Task Shifting and Sustainability: Nonphysician anesthetist satisfaction and role in the field - a mixed method cross sectional analysis in primary and secondary hospitals of Nepal

Task Shifting and Sustainability: Nonphysician anesthetist satisfaction and role in the field - a mixed method cross sectional analysis in primary and secondary hospitals of Nepal | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Task Shifting and Sustainability: Nonphysician anesthetist satisfaction and role in the field - a mixed method cross sectional analysis in primary and secondary hospitals of Nepal Janardan Pathak, Abigail Knoble, Rabindra Bhandari, Suraj Shrestha, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7805783/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 14 You are reading this latest preprint version Abstract Background The lack of skilled healthcare workers and poor retention in rural areas limits access to surgical care globally, with the greatest disparities in low- and middle-income countries. In Nepal, the one-year Anesthesia Assistant (AA) program trains non-physician cadres to provide anesthesia to address this gap. Methods A cross-sectional satisfaction survey using Spector’s Job Satisfaction Survey (JSS) was distributed to all AAs working in Primary and Secondary government hospitals, yielding 91 responses from 88 hospitals. Bivariate analyses using chi-squared and t-tests examined associations between job satisfaction and respondent or facility characteristics. Additionally, qualitative data were collected through 7 focus group discussions, 8 key informant interviews, and 14 in-depth interviews with AAs, hospital staff, and policymakers at seven purposively sampled government hospitals. Results AAs were nearly evenly split in overall job satisfaction (47% satisfied, 53% dissatisfied). Highest satisfaction was reported in domains related to the nature of work and coworker relationships, while the lowest satisfaction scores were related to pay, fringe benefits, and operating conditions. Significant associations were found between satisfaction and contract status, NSI support, and the availability of surgical services. Qualitative findings reinforced the importance of supportive teams and meaningful work, while highlighting structural barriers such as limited career progression, poor working conditions, and inadequate institutional support. Conclusions AAs play a critical role in expanding access to surgical care in rural Nepal yet face persistent structural challenges that threaten retention. Strategies to improve satisfaction must address both intrinsic motivators and systemic barriers, including formal career pathways and improved working environments, to sustain this essential workforce. Task shifting Anesthesia Assistant Job Satisfaction Figures Figure 1 Introduction A healthcare system is completely dependent on its workforce; having the right number of people with the right skills in the right place at the right time ( 1 ). Yet, there continues to be a growing global shortage of healthcare professionals ( 2 ). The WHO estimates that for every 1,000 people there are 2.9 physicians in high income countries (HICs), compared to only 0.9 in LMICs ( 3 , 4 ). On top of global pressures, low- and middle- income countries (LMICs) face even greater shortages due to discrepancies of pay and quality of life between their own country and host countries, accelerated by active recruitment by HICs to supplement their own shortages and various personal and systemic push and pull factors ( 5 , 6 ). If these trends continue, the progress towards equitable primary health care systems will remain out of reach as LMICs fall farther behind ( 7 , 8 ). Nepal has long struggled with healthcare worker retention, especially in rural and remote areas due to its mountainous terrain, where it is estimated that 2.4 million people will not have access to necessary surgical care during their lives ( 9 ). Despite challenges, efforts to improve healthcare access have shown substantial progress, reducing the maternal mortality rate from 379 per 100,000 in 2000 to 151 per 100,000 in 2021 ( 10 ). However, challenges remain. A survey conducted by the International Labour Organization found that 50% of responding medical and nursing students planned to migrate abroad, motivated mostly by better salaries, better living conditions, and better working environments ( 5 ). In an attempt to address the healthcare worker shortage, Nepal has employed task-shifting of lower level health cadres to provide specialized services, typically reserved for specialists ( 11 ). The Nick Simons Institute (NSI) has partnered closely with the Ministry of Health and Population (MoHP) to develop a myriad of healthcare cadres including the Advanced Skilled Birth Attendant (ASBA) to train medical officers to provide Cesarean sections (CSs), or the Anesthesia Assistants (AA) to train lower level health cadres to provide anesthesia under the supervision of an anesthesiologist or, more often, a family physician or MDGP ( 12 ). One study found that six AAs were conducting 8,000 operations annually at a rural 160-bed mission hospital annually in 2008 ( 13 ). In 2014, 14 AAs reported an annual caseload of 50–788 per each ( 14 ). And while Nepal’s specialist Surgeon-Anesthesiologist-Obstetrician (SAO) density was only 0.4 per 100,000 population, the density of non-specialist SAOs led by MDGPs and supported by AAs was found to be eight times higher, with a density of 3.1 per 100,000. However, this is still significantly below the Lancet Commission on Global Surgery’s 2030 target of 20 per 100,000 ( 12 ). This suggests that AAs play key roles in Nepal’s surgical workforce. However, they remain poorly studied with little known about their job satisfaction or retention in rural areas. This paper aims to fill this gap by exploring the roles of AAs in the field and better understanding the factors associated with job satisfaction. This research can inform the MoHP’s development of the National Surgical, Obstetric, and Anesthesia Plan and provide insights into task shifting and staff retention strategies in other low-resource settings. Methods Quantitative