is not limited to these 10 countries, and it is made clear that this focus is part of the grey literature search only, (the main literature search has no geographical limits as stated).The countries were chosen as they have the highest general workforce unionisation rates (according to the OECD). This data may not have been picked up by the standard search otherwise. Thank you for this suggestion. We have now edited the problem and research question in the ‘Background and introduction’’ to read as follows: ‘’As established, negative work experiences have the potential to exacerbate the workforce crisis by undermining HCP retention, and contributing to burnout and shortages. Meanwhile research has shown that solidarity shapes the working experience of HCPs, particularly that of doctors and nurses, profoundly. However, there is no universal consensus on whether doctors and nurses perceive both informal solidarity or formal representation (mainly trade union support) as effective in mediating negative work experiences. It is worthwhile, therefore, to synthesise existing literature exploring these perceptions to better inform and support health workforce policies.’’ Thank you for this suggestion. We have now mentioned defining the relationship/tensions between formal and informal solidarity in the ‘Outcomes’ section. However, these tensions do remain unclear in the literature. To our knowledge, no review provides any context as to this relationship for doctors and nurses. This relationship is something that our QES has potential to contribute to. Additionally, this will be examined in a further study as part of my PhD project (qualitative, semi-structured interviews with union and non-union member doctors and nurses). Thank you. Additional studies have now been cited which highlight the problem. QES meta-ethnography is not concerned with a large number of studies, but rather, the richness and thickness the data of the included studies contributes to the overall synthesis. In fact, a large number of studies may interfere with accurate synthesis,and may warrant employing a sampling of studies to mitigate this ( Sattar et al., 2021 )(Reference 37 in the updated manuscript). Sources of data are being assessed using the QES meta-ethnography data richness and thickness tool (Ref 29 in the updated manuscript). Thank you. We have now stated that it is not clear how exactly solidarity shapes the working experience of doctors or nurses, and thus, warrants review. This has been done towards the end of the ‘Background and introduction’ section. The objective of the QES has been re-emphasised towards the very end of the ‘Background and introduction’ section. Our research question is stated in the ‘Aims - Research Question’ section. To model your suggestion, we have edited this section to read as only one coherent question. The definitions of solidarity have been defined in Table 1. Is the study design appropriate for the research question? The use of QES has been justified throughout the protocol. Each of the 7-steps of meta-ethnography are contextualised with respects to the study processes. Each relevant research step described as part of this study is referenced back to one of the seven meta-ethnography steps (e.g. ‘’Step 3 - ‘’Reading the studies’’ ‘’...’’ (see ‘3 - METHODS - ‘Search Strategy’)’’. In line with your suggestion, we have also strengthened our justification for addressing the research question with the use of meta-ethnography, as developed by Noblit and Hare, in the first paragraph of the ‘Study Design’ section (‘3.Methods’). Thanks for this comment. We have now clarified how data extraction and analysis will be managed to account for three orders of data. This has been clarified in the ‘Study Design’, ‘Data Extraction and Analysis’ and ‘Data Synthesis’ subsections of the ‘Methods’ section. Please refer back to my comments in point 15 above, as I feel like they may also be applicable to this suggestion. Thank you for this suggestion. We have amended some references to read, e.g. ‘’Please refer to the METHODS section, specifically...’’. We appreciate this suggestion. We have now better clarified this. Studies for which there is no English language translation will be excluded. However, to avoid excluding studies with non-English titles which are otherwise supplemented with an original English translation (provided by the authors/journal), no English language filter will be applied to the search. Studies not written in English (title or otherwise), without a full-text English translation from the authors of the study or the publishing journal, will be excluded manually. We have also already included a justification for this exclusion. Qualitative study findings, especially when discussing experiences and perceptions via e.g. direct study participant quotes, can easily lose context (linguistically, in this case), when accurate translation is not provided at the original source. We have also listed excluding studies not written in the English language as a limitation. Are sufficient details of the methods provided to allow replication by others? Thank you for this suggestion. We have now stated the following in the ‘Eligibility Criteria’ section. This reads as follows: ‘’Although previously cited studies describe solidarity which may be more recent (e.g. in the context of the COVID-19 pandemic), the relevance and impact of solidarity for both doctors and nurses is a historically relevant concept. Therefore, in order to broadly address the research question, to note any historical differences in sentiment towards solidarity, and to minimise the risk of excluding older, but highly relevant literature, no publication year restriction filter will be applied.’’ As mentioned above, solidarity is a historically intricate phenomenon which evolves throughout the year across professions and culture ( Wildt, 1999 ). We have now re-emphasised that the study is limited to medical, qualified (licensed) doctors (i.e. not doctorates, PhDs or similar) and nurses. We have also clarified that, in order to capture international spelling variants and titles, MeSH terms, other database specific vocabulary and appropriate terms and truncations (e.g. ‘’physician*’’) have already been used with respects to the search strategy. Thank you for the comment. We absolutely acknowledge and agree that solidarity is often a multi-disciplinary phenomenon. However, we justify the decision to exclude other allied HCPs mainly due to the fact that these professionals tend to hold membership in multi-profession union as opposed to mostly single-profession unions, such as doctors and nurses. Also, due to this being a PhD research project QES, including other allied healthcare professionals would stretch the scope and feasibility of the study. We also discuss this in the limitations section of the protocol. Future planned research as part of the PhD project will involve qualitative interviews with doctors and nurses discussing solidarity where its multi-disciplinary nature can be explained further. Thank you – we have made the rationale for this exclusion in Table 1. This exclusion is primarily to limit the number of irrelevant search result being returned. The exclusion of mixed-methods studies and quantitative studies has been justified in the protocol as follows: ‘’Although meta-ethnography is a powerful evidence synthesis tool for qualitative research, it often necessitates an exclusion of mixed-methods and quantitative studies such as research which utilises questionnaires or surveys with an explanatory or open-text element. Therefore, “thinner” qualitative data and quantitative data fall outside the scope of this review. However, this is partially justified with the primary aim of meta-ethnography being the synthesis of valuable rich and thick qualitative data only, which tends to be reported on and generated more transparently and rigorously in a fully qualitative study, as opposed to being an adjunct of a primarily quantitative study (which oftentimes yields ‘thin’ qualitative data (Ames et al., 2024 ; Noblit and Hare, 1988)’’ (Ref 28, 29 in the updated manuscript). The ‘Limitations’ section also lists this exclusion, which the research team deems necessary in order to follow the gold standard approach to conducting meta-ethnography. Thank you for this recommendation - ‘’social capital’’ in particular is a worthwhile term to matching our search criteria. However, the current search strategy once developed and piloted has captured articles exploring this topic or referencing this particular term. Terms such as ‘’community’’ have already been included in the search strategy. Terms similar to ‘’professional identity’’ and ‘’occupational community’’ have shown to generate a large number of irrelevant results when previously piloted, and are not specific enough for the purpose of addressing the research question Thank you for this suggestion. In order to explore this topic from a social sciences perspective, we have already included the database Scopus, which provides context from a social sciences and humanities perspective, the database focus being largely multi-disciplinary. Thank you – we have clarified that the author will not be searching for non-English terms. As already mentioned, truncations and terms such as ‘’physician*’’ have already been included in the search string.We have now stated that there will be no translation of search strings or search terms for neither search. Thanks for this suggestion. However, we will not use Cohen’s Kappa or other mathematical score to evaluate inter-rater reliability. As per Smith and McGannon (2017) , the use of inter-rater reliability is in conflict with qualitative methods: ‘’ Member checking and inter-rater reliability are shown to be ineffective for verification, trustworthiness, or reliability purposes.’’ Instead, two reviewers will review the first 100 titles/abstracts as part of a pilot test. The team will discuss any conflicts. Final disagreements will be resolved by a third reviewer. Thank you for this suggestion. We have now addressed this (please refer back to point 2 of the previous section of comments). Thank you. We have now clarified the stages at which the QES assessment tool developed by Ames et al. will be implemented in the ‘Screening/Data Management & Selection’ section of the protocol. We will also include a reasoning trail for all decisions made using the tool developed by Ames et al. (Ref 28 in the updated manuscript) for screening purposes as part of the full QES publication. Thank you for this suggestion. To clarify, we are applying coding (line-by-line coding, and creating descriptive codes) to both the raw data from participants and the original researcher’s analysis from primary studies. We have amended the protocol to reflect this. Thank you for this clarification, this has been amended. Individual study results (i.e. raw data, authors’ interpretations) will be translated into one another to create/synthesise novel themes, adding to the body of knowledge i.e. new interpretations of author’s interpretations of primary data. This has now been stated in the protocol. Thank you for this suggestion. We will keep this in mind at later stages as this will be an iterative process. Some potentially relevant theoretical frameworks have been proposed, including the Social Exchange Theory and Durkheim’s Sociological Foundations (mechanical and organic solidarity ) (Ref 35 and 36 in the updated manuscript). Thank you for this comment. We have now addressed this (please refer back to point 10 above and point 2 of the previous section of comments). Thank you for this suggestion. We have now clarified that there is no hierarchy (i.e. no primary or secondary data). This decision came from discussing with the research team. Experience and impact are equally important, related and not easy to differentiate. Additionally, our research question sets out to address both the experience and impact/influence of solidarity. The ‘’data’’ referred to here refers to outcomes. Additionally, please refer to point 2 from the previous section, and points 10, 12 and 15 from this section for a clarification on how data will be managed. Thank you for this suggestion. We have now elaborated on this approach in the ‘Confidence in Cumulative Evidence’ section. Please also refer to points 11 and 5 directly above, and point 15 of the previous section). We have amended this in the protocol to emphasise that this assessment will be carried out independently by MD and JPB, and will be discussed by the team. Thank you for this suggestion. This will be addressed more comprehensively in the full QES paper. However, we have amended the ‘Discussion’ section to add an explanation stating that representative bodies and organisation will be informed of key findings regarding how solidarity can encourage workforce retention, amplify employee voice and belonging, and address some elements of the workforce crisis. Thank you for this suggestion. The purpose of this point in the limitations section was ensure transparency and highlight we are aware of limitations. Specific regions will not be targeted for more covert forms of solidarity. As mentioned, in order to capture an international perspective, our search strategy has been designed using broad terms (e.g. ‘’doctor*’’ but also ‘’physician*’’) with appropriate truncations and database specific controlled vocabulary. Thank you for this comment. Please refer to my response in point 3 above, as there is some overlap. Focusing on specific professions (i.e. doctors and nurses) will offer our study clarity and feasibility. Additionally, qualitative interviews with doctors and nurses, which will take place as part of a different study under this PhD project, will aim to capture a multi-disciplinary experience. Thank you for this comment. Please refer to point 21 and point 3 above, as my responses are also relevant here. A profession specific focus will allow for the exploration of formal and informal solidarity within the same profession, which is not inconsistent in terms of what has been set out by the research question. Theorising connections between union rates of nurses and camaraderie for other allied healthcare professionals would not necessarily provide a coherent answer to the research question. The scope of this study also requires feasibility – hence, the focus on doctors and nurses. As addressed in point 12 of the previous section of comments, the 10 countries mentioned are related to the grey literature search only. Competing Interests: N/A Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 10 Mar 2026 Maja Dumana , SPHeRE PhD Programme; Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences, Dublin, Ireland 10 Mar 2026 Author Response Thank you kindly for taking the time to publish your peer-review, it is much appreciated. Is the rationale for, and objectives of, the study clearly described? Thank you for ... Continue reading Thank you kindly for taking the time to publish your peer-review, it is much appreciated. Is the rationale for, and objectives of, the study clearly described? Thank you for this comment. We have now clarified what is meant by ‘’negative experiences’’ in the first paragraph of the ‘Introduction and background’ section. Additionally, we define solidarity – based on the references listed and discussed, in Table 1 (SPIDER). This definition also drives our search strategy. We have also clarified that the purpose of this study, in line with a meta-ethnography approach, is to produce a novel conceptualisation of the role of solidarity for doctors and nurses and their working experience. Thanks for this suggestion. In the final QES paper, we will ensure a balance between both national and international references. We refer to the Irish context in the background especially but make it clear that our search strategy and overall study scope is international literature. We have also described the ‘’healthcare workforce crisis’’ as an international phenomenon, with global evidence (WHO). We have also included evidence from countries other than Ireland, to expand the context. Thank you. As per the meta-ethnography approach, our primary goal is to develop a new theory of solidarity’s impact for doctors and nurses. This point has been clarified in the protocol aim. We really welcome this suggestion – we have added ‘’Medical Sociology’’ as a term to the protocol keywords. The term ‘’Industrial Relations’’ has already been included. Thank you, we have now clarified what is meant by ‘’negative experiences’’ (please refer to point 1 above). Thank you for this comment. References 3 and 4 provide core features defining the ‘’workforce crisis’’. These features have now been clarified in the ‘Introduction and background’ section. Thank you – we have reviewed the protocol to ensure there is no overemphasis on burnout, as it is not the sole focus of our research. Reference 2 uses burnout as one of many outcomes or issues facing healthcare staff, but focuses more on illustrating the importance of considering working lives, experiences and conditions in health systems research. Thank you very much for this suggestion. We have edited this section of the ‘Introduction and background’ to include more recent EU and UK references. We have highlighted the range of work stressors and conditions experiences by healthcare staff. Please also refer to point 7 above. Thank you. We have now expanded the citations to include various primary studies illustrating poor working conditions and mental health issues for doctors and nurses as evidence of the international crisis. Thank you. The guiding definition in our research is provided in Table 1. However, to improve clarity, we have added ‘’Please see Table 1 for specific definitions of solidarity which will guide this study.’’ in the ‘Background and introduction’’ section and the ‘Methods’ section. Thank you for this comment. To better describe an international context for the issue at heart, as well as solidarity for both doctors and nurses, more references have now been added (please see point 8 and 9). Regarding union bodies cited in the protocol, national (Irish) examples have been used for formal solidarity, as these are the most familiar to the research team. However, these bodies represent standard trade union ethos, membership and engage in activity common to many typical trade unions globally. To clarify, the study is not limited to these 10 countries, and it is made clear that this focus is part of the grey literature search only, (the main literature search has no geographical limits as stated).The countries were chosen as they have the highest general workforce unionisation rates (according to the OECD). This data may not have been picked up by the standard search otherwise. Thank you for this suggestion. We have now edited the problem and research question in the ‘Background and introduction’’ to read as follows: ‘’As established, negative work experiences have the potential to exacerbate the workforce crisis by undermining HCP retention, and contributing to burnout and shortages. Meanwhile research has shown that solidarity shapes the working experience of HCPs, particularly that of doctors and nurses, profoundly. However, there is no universal consensus on whether doctors and nurses perceive both informal solidarity or formal representation (mainly trade union support) as effective in mediating negative work experiences. It is worthwhile, therefore, to synthesise existing literature exploring these perceptions to better inform and support health workforce policies.’’ Thank you for this suggestion. We have now mentioned defining the relationship/tensions between formal and informal solidarity in the ‘Outcomes’ section. However, these tensions do remain unclear in the literature. To our knowledge, no review provides any context as to this relationship for doctors and nurses. This relationship is something that our QES has potential to contribute to. Additionally, this will be examined in a further study as part of my PhD project (qualitative, semi-structured interviews with union and non-union member doctors and nurses). Thank you. Additional studies have now been cited which highlight the problem. QES meta-ethnography is not concerned with a large number of studies, but rather, the richness and thickness the data of the included studies contributes to the overall synthesis. In fact, a large number of studies may interfere with accurate synthesis,and may warrant employing a sampling of studies to mitigate this ( Sattar et al., 2021 )(Reference 37 in the updated manuscript). Sources of data are being assessed using the QES meta-ethnography data richness and thickness tool (Ref 29 in the updated manuscript). Thank you. We have now stated that it is not clear how exactly solidarity shapes the working experience of doctors or nurses, and thus, warrants review. This has been done towards the end of the ‘Background and introduction’ section. The objective of the QES has been re-emphasised towards the very end of the ‘Background and introduction’ section. Our research question is stated in the ‘Aims - Research Question’ section. To model your suggestion, we have edited this section to read as only one coherent question. The definitions of solidarity have been defined in Table 1. Is the study design appropriate for the research question? The use of QES has been justified throughout the protocol. Each of the 7-steps of meta-ethnography are contextualised with respects to the study processes. Each relevant research step described as part of this study is referenced back to one of the seven meta-ethnography steps (e.g. ‘’Step 3 - ‘’Reading the studies’’ ‘’...’’ (see ‘3 - METHODS - ‘Search Strategy’)’’. In line with your suggestion, we have also strengthened our justification for addressing the research question with the use of meta-ethnography, as developed by Noblit and Hare, in the first paragraph of the ‘Study Design’ section (‘3.Methods’). Thanks for this comment. We have now clarified how data extraction and analysis will be managed to account for three orders of data. This has been clarified in the ‘Study Design’, ‘Data Extraction and Analysis’ and ‘Data Synthesis’ subsections of the ‘Methods’ section. Please refer back to my comments in point 15 above, as I feel like they may also be applicable to this suggestion. Thank you for this suggestion. We have amended some references to read, e.g. ‘’Please refer to the METHODS section, specifically...’’