Methods Data Collection and Preparation AAs working in governmental hospitals were assessed using Spector’s Job Satisfaction Scale (JSS) ( 15 ). The JSS survey was formatted to a Google Forms survey that was emailed to all AAs working at Primary and Secondary A government hospitals during November 2024 to December 2024 (n = 95). This included AAs working at health facilities that may not have had a functional operating theater and were not utilizing their skills to best represent actual satisfaction of the workforce. Ninety-six percent of AAs responded to the survey (n = 91). Retrospective surgical data for the 2022/23 fiscal year was retrieved from the Health Management Information System (HMIS) database. Population data by year was retrieved from the national census and province-wise HDI was obtained from the Nepal Human Development Reports. Data Analysis The survey data was downloaded as a CSV file, which was imported and analyzed in R. Job satisfaction obtained via a 6-point Likert scale was categorized using Spector’s JSS guidelines into dissatisfied, ambivalent, and satisfied ( 15 ). The data was dichotomized based on the median satisfaction score for further analysis. The primary outcome was overall satisfaction, which was assessed against relevant hospital-level variables (hospital level, hospital governance, geography, Minimum Service Standards (MSS) score similar to a hospital quality or accreditation score, and provision of surgery) and individual characteristics (education, work experience, course, and employment contract) collected through the survey. Age and sex were not available for analysis. Bivariate analysis through crosstab using chi-square test was used to identify the association between Job Satisfaction and demographic and environmental factors. Significant independent variables where p < 0.05 considered significant were then further analyzed by job satisfaction domain. Qualitative Method Data Collection and Preparation Qualitative data was purposely sampled from seven government hospitals representing each province, hospital level, and governance. Three hospitals had Anesthesiologists, three hospitals had other consultants, and one hospital had an ASBA in the OT team during the survey. Topic guides were developed iteratively throughout data collection to guide the Focus Group Discussion (FGD), Key Informants interviews (KII) and In-depth Interviews (IDI). IDI with Medical Superintendents, Anesthesiologist and directors, KII with AAs and FGD with OT team and department heads of the hospitals were conducted. Further, KIIs were completed with four directors of the Provincial Health Directorate and MoHP, Kathmandu (See Table 3 ). Interviews were transcribed and translated into English. A thematic content analysis method was applied to analyze the data, whereby the research team read a sample of the transcripts. A descriptive report of the preliminary analysis was written by one research team member, after which the research team independently generated themes from the data and came to a consensus through discussion. The data were coded according to themes and Atlas-ti was used for theme generation. Results Descriptive Analysis The JSS Google Forms survey received 91 responses from 88 different government hospitals. Basic demographics of respondents were assessed and are reported in Table 1 . Table 1 Demographics of AA Survey Respondents (n = 91). Category n (%) Work Experience < 3 years 38 (41.8%) ≥ 3 years 53 (58.2%) Contract Contract 46 (50.5%) Permanent (Loksewa) 45 (49.5%) Current Health Facility Primary Hospital 46 (52.3%) Secondary A Hospital 38 (43.2%) Secondary B Hospital 2 (2.3%) Tertiary Hospital 2 (2.3%) Hospital Governance Local 21 (23.9%) Provincial 67 (76.1%) CSSP Supported hospitals Yes 41 (46.6%) Phased Out 20 (22.7%) No 27 (30.7%) NSI-supported AA Staff Yes 29 (33.0%) No 59 (67.0%) Hospital MSS Scores Mean (± s.d.) 74.3% ± 14.0% Hospitals providing any major surgery Yes 83 (94.3%) No 5 (5.6%) Number of Major Surgeries Mean (± s.d.) 180 ± 203 Availability of Anesthesiologists or consultants Anesthesiologist 7 (7.7%) Consultant* 76 (83.5%) ASBA 3 (3.3%) No Surgeon 5 (5.5%) Anesthesia Spinal 82 (98.80%) Intravenous Anesthesia 80 (96.40%) Local 53 (63.90%) Regional Block 52 (62.70%) General 20 (24.10%) Job Satisfaction Dissatisfied 48 (52.7%) Satisfied 43 (47.3%) *Consultant: Hospitals with Consultants (MDGP, Orthopaedic, Surgeon etc) during the study period. Work experience was well distributed, suggesting long term impact on the healthcare workforce. AAs were also more likely to be working at lower-level hospitals, with a majority serving at either Primary hospitals (52.3%) or Secondary A hospitals (43.2%). Further, only 7.7% of AAs were working with an anesthesiologist, suggesting that MDGPs are providing the majority of the supervision, making AAs the primary provider of anesthesia in rural settings. Of the 91 respondents, 98.8% of AAs provided spinal anesthesia and 96.4% intravenous anesthesia, while general anesthesia was less frequently provided (24.1%). Additionally, 68.3% AAs worked alongside an MDGP, while 50.0% collaborated with gynecologists, 43.9% with orthopedic surgeons, and 40.2% with general surgeons. Besides OT departments, the majority of AA’s work took place in emergency rooms (ER) (79.6%), with occasional cases handled in the outpatient department (OPD) (35.2%), and other wards (18.5%). This suggests that AAs are utilizing their training and contributing to wider hospital functioning beyond anesthesia alone. Ten AAs (10.9%) did not have a functional operating theater (OT) at their current placement, limiting the use of their skills. The greatest hindering factor was the lack of a surgeon (n = 9), followed by shortages in medicine, equipment ( 6 ), OT facilities ( 4 ), and insufficient community support ( 2 ). Job Satisfaction The job satisfaction levels among the participants showed a slight inclination towards dissatisfaction with 53% of the respondents reported being dissatisfied with their jobs, while 47% expressed satisfaction suggesting a pretty even split in satisfaction from respondents, with average satisfaction of 60% (Fig. 1 ). Job Satisfaction by domain (n = 91) AAs reported mixed feelings across nine job satisfaction dimensions assessed in the JSS. Lowest satisfaction was with fringe benefits (46%), followed by Operating Conditions (51%), and Pay (52%). Supervision received relatively positive feedback, with more than two thirds of respondents (70%) having a positive view of their supervisor. The highest satisfaction was with Nature of Work (83%), followed by Coworkers (74%), and Supervision (70%), although these had several outliers. The bivariate analysis of job satisfaction among AAs reveals a significant association between the type of service and job satisfaction (Supplemental Table S2 ), with AAs hired on a contract basis being significantly more likely to be satisfied compared to their permanent counterparts (p < 0.001). NSI-supported AAs (p = 0.004) were also more likely to be satisfied while CSSP supported hospitals were borderline significant (p = 0.056). However, there is significant overlap between AAs supported by NSI and contract employees as 100% NSI-supported employees are hired on a contract basis, making up 63% of all contract employees of respondents. Finally, AAs at hospitals that performed more than 10 major surgeries per year were more likely to be satisfied with their position (p = 0.029). Significant results are disaggregated by domain in Fig. 1 , with contract type being selected in lieu of NSI contract. No other significant associations were found between job satisfaction and other variables such as years of experience, availability of higher supervisors, type of hospital, or hospital governance. Overall, the contract type and utilization of skills stand out as the most influential factor in determining job satisfaction among the variables studied. In summary, while some AAs are satisfied with their roles, particularly those that are supported by NSI and/or on contract, significant dissatisfaction persists concerning pay, promotion, and operating conditions. This suggests a need for targeted interventions to improve job satisfaction across the board. Job Satisfaction by Hospital Context Job satisfaction varied significantly across contract types in multiple domains, as illustrated in Fig. 1 and Table 2 . Loksewa (permanent) staff reported significantly lower mean satisfaction scores in domains regarding motivation, including Contingent Rewards (p = 0.013), Fringe Benefits (p < 0.001), and Pay (p < 0.001). Pay and Fringe benefits showed the greatest magnitude of difference between contract types, with contract employees being 19% and 16% more satisfied, on average. This suggests that systems for motivating the permanent staff are insufficient and lead to higher dissatisfaction compared to non-permanent contract staff. Inversely, it may suggest that NSI’s support via a contract employment is successful at improving satisfaction in these domains. Notable disparities were also observed in Nature of Work (p = 0.017), Communication (p = 0.005), Supervision (p = 0.016). AAs at hospitals with more than 10 major surgeries a year reported significantly greater satisfaction (61%) compared to AAs at hospitals with less than 10 major surgeries annually (55%) (p = 0.029). However, when broken up by domain, only pay (p = 0.020) and supervision (p = 0.006) were significant as shown in Fig. 1 . No significant differences were found in Operating Conditions, Coworkers, or Opportunities for Promotion (p > 0.05), suggesting similar experiences in these domains regardless of contract type. Table 2 Domains of Job Satisfaction by Contract Type (n = 91) and Surgical Volume at Hospitals (n = 88). Welch Two Sample t-test used for analysis. Job Satisfaction Domains. Mean JSS Score by Domain (%) Absolute Difference df p-value Contract Type Contract Loksewa (Permanent) Communication 64.49 53.57 10.92 84.67 0.005 ** Operating Conditions 52.36 49.60 2.76 82.89 0.362 Coworkers 76.54 70.83 5.71 78.85 0.138 Fringe benefits 53.98 38.00 15.98 84.48 < 0.001 *** Nature of Work 87.23 78.27 8.96 75.17 0.017 * Pay 60.69 41.96 18.73 85.52 < 0.001 *** Opportunities for Promotion 55.16 52.88 2.28 84.54 0.462 Contingent Rewards 58.24 48.71 9.53 85.90 0.013 * Supervision 74.73 64.48 10.25 85.97 0.016 * Surgical Volume < 10 Surgeries per year ≥ 10 Surgeries per year Communication 52.08 60.24 8.16 21.39 0.071 Operating Conditions 57.64 50.28 7.36 17.17 0.059 Coworkers 66.67 74.02 7.35 15.06 0.19 Fringe benefits 37.15 47.97 10.82 16.07 0.074 Nature of Work 76.74 84.55 7.81 14.00 0.211 Pay 42.36 53.70 11.34 23.12 0.020 * Opportunities for Promotion 52.78 54.46 1.68 13.56 0.754 Contingent Rewards 50.35 54.51 4.16 14.42 0.499 Supervision 56.60 71.88 15.28 19.07 0.006 ** Qualitative Analysis Qualitative results explore key themes related to AA’s satisfaction, including their role in peripheral and larger hospitals, perception towards AA, surgical care before and after their deployment, continuity of emergency surgical care, working environment and challenges. Table 3 summarises the characteristics of hospitals and interview types included in qualitative analysis. Table 3 Characteristics of Respondent Hospitals and Directors (n = 29). Focus Group Discussion (FGD), Key Informant Interview (KII), In Depth Interview (IDI). Category Item FGD (n = 7) KII (n = 8) IDI (n = 14) Province Koshi 1 1 2 Gandaki 1 1 2 Bagmati 1 1 2 Madhesh 1 2 1 Lumbini 1 1 1 Karnali 1 1 1 Sudurpashchim 1 1 1 Hospital Level Primary 3 4 3 Secondary A 4 4 7 Hospital Governance Province 5 5 8 Local 2 3 2 Geographical Region Hills 4 4 7 Himal 1 1 1 Terai 2 3 2 Directors Province 0 0 3 Federal 0 0 1 Perceived Role and Value of AAs Across both rural and urban hospitals, AAs are widely recognized as essential members of the surgical team. Their contributions vary by context, but their value is consistently emphasized by clinicians, hospital leaders, and the AAs themselves who find satisfaction in their work. Rural and Peripheral Hospitals In rural and peripheral hospitals, AAs are often the enablers of any surgical services at all, making cesarean sections and emergency surgeries possible. As one health worker at a remote primary hospital described, “Last week AA went for the exposure