. We appreciate this suggestion. We have now better clarified this. Studies for which there is no English language translation will be excluded. However, to avoid excluding studies with non-English titles which are otherwise supplemented with an original English translation (provided by the authors/journal), no English language filter will be applied to the search. Studies not written in English (title or otherwise), without a full-text English translation from the authors of the study or the publishing journal, will be excluded manually. We have also already included a justification for this exclusion. Qualitative study findings, especially when discussing experiences and perceptions via e.g. direct study participant quotes, can easily lose context (linguistically, in this case), when accurate translation is not provided at the original source. We have also listed excluding studies not written in the English language as a limitation. Are sufficient details of the methods provided to allow replication by others? Thank you for this suggestion. We have now stated the following in the ‘Eligibility Criteria’ section. This reads as follows: ‘’Although previously cited studies describe solidarity which may be more recent (e.g. in the context of the COVID-19 pandemic), the relevance and impact of solidarity for both doctors and nurses is a historically relevant concept. Therefore, in order to broadly address the research question, to note any historical differences in sentiment towards solidarity, and to minimise the risk of excluding older, but highly relevant literature, no publication year restriction filter will be applied.’’ As mentioned above, solidarity is a historically intricate phenomenon which evolves throughout the year across professions and culture ( Wildt, 1999 ). We have now re-emphasised that the study is limited to medical, qualified (licensed) doctors (i.e. not doctorates, PhDs or similar) and nurses. We have also clarified that, in order to capture international spelling variants and titles, MeSH terms, other database specific vocabulary and appropriate terms and truncations (e.g. ‘’physician*’’) have already been used with respects to the search strategy. Thank you for the comment. We absolutely acknowledge and agree that solidarity is often a multi-disciplinary phenomenon. However, we justify the decision to exclude other allied HCPs mainly due to the fact that these professionals tend to hold membership in multi-profession union as opposed to mostly single-profession unions, such as doctors and nurses. Also, due to this being a PhD research project QES, including other allied healthcare professionals would stretch the scope and feasibility of the study. We also discuss this in the limitations section of the protocol. Future planned research as part of the PhD project will involve qualitative interviews with doctors and nurses discussing solidarity where its multi-disciplinary nature can be explained further. Thank you – we have made the rationale for this exclusion in Table 1. This exclusion is primarily to limit the number of irrelevant search result being returned. The exclusion of mixed-methods studies and quantitative studies has been justified in the protocol as follows: ‘’Although meta-ethnography is a powerful evidence synthesis tool for qualitative research, it often necessitates an exclusion of mixed-methods and quantitative studies such as research which utilises questionnaires or surveys with an explanatory or open-text element. Therefore, “thinner” qualitative data and quantitative data fall outside the scope of this review. However, this is partially justified with the primary aim of meta-ethnography being the synthesis of valuable rich and thick qualitative data only, which tends to be reported on and generated more transparently and rigorously in a fully qualitative study, as opposed to being an adjunct of a primarily quantitative study (which oftentimes yields ‘thin’ qualitative data (Ames et al., 2024 ; Noblit and Hare, 1988)’’ (Ref 28, 29 in the updated manuscript). The ‘Limitations’ section also lists this exclusion, which the research team deems necessary in order to follow the gold standard approach to conducting meta-ethnography. Thank you for this recommendation - ‘’social capital’’ in particular is a worthwhile term to matching our search criteria. However, the current search strategy once developed and piloted has captured articles exploring this topic or referencing this particular term. Terms such as ‘’community’’ have already been included in the search strategy. Terms similar to ‘’professional identity’’ and ‘’occupational community’’ have shown to generate a large number of irrelevant results when previously piloted, and are not specific enough for the purpose of addressing the research question Thank you for this suggestion. In order to explore this topic from a social sciences perspective, we have already included the database Scopus, which provides context from a social sciences and humanities perspective, the database focus being largely multi-disciplinary. Thank you – we have clarified that the author will not be searching for non-English terms. As already mentioned, truncations and terms such as ‘’physician*’’ have already been included in the search string.We have now stated that there will be no translation of search strings or search terms for neither search. Thanks for this suggestion. However, we will not use Cohen’s Kappa or other mathematical score to evaluate inter-rater reliability. As per Smith and McGannon (2017) , the use of inter-rater reliability is in conflict with qualitative methods: ‘’ Member checking and inter-rater reliability are shown to be ineffective for verification, trustworthiness, or reliability purposes.’’ Instead, two reviewers will review the first 100 titles/abstracts as part of a pilot test. The team will discuss any conflicts. Final disagreements will be resolved by a third reviewer. Thank you for this suggestion. We have now addressed this (please refer back to point 2 of the previous section of comments). Thank you. We have now clarified the stages at which the QES assessment tool developed by Ames et al. will be implemented in the ‘Screening/Data Management & Selection’ section of the protocol. We will also include a reasoning trail for all decisions made using the tool developed by Ames et al. (Ref 28 in the updated manuscript) for screening purposes as part of the full QES publication. Thank you for this suggestion. To clarify, we are applying coding (line-by-line coding, and creating descriptive codes) to both the raw data from participants and the original researcher’s analysis from primary studies. We have amended the protocol to reflect this. Thank you for this clarification, this has been amended. Individual study results (i.e. raw data, authors’ interpretations) will be translated into one another to create/synthesise novel themes, adding to the body of knowledge i.e. new interpretations of author’s interpretations of primary data. This has now been stated in the protocol. Thank you for this suggestion. We will keep this in mind at later stages as this will be an iterative process. Some potentially relevant theoretical frameworks have been proposed, including the Social Exchange Theory and Durkheim’s Sociological Foundations (mechanical and organic solidarity ) (Ref 35 and 36 in the updated manuscript). Thank you for this comment. We have now addressed this (please refer back to point 10 above and point 2 of the previous section of comments). Thank you for this suggestion. We have now clarified that there is no hierarchy (i.e. no primary or secondary data). This decision came from discussing with the research team. Experience and impact are equally important, related and not easy to differentiate. Additionally, our research question sets out to address both the experience and impact/influence of solidarity. The ‘’data’’ referred to here refers to outcomes. Additionally, please refer to point 2 from the previous section, and points 10, 12 and 15 from this section for a clarification on how data will be managed. Thank you for this suggestion. We have now elaborated on this approach in the ‘Confidence in Cumulative Evidence’ section. Please also refer to points 11 and 5 directly above, and point 15 of the previous section). We have amended this in the protocol to emphasise that this assessment will be carried out independently by MD and JPB, and will be discussed by the team. Thank you for this suggestion. This will be addressed more comprehensively in the full QES paper. However, we have amended the ‘Discussion’ section to add an explanation stating that representative bodies and organisation will be informed of key findings regarding how solidarity can encourage workforce retention, amplify employee voice and belonging, and address some elements of the workforce crisis. Thank you for this suggestion. The purpose of this point in the limitations section was ensure transparency and highlight we are aware of limitations. Specific regions will not be targeted for more covert forms of solidarity. As mentioned, in order to capture an international perspective, our search strategy has been designed using broad terms (e.g. ‘’doctor*’’ but also ‘’physician*’’) with appropriate truncations and database specific controlled vocabulary. Thank you for this comment. Please refer to my response in point 3 above, as there is some overlap. Focusing on specific professions (i.e. doctors and nurses) will offer our study clarity and feasibility. Additionally, qualitative interviews with doctors and nurses, which will take place as part of a different study under this PhD project, will aim to capture a multi-disciplinary experience. Thank you for this comment. Please refer to point 21 and point 3 above, as my responses are also relevant here. A profession specific focus will allow for the exploration of formal and informal solidarity within the same profession, which is not inconsistent in terms of what has been set out by the research question. Theorising connections between union rates of nurses and camaraderie for other allied healthcare professionals would not necessarily provide a coherent answer to the research question. The scope of this study also requires feasibility – hence, the focus on doctors and nurses. As addressed in point 12 of the previous section of comments, the 10 countries mentioned are related to the grey literature search only. Thank you kindly for taking the time to publish your peer-review, it is much appreciated. Is the rationale for, and objectives of, the study clearly described? Thank you for this comment. We have now clarified what is meant by ‘’negative experiences’’ in the first paragraph of the ‘Introduction and background’ section. Additionally, we define solidarity – based on the references listed and discussed, in Table 1 (SPIDER). This definition also drives our search strategy. We have also clarified that the purpose of this study, in line with a meta-ethnography approach, is to produce a novel conceptualisation of the role of solidarity for doctors and nurses and their working experience. Thanks for this suggestion. In the final QES paper, we will