visit, in his absence we had to refer surgical cases to another hospital. So, there is no possibility of surgeries without AA even if we hire multiple surgeons.” Larger Hospitals In larger or Secondary A hospitals, AAs enhance capacity by providing around-the-clock coverage and enabling multiple surgeries to take place concurrently. An anesthesiologist working alongside an AA shared, “Based on the situation in Nepal, I have found that the role of an anesthesia assistant is crucial. I previously worked at a provincial hospital, one of the largest in western Nepal, where there was a significant need for anesthesia assistants to run multiple OT simultaneously. Emergency care services were being provided even in my absence.” However, one AA is not enough. At least four should be available with four shifts.” Similarly, a Me.Su. noted a shift in recognition, “A surgeon is mandatory to perform surgery, and the presence of AA is necessary… After stopping surgery due to the lack of AA, the importance of AA is now understood by all.” Perception of AAs AAs are also praised for their dedication, professionalism, and teamwork. A surgeon at a primary hospital noted, “They are very dedicated to their work with no compromise. They are working 24 hours, seven days, and are always available whenever we need. ” Their clinical competencies are well-regarded, as an Anesthesiologist at a Secondary A hospital said, “The AA working in our hospital is really good at her job. She gives general anesthesia in my presence… There have been no errors from her side ever since I worked here. ” Satisfaction While some AAs express concern about long working hours and limited support, most describe their work as meaningful, with high levels of intrinsic motivation tied to service delivery, particularly for underserved populations. This highlights the component of equity that AAs provide, ensuring affordable and accessible life-saving services in rural Nepal. An AA at a Primary hospital said, “Talking about job satisfaction, I am happy. We perform 55–60 CS per month. Many cases come with uterine rupture and with our effort their life is saved. The patients visiting this hospital are mainly poor. The rich patients go to private hospitals or urban areas. The patients visiting these 15 bedded hospitals are from surrounding municipalities and referred cases from neighboring districts. These cases bring me satisfaction.” Surgical Services Before and After AA Deployment Before AA Deployment Before the deployment of AAs, many district hospitals, especially primary-level facilities, were unable to provide even basic surgical services. Operations were limited by poor infrastructure, lack of equipment, and a shortage of trained personnel. “I joined this hospital seven years ago; I heard that before that some surgeons have worked here and performed some surgeries, but service was not regular, when I joined the condition of the OT set up was very poor, there was limited surgical equipment and sets.” AA, Secondary A Hospital After AA Deployment The introduction of AAs marked a turning point. In many hospitals, they were instrumental in initiating and expanding cesarean sections, general surgeries, and even laparoscopic procedures. As one clinician reported, “We have been performing all the surgeries: General, Orthopedics, and Gynecology. Today we are starting laparoscopy.” While the scope of services continues to vary based on available human and material resources, AAs have enabled a clear expansion in surgical capacity. A director from the Ministry of Health and Population reflected, “We do not have exact data… but with an overview from MoHP, the rate of surgery is higher in higher-level hospitals and less in peripheral hospitals. Nevertheless, some peripheral hospitals are performing well despite limited infrastructure and HR.” Barriers Provincial health leaders emphasized the lingering barriers, particularly infrastructure, equipment, and trained staff, and the need for systemic investments to sustain and scale up surgical services. A provincial Director said, “We have many barriers to start surgical services—like infrastructure, equipment, skilled HR like MDGP, AA etc. We cannot imagine hospitals without surgery. ” “Currently some of the surgeons like MDGP, Surgeon, Gynecologist started to work in some of the hospitals however we are not in the condition to deploy Anesthesiologists to all the district level hospitals to support surgeons and surgeons cannot perform alone. So AA is the only option that we have for now, we have deployed one anesthesia assistant to each hospital via various resources, however the number is not sufficient, if he/she must leave the hospital the service is interrupted, so there should be at least two AA in the hospital to fill the gap.” - Provincial Director The federal government has begun to respond, with planning underway to address gaps more strategically. The “MoHP is developing a National Anesthesia and Surgical Obstetric Plan… a 5-year plan in which we will design necessary HR and other necessities for emergency surgeries.” , stated an MoHP Director Overall, the deployment of AAs is widely seen as a foundational step in improving surgical access in Nepal’s peripheral hospitals. However, continued support across all levels of government is needed to translate this early success into a fully functional and equitable surgical system. AAs Role in Emergency and Surgical Continuity Referrals Building on their critical role in expanding surgical capacity, AAs are also central to maintaining emergency services and reducing patient referrals, especially in remote and resource-constrained settings. Their presence has not only enabled surgeries to occur, but has also ensured continuity of care during emergencies, where delays can be fatal. In many hospitals, AAs have become the de facto frontline providers for stabilizing patients and managing critical cases that would otherwise be referred to distant tertiary centers. As an AA at one of the most remote districts shared, “Referrals have decreased significantly as we provide emergency surgical and medical services from here. only case that need specialist services are refereed from here” When AAs are unavailable, hospitals are forced to refer even routine emergencies. A Me.Su. shared a stark example, “AAs are the backbone of peripheral hospitals. Last week, when our AA was unavailable, we had to call a helicopter to refer a pregnant woman. This shows their importance in reducing referrals and saving lives.” Even in better-equipped hospitals, the absence of general anesthesia machines, CT scanners, or ICUs limits service delivery. In such cases, AAs do their best to triage and manage patients before referral. “Cases that need ICU set up, complicated cases that need multispeciality services are referred” - AA at a Primary hospital. “Nowadays most of the cases are managed here, complex cardiac cases that need specialized set up are referred from here.” Anesthesiologist, Secondary A Despite system constraints, AAs serve as a stabilizing force in Nepal’s district hospitals. Their presence ensures continuity of care, timely emergency response, and reduced financial and physical burden on patients who would otherwise need to travel long distances, preventing catastrophic health expenditures. Work Environment and Challenges While AAs are highly valued for their contributions, their ability to function effectively is often limited by structural and systemic challenges. These include inadequate equipment, resource delays, overwork, and bureaucratic barriers. These issues compromise both the quality of care and the wellbeing of the providers themselves. Supportive but Constrained Settings In some facilities, AAs report positive relationships with colleagues and opportunities to apply their skills. However, these are often tempered by practical limitations. One AA shared, “I am inspired and motivated through this hospital to implement the skills I learned. But due to the lack of anesthesia machines and anesthesiologists, we are not able to implement our skills in general anesthesia.” Hospital leaders, too, expressed frustration about the disconnect between motivation and means. A Superintendent said, “The provincial government sends medicine and HR to provincial hospitals. But in local-level hospitals, we must get permission for everything—HR, supplies. There is no autonomy. We are stuck.” Supply Chain and Infrastructure Gaps A common thread across interviews was the persistent delay or absence of essential supplies. These disruptions significantly affect surgical and emergency services. An AA at a Secondary A hospital said, “Medicines are delayed for almost a month. Our suggestions to purchase from other sources are seen as corruption, which is wrong. Medicines should always be available.” These logistical delays are not just operational, but they undermine morale and disrupt continuity of care. Excessive Workload and Role Creep AAs are frequently responsible for multiple clinical areas, often beyond their formal training. AAs were found to be handling multiple roles beyond anesthesia, such as emergency resuscitation and patient care. Further, the growing number of surgical cases, particularly in orthopedic and caesarean surgeries, without a corresponding increase in AAs is contributing to increased workload. “Besides AA, I work as OT in-charge, I’m on call for emergencies, I do resuscitation, intubation, IV access for difficult cases.” - AA, Primary Hospital Workload pressures are particularly intense in busier, high-level hospitals and both anesthesiologists and hospital leadership echoed the need for increased staffing. “Usually we have 120–130 orthopedic cases, 80–90 surgery cases, and 25–30 CS cases per month. It’s too much.” - AA, Secondary A Hospital “The workload is so much that two people cannot handle it. We’re on call 24 hours and doing major cases frequently—it’s hectic. ” (Anesthesiologist, Secondary A, Gandaki) “Due to 8–10 surgeries per day, both the AA and anesthesiologist are overloaded. One more AA is definitely needed.” - Me.Su., Secondary A Retention and Career Progression The demanding working environment, combined with limited recognition and unclear career pathways, presents significant challenges to the long-term retention of AAs in Nepal’s public hospitals. While many AAs are committed to serving rural communities, the absence of financial incentives, opportunities for growth, and professional legitimacy undermines motivation over time. Financial Incentives and Motivation AAs frequently work long hours with minimal compensation. While many express satisfactions in saving lives, this is not always enough to sustain retention. This is known by leadership, as Me.Su. at a Primary Hospital shared, “If they are working for many hours, then they need to be motivated with some extra benefits. If their expectations cannot be met, it is very difficult to retain anyone. ” A Provincial director shared, “Currently, health workers are overburdened with minimal pay. With this condition, they cannot work for a long time.”. Career Stagnation and Policy Frustration Despite undergoing specialized training, many AAs remain at the same civil service level as before. This is a recurring source of frustration, especially for those with advanced qualifications, Even AAs with bachelor’s and master’s degrees face limitations. “We study three years PCL, gain two years’ experience, train for one more year, and still must work in a fifth-level position. Policymakers did not think about our careers.” - AA, Primary Hospital “I was fifth level as a nurse, and after doing the AA course, I’m still fifth level. There is no growth. Sometimes I think of changing my profession.” - AA, Secondary A, “There is huge discrimination. We [anesthesia graduates] can only reach the seventh level. Entry for all the graduates is limited to the fifth level. This must be addressed.” - AA Further, the lack of a professional post for AAs despite their training exacerbates the issue: “AA is seen as a training, not an academic course. But there is no designated post for it. Unless we make this an academic program, it’s hard to create appropriate posts. ” - Director, Federal MoHP Limited Incentives to Enter the Field Health Assistants and nurses often see little value in pursuing the one-year AA course because