ensure a balance between both national and international references. We refer to the Irish context in the background especially but make it clear that our search strategy and overall study scope is international literature. We have also described the ‘’healthcare workforce crisis’’ as an international phenomenon, with global evidence (WHO). We have also included evidence from countries other than Ireland, to expand the context. Thank you. As per the meta-ethnography approach, our primary goal is to develop a new theory of solidarity’s impact for doctors and nurses. This point has been clarified in the protocol aim. We really welcome this suggestion – we have added ‘’Medical Sociology’’ as a term to the protocol keywords. The term ‘’Industrial Relations’’ has already been included. Thank you, we have now clarified what is meant by ‘’negative experiences’’ (please refer to point 1 above). Thank you for this comment. References 3 and 4 provide core features defining the ‘’workforce crisis’’. These features have now been clarified in the ‘Introduction and background’ section. Thank you – we have reviewed the protocol to ensure there is no overemphasis on burnout, as it is not the sole focus of our research. Reference 2 uses burnout as one of many outcomes or issues facing healthcare staff, but focuses more on illustrating the importance of considering working lives, experiences and conditions in health systems research. Thank you very much for this suggestion. We have edited this section of the ‘Introduction and background’ to include more recent EU and UK references. We have highlighted the range of work stressors and conditions experiences by healthcare staff. Please also refer to point 7 above. Thank you. We have now expanded the citations to include various primary studies illustrating poor working conditions and mental health issues for doctors and nurses as evidence of the international crisis. Thank you. The guiding definition in our research is provided in Table 1. However, to improve clarity, we have added ‘’Please see Table 1 for specific definitions of solidarity which will guide this study.’’ in the ‘Background and introduction’’ section and the ‘Methods’ section. Thank you for this comment. To better describe an international context for the issue at heart, as well as solidarity for both doctors and nurses, more references have now been added (please see point 8 and 9). Regarding union bodies cited in the protocol, national (Irish) examples have been used for formal solidarity, as these are the most familiar to the research team. However, these bodies represent standard trade union ethos, membership and engage in activity common to many typical trade unions globally. To clarify, the study is not limited to these 10 countries, and it is made clear that this focus is part of the grey literature search only, (the main literature search has no geographical limits as stated).The countries were chosen as they have the highest general workforce unionisation rates (according to the OECD). This data may not have been picked up by the standard search otherwise. Thank you for this suggestion. We have now edited the problem and research question in the ‘Background and introduction’’ to read as follows: ‘’As established, negative work experiences have the potential to exacerbate the workforce crisis by undermining HCP retention, and contributing to burnout and shortages. Meanwhile research has shown that solidarity shapes the working experience of HCPs, particularly that of doctors and nurses, profoundly. However, there is no universal consensus on whether doctors and nurses perceive both informal solidarity or formal representation (mainly trade union support) as effective in mediating negative work experiences. It is worthwhile, therefore, to synthesise existing literature exploring these perceptions to better inform and support health workforce policies.’’ Thank you for this suggestion. We have now mentioned defining the relationship/tensions between formal and informal solidarity in the ‘Outcomes’ section. However, these tensions do remain unclear in the literature. To our knowledge, no review provides any context as to this relationship for doctors and nurses. This relationship is something that our QES has potential to contribute to. Additionally, this will be examined in a further study as part of my PhD project (qualitative, semi-structured interviews with union and non-union member doctors and nurses). Thank you. Additional studies have now been cited which highlight the problem. QES meta-ethnography is not concerned with a large number of studies, but rather, the richness and thickness the data of the included studies contributes to the overall synthesis. In fact, a large number of studies may interfere with accurate synthesis,and may warrant employing a sampling of studies to mitigate this ( Sattar et al., 2021 )(Reference 37 in the updated manuscript). Sources of data are being assessed using the QES meta-ethnography data richness and thickness tool (Ref 29 in the updated manuscript). Thank you. We have now stated that it is not clear how exactly solidarity shapes the working experience of doctors or nurses, and thus, warrants review. This has been done towards the end of the ‘Background and introduction’ section. The objective of the QES has been re-emphasised towards the very end of the ‘Background and introduction’ section. Our research question is stated in the ‘Aims - Research Question’ section. To model your suggestion, we have edited this section to read as only one coherent question. The definitions of solidarity have been defined in Table 1. Is the study design appropriate for the research question? The use of QES has been justified throughout the protocol. Each of the 7-steps of meta-ethnography are contextualised with respects to the study processes. Each relevant research step described as part of this study is referenced back to one of the seven meta-ethnography steps (e.g. ‘’Step 3 - ‘’Reading the studies’’ ‘’...’’ (see ‘3 - METHODS - ‘Search Strategy’)’’. In line with your suggestion, we have also strengthened our justification for addressing the research question with the use of meta-ethnography, as developed by Noblit and Hare, in the first paragraph of the ‘Study Design’ section (‘3.Methods’). Thanks for this comment. We have now clarified how data extraction and analysis will be managed to account for three orders of data. This has been clarified in the ‘Study Design’, ‘Data Extraction and Analysis’ and ‘Data Synthesis’ subsections of the ‘Methods’ section. Please refer back to my comments in point 15 above, as I feel like they may also be applicable to this suggestion. Thank you for this suggestion. We have amended some references to read, e.g. ‘’Please refer to the METHODS section, specifically...’’. We appreciate this suggestion. We have now better clarified this. Studies for which there is no English language translation will be excluded. However, to avoid excluding studies with non-English titles which are otherwise supplemented with an original English translation (provided by the authors/journal), no English language filter will be applied to the search. Studies not written in English (title or otherwise), without a full-text English translation from the authors of the study or the publishing journal, will be excluded manually. We have also already included a justification for this exclusion. Qualitative study findings, especially when discussing experiences and perceptions via e.g. direct study participant quotes, can easily lose context (linguistically, in this case), when accurate translation is not provided at the original source. We have also listed excluding studies not written in the English language as a limitation. Are sufficient details of the methods provided to allow replication by others? Thank you for this suggestion. We have now stated the following in the ‘Eligibility Criteria’ section. This reads as follows: ‘’Although previously cited studies describe solidarity which may be more recent (e.g. in the context of the COVID-19 pandemic), the relevance and impact of solidarity for both doctors and nurses is a historically relevant concept. Therefore, in order to broadly address the research question, to note any historical differences in sentiment towards solidarity, and to minimise the risk of excluding older, but highly relevant literature, no publication year restriction filter will be applied.’’ As mentioned above, solidarity is a historically intricate phenomenon which evolves throughout the year across professions and culture ( Wildt, 1999 ). We have now re-emphasised that the study is limited to medical, qualified (licensed) doctors (i.e. not doctorates, PhDs or similar) and nurses. We have also clarified that, in order to capture international spelling variants and titles, MeSH terms, other database specific vocabulary and appropriate terms and truncations (e.g. ‘’physician*’’) have already been used with respects to the search strategy. Thank you for the comment. We absolutely acknowledge and agree that solidarity is often a multi-disciplinary phenomenon. However, we justify the decision to exclude other allied HCPs mainly due to the fact that these professionals tend to hold membership in multi-profession union as opposed to mostly single-profession unions, such as doctors and nurses. Also, due to this being a PhD research project QES, including other allied healthcare professionals would stretch the scope and feasibility of the study. We also discuss this in the limitations section of the protocol. Future planned research as part of the PhD project will involve qualitative interviews with doctors and nurses discussing solidarity where its multi-disciplinary nature can be explained further. Thank you – we have made the rationale for this exclusion in Table 1. This exclusion is primarily to limit the number of irrelevant search result being returned. The exclusion of mixed-methods studies and quantitative studies has been justified in the protocol as follows: ‘’Although meta-ethnography is a powerful evidence synthesis tool for qualitative research, it often necessitates an exclusion of mixed-methods and quantitative studies such as research which utilises questionnaires or surveys with an explanatory or open-text element. Therefore, “thinner” qualitative data and quantitative data fall outside the scope of this review. However, this is partially justified with the primary aim of meta-ethnography being the synthesis of valuable rich and thick qualitative data only, which tends to be reported on and generated more transparently and rigorously in a fully qualitative study, as opposed to being an adjunct of a primarily quantitative study (which oftentimes yields ‘thin’ qualitative data (Ames et al., 2024 ; Noblit and Hare, 1988)’’ (Ref 28, 29 in the updated manuscript). The ‘Limitations’ section also lists this exclusion, which the research team deems necessary in order to follow the gold standard approach to conducting meta-ethnography. Thank you for this recommendation - ‘’social capital’’ in particular is a worthwhile term to matching our search criteria. However, the current search strategy once developed and piloted has captured articles exploring this topic or referencing this particular term. Terms such as ‘’community’’ have already been included in the search strategy. Terms similar to ‘’professional identity’’ and ‘’occupational community’’ have shown to generate a large number of irrelevant results when previously piloted, and are not specific enough for the purpose of addressing the research question Thank you for this suggestion. In order to explore this topic from a social sciences perspective, we have already included the database Scopus, which provides context from a social sciences and humanities perspective, the database focus being largely multi-disciplinary. Thank you – we have clarified that the author will not be searching for non-English terms. As already mentioned, truncations and terms such as ‘’physician*’’ have already been included in the search string.We have now stated that there will be no translation of search strings or search terms for neither search. Thanks for this suggestion. However, we will not use Cohen’s Kappa or other mathematical score to evaluate inter-rater reliability. As per Smith and McGannon (2017) , the use of inter-rater reliability is in conflict with qualitative methods: ‘’ Member checking and inter-rater reliability are shown to be ineffective for verification, trustworthiness, or reliability purposes.’’ Instead, two reviewers will review the first 100 titles/abstracts as part of a pilot test. The team will discuss any conflicts. Final disagreements will be resolved by a third reviewer. Thank you for this suggestion. We have now addressed this (please refer back to point 2 of the previous section of comments). Thank you. We have now clarified the stages at which the QES assessment tool developed by Ames et al. will be implemented in the ‘Screening/Data Management & Selection’ section of the protocol. We will also include a reasoning trail for all decisions made using the tool developed by Ames et al. (Ref 28 in the updated manuscript) for screening purposes as part of the full QES publication. Thank you for this suggestion. To clarify, we are applying coding (line-by-line coding, and creating descriptive codes) to both the raw data from participants and the original researcher’s analysis from primary studies. We have amended the protocol to reflect this. Thank you for this clarification, this has been amended. Individual study results (i.e. raw data, authors’ interpretations) will be translated into one another to create/synthesise novel themes, adding to the body of knowledge i.e. new interpretations of author’s interpretations of primary data. This has now been stated in the protocol. Thank you for this suggestion. We will keep this in mind at later stages as this will be an iterative process. Some potentially relevant theoretical frameworks have been proposed, including the Social Exchange Theory and Durkheim’s Sociological Foundations (mechanical and organic solidarity ) (Ref 35 and 36 in the updated manuscript). Thank you for this comment. We have now addressed this (please refer back to point 10 above and point 2 of the previous section of comments). Thank you for this suggestion. We have now clarified that there is no hierarchy (i.e. no primary or secondary data). This decision came from discussing with the research team. Experience and impact are equally important, related and not easy to differentiate. Additionally, our research question sets out to address both the experience and impact/influence of solidarity. The ‘’data’’ referred to here refers to outcomes. Additionally, please refer to point 2 from the previous section, and points 10, 12 and 15 from this section for a clarification on how data will be managed. Thank you for this suggestion. We have now elaborated on this approach in the ‘Confidence in Cumulative Evidence’ section. Please also refer to points 11 and 5 directly above, and point 15 of the previous section). We have amended this in the protocol to emphasise that this assessment will be carried out independently by MD and JPB, and will be discussed by the team. Thank you for this suggestion. This will be addressed more comprehensively in the full QES paper. However, we have amended the ‘Discussion’ section to add an explanation stating that representative bodies and organisation will be informed of key findings regarding how solidarity can encourage workforce retention, amplify employee voice and belonging, and address some elements of the workforce crisis. Thank you for this suggestion. The purpose of this point in the limitations section was ensure transparency and highlight we are aware of limitations. Specific regions will not be targeted for more covert forms of solidarity. As mentioned, in order to capture an international perspective, our search strategy has been designed using broad terms (e.g. ‘’doctor*’’ but also ‘’physician*’’) with appropriate truncations and database specific controlled vocabulary. Thank you for this comment. Please refer to my response in point 3 above, as there is some overlap. Focusing on specific professions (i.e. doctors and nurses) will offer our study clarity and feasibility. Additionally, qualitative interviews with doctors and nurses, which will take place as part of a different study under this PhD project, will aim to capture a multi-disciplinary experience. Thank you for this comment. Please refer to point 21 and point 3 above, as my responses are also relevant here. A profession specific focus will allow for the exploration of formal and informal solidarity within the same profession, which is not inconsistent in terms of what has been set out by the research question. Theorising connections between union rates of nurses and camaraderie for other allied healthcare professionals would not necessarily provide a coherent answer to the research question. The scope of this study also requires feasibility – hence, the focus on doctors and nurses. As addressed in point 12 of the previous section of comments, the 10 countries mentioned are related to the grey literature search only. Competing Interests: N/A Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Chudleigh J. Reviewer Report For: Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :128 ( https://doi.org/10.21956/hrbopenres.15731.r52933 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-128/v1#referee-response-52933 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 29 Jan 2026 Jane Chudleigh , King's College London, London, England, UK Approved VIEWS 0 https://doi.org/10.21956/hrbopenres.15731.r52933 Thank you for submitting this protocol for a review conceptualizing doctors' and nurses' experiences of formal and informal solidarity. The protocol is very well written. I only have one minor suggestion/query; might you be able to state in ... Continue reading READ ALL Thank you for submitting this protocol for a review conceptualizing doctors' and nurses' experiences of formal and informal solidarity. The protocol is very well written. I only have one minor suggestion/query; might you be able to state in the screening section which reviewers (initials) will be reviewing and resolving conflicts (similar to the section on risk of bias)? Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: Screening, genetics, communication of genetic risk, cystic fibrosis, sickle cell. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Chudleigh J. Reviewer Report For: Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :128 ( https://doi.org/10.21956/hrbopenres.15731.r52933 ) The direct URL for this report is: https://hrbopenresearch.org/articles/8-128/v1#referee-response-52933 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 10 Mar 2026 Maja Dumana , SPHeRE PhD Programme; Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences, Dublin, Ireland 10 Mar 2026 Author Response Thank you for your suggestion – we have identified the reviewers throughout the screening section by adding their initials. Competing Interests: N/A Thank you for your suggestion – we have identified the reviewers throughout the screening section by adding their initials. Thank you for your suggestion – we have identified the reviewers throughout the screening section by adding their initials. Competing Interests: N/A Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 10 Mar 2026 Maja Dumana , SPHeRE PhD Programme; Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences, Dublin, Ireland 10 Mar 2026 Author Response Thank you for your suggestion – we have identified the reviewers throughout the screening section by adding their initials. Competing Interests: N/A Thank you for your suggestion – we have identified the reviewers throughout the screening section by adding their initials. Thank you for your suggestion – we have identified the reviewers throughout the screening section by adding their initials. Competing Interests: N/A Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 05 Dec 2025 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 10 Mar 26 read Version 1 05 Dec 25 read read Jane Chudleigh , King's College London, London, UK Brenna Doran , University of California San Francisco, San Francisco, Canada Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Doran B. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 19 Mar 2026 | for Version 2 Brenna Doran , University of California San Francisco, San Francisco, Canada 0 Views copyright © 2026 Doran B. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The authors have systematically addressed the concerns raised in the initial review. The clarification of the meta-ethnography 'audit trail' and the integration of specific sociological frameworks (Social Exchange Theory, Durkheim) significantly strengthens the protocol's theoretical foundation. While the exclusion of Allied Health Professionals remains a limitation regarding the understanding of multi-disciplinary informal solidarity, the authors have adequately justified this via project feasibility and have appropriately noted this in the limitations section. I am satisfied with the methodological refinements. Competing Interests No competing interests were disclosed. Reviewer Expertise My research and professional expertise focus on the operational challenges and psychological well-being of the infection prevention workforce, with specific emphasis on the following topics: Infection preventionist staffing and workload, Healthcare worker burnout and attrition, Professional resilience and leadership coaching, Retention factors in specialized healthcare roles, Infectious disease epidemiology and clinical microbiology, and Change management and patient safety advocacy. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Doran B. Peer Review Report For: Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :128 ( https://doi.org/10.21956/hrbopenres.15818.r54067) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-128/v2#referee-response-54067 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Doran B. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 29 Jan 2026 | for Version 1 Brenna Doran , University of California San Francisco, San Francisco, Canada 0 Views copyright © 2026 Doran B. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Article Summary This protocol outlines a Qualitative Evidence Synthesis (QES) designed to conceptualize formal and informal "solidarity" among qualified doctors and nurses. The study focuses on how these solidarities influence the working experience and potentially address health system instability and workforce retention issues. The methodology follows the Noblit and Hare seven-step meta-ethnography approach, utilizing a search strategy refined by the PRESS process across major databases (MEDLINE, CINAHL, Scopus, Embase, and PubMed). The authors plan to utilize the SPIDER framework for criteria definition, CASP for quality appraisal, and GRADE-CERQual for assessing confidence in the cumulative findings. Overall Strengths: The manuscript addresses a timely and significant topic—healthcare workforce retention and the role of solidarity. The use of the PRESS process and professional librarians makes the search strategy highly transparent and reproducible. Using Noblit and Hare’s meta-ethnography and the SPIDER framework provides a solid academic structure for the study. Is the rationale for, and objectives of, the study clearly described? Answer: Partly While the manuscript identifies a significant gap regarding healthcare workforce retention, the rationale would benefit from further strengthening. For primary research terms such as “negative experiences” and “solidarity,” recommend using the definitions from the studies being referenced unless the intent is to provide a novel definition. If a novel definition is intended, this must be clearly communicated. Recommend ensuring the use of international references aligns with the stated local focus and application of the findings. Recommend stating if the goal of "conceptualizing" solidarity is to create a brand-new theory or to refine an existing one. Recommend including terms like "Medical Sociology" or "Industrial Relations" to improve the study's discoverability. The phrase "negative experiences" is broad. Recommend adding context regarding the root causes of these experiences and the role of the work environment. Recommend defining the "workplace crisis" more clearly (e.g., chronic staff shortages, increased patient mortality) and supporting it with appropriate citations. Ref 2 primarily identifies burnout as the issue. Recommend clarifying if burnout is the primary focus and ensuring the terminology used in the paper aligns with the cited references. Ref 2 is from 2014 and is based on a US study. Depending on the intended scope, recommend adding more current studies and references that reflect the appropriate geographical and historical scope to demonstrate the chronic nature of the issue. The paper states the crisis exists internationally; however, Reference 3 appears to be an opinion article focused on Europe that cites other studies. Recommend citing the original research studies and including a broader international lens to support the "labour and mental health crisis" claim. As "solidarity" is a primary variable, recommend clearly defining it and explaining how it relates to the specific problem being addressed. The current text provides multiple definitions; recommend specifying which one the reader is to follow. There is a heavy reliance on references from Ireland. If the Irish context is unique or superior in its research on solidarity, recommend providing that context. There is a disconnect between the global scope (WHO) and the specific geographical scope (10 OECD countries). If the research is limited to these 10 countries, recommend reconsidering the references in the introduction to support that specific scope. The specific problem and research question require greater clarity. Recommend explaining why a lack of knowledge regarding solidarity is a problem. For example: The workforce crisis harms retention → Solidarity may be the "glue" that prevents quitting → We do not know if staff perceive unions or peer support as effective → Therefore, this study is needed to inform policy. Recommend further elaborating on the tensions between informal solidarity, formal solidarity, and the role of the union, as these remain unclear. Regarding the use of the RETREAT methodology, it is unclear if there are enough primary studies to synthesize. Recommend addressing this concern, which is reinforced by the absence of robust references in the section outlining the research problem. To strengthen the introduction, recommend considering the following: Define the “so what” of the problem (e.g., “we don't know if solidarity is enough to stop doctors and nurses from leaving”). Explicitly state the objective around the third paragraph using a phrase like: "The objective of this Qualitative Evidence Synthesis is to..." State the research question clearly (e.g., "How do doctors and nurses perceive the influence of both informal peer support and formal union representation on their decision to remain in the workforce?"). Streamline the definitions of solidarity to focus on why the study is necessary. Is the study design appropriate for the research question? Answer: Partly This section outlines the steps of the meta-ethnography method without clearly explaining how it will be applied to this specific study. Recommend adding a justification for why these specific steps are the most appropriate tools to address the "solidarity" problem. The author describes the seven steps of Noblit and Hare in a general sense, but the section lacks a clear "audit trail." Specifically, how will the author ensure that ‘third-order' interpretations remain grounded in the original contexts of the international studies. Example (1 st order: The raw quotes from the doctors/nurses in the original studies, 2nd order: The original researchers' interpretations of those quotes, and 3 rd order the new synthesis of those interpretations.) This will also help the reader understand how the author will address a potential limited size of original research papers. Providing this detail will also help the reader understand how the author will address the potential issue of a limited number of original research papers. There is a heavy use of circular referencing (e.g., multiple references to Section 3 and Table 1). While referencing is appropriate, recommend streamlining these mentions to avoid repetitive citations. The author states that an English filter will not be applied to avoid excluding translated articles, yet also states that studies without English full-text will be manually removed. Recommend clarifying this contradiction; excluding non-English studies may result in missing key international research. Are sufficient details of the methods provided to allow replication by others? Answer: Partly The historical scope (dating back to 1970) appears broader than the background and research problem, which focus on COVID-19 and modern aging populations. If historical studies are to be included, recommend adding an explanation of how contexts from the 1970s forward remain relevant to the current healthcare environment and modern union relationships. Regarding the sample, recommend clarifying the specific criteria for "doctor" and "nurse" from an international perspective (e.g., education and licensure). For example, in the US, "doctor" can refer to many terminal degrees (MD, DNP, PhD); recommend specifying if the study is limited to physicians (MD/DO) and how allied health professionals with similar degrees will be handled. Recommend clarifying the definition of "experiences" in the context of the exclusion criteria for allied healthcare providers. Excluding frontline staff such as respiratory therapists, surgical technicians, and pharmacists may result in missing impactful studies, as "solidarity" is often a multi-disciplinary phenomenon. The exclusion of "patient peer-support groups" is noted; recommend providing a clear justification for why this specific group is being excluded from a study on workplace solidarity. High-quality healthcare studies often use mixed-method approaches to show both what is happening (quantitative) and why (qualitative). By excluding these entirely, the author may miss "thick and rich" qualitative data. Recommend the author justify why the qualitative components of mixed-methods studies are considered insufficient for this specific synthesis. Most current keywords focus on "strikes" and "unions." Recommend adding sociological terms like "professional identity," "occupational community," or "social capital" to find studies on informal support that the current industrial relations terms might miss. Since this is a social topic, consider searching databases like PsycINFO or SocINDEX. As Table One includes excluding non-english full-texts please clarify if the author will be searching for non-english terms. If search is limited to English Keywords, the ‘translation’ of the string (for grey searches) is purely technical rather than linguistic and needs to be specified. When two people test the first 100 articles, recommend using a math-based score (like Cohen’s Kappa) to prove both reviewers are truly aligned on the study criteria before proceeding. In a meta-ethnography, it is vital to distinguish between 1st-order constructs (participant quotes) and 2nd-order constructs (original author interpretations) during extraction. Recommend explicitly stating how the extraction form will separate these to ensure an organized translation process. The author mentions using a QES assessment tool (Ref 24) but does not explain when the quality appraisal occurs. Recommend clarifying the timing of this step (e.g., during full-text screening or after extraction) and at what point "thin" studies are discarded. The author defines 1st-order constructs as "line-by-line coding" and 2nd-order as "descriptive codes." Recommend clarifying whether the coding is being applied to the raw data or the original researchers' analysis. The author mentions that analytical themes will be "translated into the results of the individual studies." As Step 6 is typically the reverse—where individual studies are translated into one another to create themes—recommend confirming the order and ensuring the synthesis emerges from the studies. Regarding 3rd-order constructs, recommend naming the "existing conceptual or theoretical frameworks" being considered to ensure the interpretations have a strong theoretical grounding. The protocol mentions "refutational translation" but lacks an execution plan. Recommend detailing how the team will handle "disconfirming cases" (e.g., where formal solidarity undermines informal camaraderie) to avoid a homogenized result that ignores contextual tensions. It is unclear how the author will distinguish between the "experience" (primary data) and "impact" (secondary data) of solidarity, as these are often linked in narratives. Recommend justifying the prioritization of these data items, particularly given that "intention to leave" is a core problem identified in the introduction. Regarding the GRADE-CERQual approach, recommend clarifying how the four components (Methodological Limitations, Relevance, Coherence, and Adequacy) will be operationalized. Specifically, recommend defining "Adequacy"—whether it is based on the number of studies or the "thickness" of the data. Recommend specifying if the CERQual assessment will be