it does not offer promotion or improved status as one Me.Su. shared, “HA or Staff Nurses already at fifth level see no benefit in taking the AA course. After completing it, they stay at the same level. There should be a provision for sixth-level posting. ” This disconnect between training, recognition, and advancement discourages future enrolment and weakens retention in the long term. Triangulation of Results Results from the quantitative and qualitative portions were then triangulated using JSS domains to identify areas of convergence and divergence. Almost all areas had strong convergence, with qualitative data providing insight into why domains were seen negatively or positively. Communication, operating conditions, coworkers, nature of work, opportunities for promotion, and contingent rewards had strong convergence. In contrast, fringe benefits, pay, and supervision at least partially diverged, shown in Table 4 . Table 4 Triangulation Matrix of Quantitative and Qualitative Findings by Job Satisfaction Domain. Domain Quantitative Findings Qualitative Findings Convergence/ Divergence Communication Moderate satisfaction overall (Contract: 64.5%; Permanent: 53.6%, p = 0.005). AAs report unclear expectations from leadership; poor vertical communication, especially under local governance. Convergence : Both sources identify communication challenges, especially under bureaucratic hospital systems. Operating Conditions Lowest rated domain overall; not significantly different by contract type or volume of surgery. AAs cite lack of equipment, delayed supplies, and poor infrastructure, especially in local-level hospitals. Convergence : Strong alignment on the impact of poor working conditions. Coworkers High satisfaction across all groups (Contract: 76.5%, Loksewa: 70.8%). AAs described strong team cohesion and mutual respect with OT staff and surgeons. This was reflected by team and supervisor attitudes towards AAs. Convergence : Consistent reports of collegial relationships and supportive team dynamics. Fringe Benefits Lowest satisfaction, especially among Loksewa staff (38.0% vs. Contract: 54.0%, p < 0.001). Not a major theme in interviews, though some mentioned lack of housing or living support indirectly. Partial Divergence : Quantitative data showed very low satisfaction, especially among permanent staff, but qualitative data did not highlight this as a major concern. Nature of Work Very high satisfaction (Contract: 87.2%, Loksewa: 78.3%, p = 0.017). AAs find meaning in emergency care, maternal health, and surgical work, especially in underserved areas and serving the poor. Convergence : Both methods show intrinsic motivation and pride in clinical service. Pay Among the lowest-rated domains. Significantly lower satisfaction for Loksewa (42.0%; p < 0.001) and low surgical volume (42.4%; p = 0.020) Strong qualitative dissatisfaction: " We are working so much but paid so little "; linked to burnout. Convergence : Reinforced concern about pays across both data types. Partial Divergence : AAs with higher surgical volume are less dissatisfied with pay, suggesting skills utilisation may eliminate some pay dissatisfaction. Opportunities for Promotion Low ratings overall but no significant difference by group. Strong qualitative theme: AAs report stagnant roles, lack of recognition, and no incentive to enroll in AA courses. Convergence : Clear and aligned across sources. AAs do not see a way forward in their careers. Contingent Rewards Low satisfaction (Contract: 58.2%, Loksewa: 48.7%, p = 0.013). AAs feel overlooked; effort not rewarded unless tied to external support such as NSI incentives. Convergence : Strong alignment in perceived lack of reward structure and aligned with poor pay. Supervision Higher satisfaction among contract staff (74.7%, p = 0.016) and higher surgical volume hospitals (71.9%; p = 0.006) Mixed views: AAs trust immediate supervisors (MDGPs) but feel unsupported and frustrated institutionally. Partial Divergence : Quantitatively, supervision scored relatively high, especially for contract staff and hospitals with higher volumes of surgeries. However, some AAs expressed frustration at lack of institutional support, unclear hierarchies, or autonomy under local governments. This suggests a differentiation between direct clinical supervision and system-level management. Fringe benefits were rated the lowest for any domain. However, this theme did not emerge in the interviews suggesting that although AAs may be very dissatisfied by fringe benefits, or lack-there-of, they are not top-of-mind to AAs and thus may not have a large influence on overall satisfaction. Further, although Pay showed strong convergence, strongly reinforcing concerns about low pay, there was partial divergence. AAs with higher surgical volume were less dissatisfied with pay, suggesting skills utilisation may eliminate some pay dissatisfaction and make AAs more satisfied overall. Finally, supervision saw the greatest divergence with themes emerging differentiating between local, direct, medical supervision, and system-level and institutional supervision. Overall, AAs were highly satisfied with supervision but themes in the qualitative interviews highlighted strong dissatisfaction with a lack of institutional support, unclear hierarchies or autonomy under local governments in interviews. This suggests a differentiation between direct clinical supervision, which was more positive, and system-level management. Further, AAs at hospitals with a lower surgery volume were significantly less satisfied with supervision (p = 0.006), suggesting they may be unhappy with the lack of skill utilisation. Discussion Five billion people lack access to safe and affordable surgical care, with the majority residing in low- and middle-income countries (LMICs), where 9 out of 10 individuals are without basic surgical services ( 16 ). Further, only 6% of surgical procedures are performed in these countries despite comprising 48% of the global population ( 17 ). Of the nearly half a million specialists/physician anesthesiologists globally, only 12% reside in LMICs ( 17 ). Expectedly, this has been associated with a high perioperative morbidity and mortality rate and it is estimated that one quarter of maternal deaths could be prevented with access to surgical and anesthesia care in LMICs ( 18 , 19 ). The Anesthesia Assistant (AA) is a task-shifting program to train health assistants and nursing staff to perform anesthesia under supervision by the Nick Simons Institute and the Government of Nepal’s MoHP. This paper’s mixed-methods approach clarifies the important role that AAs play in surgical access across Nepal, highlighting challenges and opportunities to improve retention of healthcare workers and surgical access. AAs were repeatedly described as the “ backbone ” of the healthcare system and playing a “ vital role in the team ” across hospitals. They frequently enabled major surgery at lower-level hospitals, serving poor and remote populations, such as CSs or orthopedics, where surgeries would otherwise have been impossible. As one respondent noted, “ If an AA was available, the poor people would not have to spend a lot of money.” Another AA shared, “ The patients visiting this hospital are mainly poor. The rich patients go to private hospitals or urban areas… These cases bring me satisfaction. ” These narratives highlight how AAs help mitigate both geographic and financial barriers to care, two core dimensions of inequity in LMIC health systems ( 13 , 20 ). Their presence reduces the risk of catastrophic health expenditures and promotes timely access to essential services. In this way, AAs contribute not only to surgical scale-up, but to the broader goals of universal health coverage and social protection in rural Nepal. At higher level hospitals, AA played a supportive role, enabling concurrent surgeries and 24 hour coverage of the emergency room, allowing for shared shifts and reduced load on a single staff member. This reflects findings from other task-shifting initiatives in Nepal, such as ASBAs, who were associated with reduced burnout and improved morale through shared shifts and distributed workload ( 14 ). Overall, AAs were nearly evenly split, with 47% reporting satisfaction and 53% dissatisfaction. The domains with the greatest satisfaction were nature of work (83%), coworkers (74%), and supervision (70%). Other research found that interpersonal relationships, work climate, and supportive supervision were the most important influences on satisfaction of rural healthcare workers in LMICs ( 21 ). The poorest satisfaction domains were fringe benefits - or the lack thereof (46%), operating conditions (51%), and pay (52%). These results echo existing research, which found main motivating factors to be interpersonal, while discouraging factors included low salaries and poor working conditions in Viet Nam ( 22 ). Another study of surgeons in east, central, and southern Africa found that addressing working conditions and equality of promotion opportunities was necessary to reduce burnout and improve retention ( 23 ). These findings suggest that job satisfaction among AAs in Nepal is not driven by a single continuum from dissatisfaction to satisfaction, but by two distinct sets of influences. This aligns with Herzberg’s Two-Factor Theory, which distinguishes between motivators, such as the nature of the work and coworker relationships, which actively promote satisfaction. This is in contrast to hygiene factors, such as poor working conditions, low pay, and weak promotion pathways, which primarily prevents dissatisfaction ( 22 , 24 , 25 ). This pattern is reflected in our findings: while a functional operating theater is necessary to avoid frustration, it does not appear to enhance satisfaction. In contrast, saving maternal lives and working within cohesive operating theater teams clearly fueled intrinsic motivation. AAs working in hospitals performing ≥ 10 major surgeries annually were significantly more satisfied (p = 0.006), suggesting that opportunities for skills utilization reduce dissatisfaction while also enhancing motivation. As one AA shared: “ We perform 55–60 CS per month… with our effort their life is saved… These cases bring me satisfaction .” Skills utilization also appeared to buffer dissatisfaction with poor pay (p = 0.020), suggesting that professional fulfillment can partially offset other frustrations. Inversely, a study in the Philippines found that increasing pay, when working conditions remained poor, did not improve healthcare workers satisfaction ( 26 ). Ultimately, well-functioning hospitals may contribute to a positive feedback loop, improving both workforce satisfaction and staff retention in parallel. Despite undergoing specialized training, AAs reported feeling stuck in low-level civil service positions with no formal post, limited pathways for promotion, and no regulatory recognition. This frustration was universally echoed across interviews and reflected in low satisfaction scores in the Opportunities for Promotion domain. Although a higher level cadre, MDGPs cited similar frustration around limited career opportunities, a significant barrier to rural retention nearly 20 years ago in 2008 ( 27 ). Further, permanent (Loksewa) staff were consistently more dissatisfied across nearly all domains (p < 0.001), similar to findings in the ASBA study ( 11 ). The absence of professional growth not only demotivates current AAs but deters future candidates from entering the field. The structural reality stands in sharp contrast to the swell of support and positive feedback from hospital staff, describing the AAs as essential to surgical services across settings. This mismatch must be addressed at the structural level to ensure that AAs are provided pathways to success as a reflection of their role on the ground, as described in a systematic review that found that task-shifting can be effective and affordable “ if accompanied by health system re-structuring” ( 28 ). Similarly, another qualitative systematic review of midwifery, called for “legal protections and liabilities and the regulatory framework” , reiterating the need for systematic changes to support task-shifted cadres ( 29 ). Despite their strong intrinsic motivation, AAs face systemic barriers that threaten long-term retention and performance, similar