performed independently by two reviewers to reduce subjective bias and increase confidence in the cumulative findings. The discussion focuses heavily on the COVID-19 pandemic and the WHO Framework. Recommend explicitly connecting the potential findings of this QES to specific policy levers beyond "wellbeing," such as how solidarity might practically influence retention strategies. The author acknowledges that countries where unionization is "taboo" may be underrepresented. Recommend clarifying if the search strategy will proactively look for "alternative" forms of solidarity in these regions to ensure the study is truly international as claimed. The limitation regarding the exclusion of "allied healthcare professionals" is noted. However, since the author justifies this by focusing on high unionization rates in nursing and medicine, recommend discussing how the exclusion of the "wider team" might limit the understanding of "informal solidarity" (camaraderie), which is often multi-disciplinary. The author justifies the exclusion of allied healthcare professionals by citing the high unionization rates of doctors and nurses. However, since the study aims to explore both unionized and non-unionized staff, this justification appears inconsistent. Furthermore, because "informal solidarity" (camaraderie) is inherently multi-disciplinary, excluding the "wider team" may result in a fragmented or incomplete understanding of how doctors and nurses experience workplace support. Recommend the author clarify this exclusion, especially since unionization structures and professional roles vary significantly across the ten countries included in the study. Is the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise My research and professional expertise focus on the operational challenges and psychological well-being of the infection prevention workforce, with specific emphasis on the following topics: Infection preventionist staffing and workload, Healthcare worker burnout and attrition, Professional resilience and leadership coaching, Retention factors in specialized healthcare roles, Infectious disease epidemiology and clinical microbiology, and Change management and patient safety advocacy. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 10 Mar 2026 Maja Dumana, SPHeRE PhD Programme; Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences, Dublin, Ireland Thank you kindly for taking the time to publish your peer-review, it is much appreciated. Is the rationale for, and objectives of, the study clearly described? Thank you for this comment. We have now clarified what is meant by ‘’negative experiences’’ in the first paragraph of the ‘Introduction and background’ section. Additionally, we define solidarity – based on the references listed and discussed, in Table 1 (SPIDER). This definition also drives our search strategy. We have also clarified that the purpose of this study, in line with a meta-ethnography approach, is to produce a novel conceptualisation of the role of solidarity for doctors and nurses and their working experience. Thanks for this suggestion. In the final QES paper, we will ensure a balance between both national and international references. We refer to the Irish context in the background especially but make it clear that our search strategy and overall study scope is international literature. We have also described the ‘’healthcare workforce crisis’’ as an international phenomenon, with global evidence (WHO). We have also included evidence from countries other than Ireland, to expand the context. Thank you. As per the meta-ethnography approach, our primary goal is to develop a new theory of solidarity’s impact for doctors and nurses. This point has been clarified in the protocol aim. We really welcome this suggestion – we have added ‘’Medical Sociology’’ as a term to the protocol keywords. The term ‘’Industrial Relations’’ has already been included. Thank you, we have now clarified what is meant by ‘’negative experiences’’ (please refer to point 1 above). Thank you for this comment. References 3 and 4 provide core features defining the ‘’workforce crisis’’. These features have now been clarified in the ‘Introduction and background’ section. Thank you – we have reviewed the protocol to ensure there is no overemphasis on burnout, as it is not the sole focus of our research. Reference 2 uses burnout as one of many outcomes or issues facing healthcare staff, but focuses more on illustrating the importance of considering working lives, experiences and conditions in health systems research. Thank you very much for this suggestion. We have edited this section of the ‘Introduction and background’ to include more recent EU and UK references. We have highlighted the range of work stressors and conditions experiences by healthcare staff. Please also refer to point 7 above. Thank you. We have now expanded the citations to include various primary studies illustrating poor working conditions and mental health issues for doctors and nurses as evidence of the international crisis. Thank you. The guiding definition in our research is provided in Table 1. However, to improve clarity, we have added ‘’Please see Table 1 for specific definitions of solidarity which will guide this study.’’ in the ‘Background and introduction’’ section and the ‘Methods’ section. Thank you for this comment. To better describe an international context for the issue at heart, as well as solidarity for both doctors and nurses, more references have now been added (please see point 8 and 9). Regarding union bodies cited in the protocol, national (Irish) examples have been used for formal solidarity, as these are the most familiar to the research team. However, these bodies represent standard trade union ethos, membership and engage in activity common to many typical trade unions globally. To clarify, the study is not limited to these 10 countries, and it is made clear that this focus is part of the grey literature search only, (the main literature search has no geographical limits as stated).The countries were chosen as they have the highest general workforce unionisation rates (according to the OECD). This data may not have been picked up by the standard search otherwise. Thank you for this suggestion. We have now edited the problem and research question in the ‘Background and introduction’’ to read as follows: ‘’As established, negative work experiences have the potential to exacerbate the workforce crisis by undermining HCP retention, and contributing to burnout and shortages. Meanwhile research has shown that solidarity shapes the working experience of HCPs, particularly that of doctors and nurses, profoundly. However, there is no universal consensus on whether doctors and nurses perceive both informal solidarity or formal representation (mainly trade union support) as effective in mediating negative work experiences. It is worthwhile, therefore, to synthesise existing literature exploring these perceptions to better inform and support health workforce policies.’’ Thank you for this suggestion. We have now mentioned defining the relationship/tensions between formal and informal solidarity in the ‘Outcomes’ section. However, these tensions do remain unclear in the literature. To our knowledge, no review provides any context as to this relationship for doctors and nurses. This relationship is something that our QES has potential to contribute to. Additionally, this will be examined in a further study as part of my PhD project (qualitative, semi-structured interviews with union and non-union member doctors and nurses). Thank you. Additional studies have now been cited which highlight the problem. QES meta-ethnography is not concerned with a large number of studies, but rather, the richness and thickness the data of the included studies contributes to the overall synthesis. In fact, a large number of studies may interfere with accurate synthesis,and may warrant employing a sampling of studies to mitigate this ( Sattar et al., 2021 )(Reference 37 in the updated manuscript). Sources of data are being assessed using the QES meta-ethnography data richness and thickness tool (Ref 29 in the updated manuscript). Thank you. We have now stated that it is not clear how exactly solidarity shapes the working experience of doctors or nurses, and thus, warrants review. This has been done towards the end of the ‘Background and introduction’ section. The objective of the QES has been re-emphasised towards the very end of the ‘Background and introduction’ section. Our research question is stated in the ‘Aims - Research Question’ section. To model your suggestion, we have edited this section to read as only one coherent question. The definitions of solidarity have been defined in Table 1. Is the study design appropriate for the research question? The use of QES has been justified throughout the protocol. Each of the 7-steps of meta-ethnography are contextualised with respects to the study processes. Each relevant research step described as part of this study is referenced back to one of the seven meta-ethnography steps (e.g. ‘’Step 3 - ‘’Reading the studies’’ ‘’...’’ (see ‘3 - METHODS - ‘Search Strategy’)’’. In line with your suggestion, we have also strengthened our justification for addressing the research question with the use of meta-ethnography, as developed by Noblit and Hare, in the first paragraph of the ‘Study Design’ section (‘3.Methods’). Thanks for this comment. We have now clarified how data extraction and analysis will be managed to account for three orders of data. This has been clarified in the ‘Study Design’, ‘Data Extraction and Analysis’ and ‘Data Synthesis’ subsections of the ‘Methods’ section. Please refer back to my comments in point 15 above, as I feel like they may also be applicable to this suggestion. Thank you for this suggestion. We have amended some references to read, e.g. ‘’Please refer to the METHODS section, specifically...’’. We appreciate this suggestion. We have now better clarified this. Studies for which there is no English language translation will be excluded. However, to avoid excluding studies with non-English titles which are otherwise supplemented with an original English translation (provided by the authors/journal), no English language filter will be applied to the search. Studies not written in English (title or otherwise), without a full-text English translation from the authors of the study or the publishing journal, will be excluded manually. We have also already included a justification for this exclusion. Qualitative study findings, especially when discussing experiences and perceptions via e.g. direct study participant quotes, can easily lose context (linguistically, in this case), when accurate translation is not provided at the original source. We have also listed excluding studies not written in the English language as a limitation. Are sufficient details of the methods provided to allow replication by others? Thank you for this suggestion. We have now stated the following in the ‘Eligibility Criteria’ section. This reads as follows: ‘’Although previously cited studies describe solidarity which may be more recent (e.g. in the context of the COVID-19 pandemic), the relevance and impact of solidarity for both doctors and nurses is a historically relevant concept. Therefore, in order to broadly address the research question, to note any historical differences in sentiment towards solidarity, and to minimise the risk of excluding older, but highly relevant literature, no publication year restriction filter will be applied.’’ As mentioned above, solidarity is a historically intricate phenomenon which evolves throughout the year across professions and culture ( Wildt, 1999 ). We have now re-emphasised that the study is limited to medical, qualified (licensed) doctors (i.e. not doctorates, PhDs or similar) and nurses. We have also clarified that, in order to capture international spelling variants and titles, MeSH terms, other database specific vocabulary and appropriate terms and truncations (e.g. ‘’physician*’’) have already been used with respects to the search strategy. Thank you for the comment. We absolutely acknowledge and agree that solidarity is often a multi-disciplinary phenomenon. However, we justify the decision to exclude other allied HCPs mainly due to the fact that these professionals tend to hold membership in multi-profession union as opposed to mostly single-profession unions, such as doctors and nurses. Also, due to this being a PhD research project QES, including other allied healthcare professionals would stretch the scope and feasibility of the study. We also discuss this in the limitations section of the protocol. Future planned research as part of the PhD project will involve qualitative interviews with doctors and nurses discussing solidarity where its multi-disciplinary nature can be explained further. Thank you – we have made the rationale for this exclusion in Table 1. This exclusion is primarily to limit the number of irrelevant search result being returned. The exclusion of mixed-methods studies and quantitative studies has been justified in the protocol as follows: ‘’Although meta-ethnography is a powerful evidence synthesis tool for qualitative research, it often necessitates an exclusion of mixed-methods and quantitative studies such as research which utilises questionnaires or surveys with an explanatory or open-text element. Therefore, “thinner” qualitative data and quantitative data fall outside the scope of this review. However, this is partially justified with the primary aim of meta-ethnography being the synthesis of valuable rich and thick qualitative data only, which tends to be reported on and generated more transparently and rigorously in a fully qualitative study, as opposed to being an adjunct of a primarily quantitative study (which oftentimes yields ‘thin’ qualitative data (Ames et al., 2024 ; Noblit and Hare, 1988)’’ (Ref 28, 29 in the updated manuscript). The ‘Limitations’ section also lists this exclusion, which the research team deems necessary in order to follow the gold standard approach to conducting meta-ethnography. Thank you for this recommendation - ‘’social capital’’ in particular is a worthwhile term to matching our search criteria. However, the current search strategy once developed and piloted has captured articles exploring this topic or referencing this particular term. Terms such as ‘’community’’ have already been included in the search strategy. Terms similar to ‘’professional identity’’ and ‘’occupational community’’ have shown to generate a large number of irrelevant results when previously piloted, and are not specific enough for the purpose of addressing the research question Thank you for this suggestion. In order to explore this topic from a social sciences perspective, we have already included the database Scopus, which provides context from a social sciences and humanities perspective, the database focus being largely multi-disciplinary. Thank you – we have clarified that the author will not be searching for non-English terms. As already mentioned, truncations and terms such as ‘’physician*’’ have already been included in the search string.We have now stated that there will be no translation of search strings or search terms for neither search. Thanks for this suggestion. However, we will not use Cohen’s Kappa or other mathematical score to evaluate inter-rater reliability. As per Smith and McGannon (2017) , the use of inter-rater reliability is in conflict with qualitative methods: ‘’ Member checking and inter-rater reliability are shown to be ineffective for verification, trustworthiness, or reliability purposes.’’ Instead, two reviewers will review the first 100 titles/abstracts as part of a pilot test. The team will discuss any conflicts. Final disagreements will be resolved by a third reviewer. Thank you for this suggestion. We have now addressed this (please refer back to point 2 of the previous section of comments). Thank you. We have now clarified the stages at which the QES assessment tool developed by Ames et al. will be implemented in the ‘Screening/Data Management & Selection’ section of the protocol. We will also include a reasoning trail for all decisions made using the tool developed by Ames et al. (Ref 28 in the updated manuscript) for screening purposes as part of the full QES publication. Thank you for this suggestion. To clarify, we are applying coding (line-by-line coding, and creating descriptive codes) to both the raw data from participants and the original researcher’s analysis from primary studies. We have amended the protocol to reflect this. Thank you for this clarification, this has been amended. Individual study results (i.e. raw data, authors’ interpretations) will be translated into one another to create/synthesise novel themes, adding to the body of knowledge i.e. new interpretations of author’s interpretations of primary data. This has now been stated in the protocol. Thank you for this suggestion. We will keep this in mind at later stages as this will be an iterative process. Some potentially relevant theoretical frameworks have been proposed, including the Social Exchange Theory and Durkheim’s Sociological Foundations (mechanical and organic solidarity ) (Ref 35 and 36 in the updated manuscript). Thank you for this comment. We have now addressed this (please refer back to point 10 above and point 2 of the previous section of comments). Thank you for this suggestion. We have now clarified that there is no hierarchy (i.e. no primary or secondary data). This decision came from discussing with the research team. Experience and impact are equally important, related and not easy to differentiate. Additionally, our research question sets out to address both the experience and impact/influence of solidarity. The ‘’data’’ referred to here refers to outcomes. Additionally, please refer to point 2 from the previous section, and points 10, 12 and 15 from this section for a clarification on how data will be managed. Thank you for this suggestion. We have now elaborated on this approach in the ‘Confidence in Cumulative Evidence’ section. Please also refer to points 11 and 5 directly above, and point 15 of the previous section). We have amended this in the protocol to emphasise that this assessment will be carried out independently by MD and JPB, and will be discussed by the team. Thank you for this suggestion. This will be addressed more comprehensively in the full QES paper. However, we have amended the ‘Discussion’ section to add an explanation stating that representative bodies and organisation will be informed of key findings regarding how solidarity can encourage workforce retention, amplify employee voice and belonging, and address some elements of the workforce crisis. Thank you for this suggestion. The purpose of this point in the limitations section was ensure transparency and highlight we are aware of limitations. Specific regions will not be targeted for more covert forms of solidarity. As mentioned, in order to capture an international perspective, our search strategy has been designed using broad terms (e.g. ‘’doctor*’’ but also ‘’physician*’’) with appropriate truncations and database specific controlled vocabulary. Thank you for this comment. Please refer to my response in point 3 above, as there is some overlap. Focusing on specific professions (i.e. doctors and nurses) will offer our study clarity and feasibility. Additionally, qualitative interviews with doctors and nurses, which will take place as part of a different study under this PhD project, will aim to capture a multi-disciplinary experience. Thank you for this comment. Please refer to point 21 and point 3 above, as my responses are also relevant here. A profession specific focus will allow for the exploration of formal and informal solidarity within the same profession, which is not inconsistent in terms of what has been set out by the research question. Theorising connections between union rates of nurses and camaraderie for other allied healthcare professionals would not necessarily provide a coherent answer to the research question. The scope of this study also requires feasibility – hence, the focus on doctors and nurses. As addressed in point 12 of the previous section of comments, the 10 countries mentioned are related to the grey literature search only. View more View less Competing Interests N/A reply Respond Report a concern Doran B. Peer Review Report For: Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :128 ( https://doi.org/10.21956/hrbopenres.15731.r52942) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://hrbopenresearch.org/articles/8-128/v1#referee-response-52942 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2026 Chudleigh J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 29 Jan 2026 | for Version 1 Jane Chudleigh , King's College London, London, England, UK 0 Views copyright © 2026 Chudleigh J. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Thank you for submitting this protocol for a review conceptualizing doctors' and nurses' experiences of formal and informal solidarity. The protocol is very well written. I only have one minor suggestion/query; might you be able to state in the screening section which reviewers (initials) will be reviewing and resolving conflicts (similar to the section on risk of bias)? Is the rationale for, and objectives of, the study clearly described? Yes Is the study design appropriate for the research question? Yes Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise Screening, genetics, communication of genetic risk, cystic fibrosis, sickle cell. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (1) Author Response 10 Mar 2026 Maja Dumana, SPHeRE PhD Programme; Graduate School of Healthcare Management, RCSI University of Medicine and Health Sciences, Dublin, Ireland Thank you for your suggestion – we have identified the reviewers throughout the screening section by adding their initials. View more View less Competing Interests N/A reply Respond Report a concern Chudleigh J. Peer Review Report For: Conceptualising doctors’ and nurses’ experience of formal and informal solidarity: A Meta-Ethnography Protocol [version 1; peer review: 1 approved, 1 approved with reservations] . HRB Open Res 2025, 8 :128 ( https://doi.org/10.21956/hrbopenres.15731.r52933) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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