to task-shifted cadres elsewhere ( 28 , 30 , 31 ). Addressing institutional shortcomings, including delayed supplies, bureaucratic rigidity, and lack of clarity in governance, is critical to sustaining this vital cadre and ensuring the resilience of Nepal’s rural surgical system ( 28 ). Although this study aimed to include as many AAs as possible, the response rate only reflected a portion of AAs in the field, limiting generalizability. Furthermore, only seven hospitals were selected for qualitative interviews. Given dramatically different environments and the impact they have on satisfaction, results should be interpreted with caution. Finally, AAs are a new cadre with evolving structures around their role, which may limit generalizability to other healthcare cadres that are more established, such as nurses or MDGPs. However, there may be useful insights to other new task-shifted cadres. Conclusion Anesthesia Assistants are a vital, task-shifted workforce supporting surgical access across Nepal’s rural hospitals. They reduce geographic and financial barriers, enable emergency care, and are widely recognized by hospital teams for their contributions. While many find meaning in their work, systemic challenges including low pay, poor infrastructure, and lack of career growth limit satisfaction. These findings highlight the need for dual strategies that both sustain intrinsic motivation and address structural barriers. Strengthening institutional support and formalizing career pathways will be essential to protect and expand this critical cadre. Abbreviations AA Anesthesia Assistant ASBA Advance Skilled Birth Attendant CS Caesarean Section CSSP Curative Service Support Program CSV Comma Separated Values CT Computed Tomography ER Emergency FGD Focus Group Discussion HIC High Income Countries HR Human Resource ICU Intensive Care Unit IDI In-depth Interview JSS Job Satisfaction Survey KII Key Informant Interview LMIC Low and Middle Income Countries MDGP Medical Doctorate in General Practice MoHP Ministry of Health and Population MSS Minimum Service Standard NSI Nick Simons Institute OPD Out Patient Department OT Operation Theater SAO Surgeon-Anesthesiologist-Obstetrician Declarations Ethical Consideration The research was conducted in accordance with Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Participants. Ethical approval was obtained from the Nepal Health Research Council (reg no. 1002) based on National Ethical Guidelines for Health Research in Nepal and the administrative approval was taken from MoHP prior to conduction of the study (See supplemental materials). Written informed consent was taken from all the study participants. Voluntary participation was considered for the study. Data were de-identified prior to analysis to protect the privacy and confidentiality of participants. Disclosure Statement No potential conflict of interest was reported by the authors. Funding Statement While the Nick Simons Foundation provides regular funding to the Nick Simons Institute, the research outcomes presented in this paper have no effect on the funding received. The authors did not receive grants directly supporting this work. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. None of the authors’ affiliations or organizations have any financial interest in the outcomes of the research publications. Author Contributions JP conceptualized the study, completed the initial literature review, and collected primary quantitative and qualitative data. JP analyzed and interpreted the qualitative data and developed descriptive statistics of the quantitative data with technical support from RR, RB and AK. AK cleaned and analyzed the data, completed the quantitative analysis and interpretation and created Figure 1. Triangulation was done by AK. JP drafted the first manuscript with support from BS. The manuscript was revised by AK, with support from JP, RR, AA, RB, ABK, MKS, SS. All authors reviewed and approved the final version of the manuscript. Acknowledgement We like to express our sincere gratitude to the Nick Simons Institute for providing the platform and support to conduct this research. We are also thankful to the Ministry of Health and Population, as well as the Provincial Ministries of Health, and the Directors of Health Directorates from all seven provinces, for their valuable support and facilitation. We deeply appreciate the assistance of Mr. Arjun Ghimire and Mr. Khurshid Ahmed in the data collection process. Finally, we extend our heartfelt thanks to all Anesthesia Assistants and Medical Superintendents from the respective hospitals for their cooperation and participation, which made this study possible. We are grateful to Pravin Paudel for his contribution and inputs during the proposal development and data analysis phase of this study. References Džakula A, Relić D, Michelutti P. Health workforce shortage – doing the right things or doing things right? Croat Med J. 2022;63(2):107–9. Liu JX, Goryakin Y, Maeda A, Bruckner T, Scheffler R. Global Health Workforce Labor Market Projections for 2030. Hum Resour Health. 2017;15(1):11. 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Additional Declarations No competing interests reported. Supplementary Files SupplementaryTableandFig.docx AAQuestinnaireQualEng.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 28 Apr, 2026 Reviews received at journal 27 Apr, 2026 Reviewers agreed at journal 16 Apr, 2026 Reviews received at journal 25 Nov, 2025 Reviewers agreed at journal 25 Nov, 2025 Reviewers agreed at journal 25 Nov, 2025 Reviews received at journal 22 Nov, 2025 Reviewers agreed at journal 22 Nov, 2025 Reviewers agreed at journal 20 Nov, 2025 Reviewers invited by journal 20 Nov, 2025 Editor assigned by journal 18 Nov, 2025 Editor invited by journal 27 Oct, 2025 Submission checks completed at journal 27 Oct, 2025 First submitted to journal 27 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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1","display":"","copyAsset":false,"role":"figure","size":302063,"visible":true,"origin":"","legend":"\u003cp\u003eJob Satisfaction by Domain (n=91). A. Overall Job Satisfaction by Domain; B. Job Satisfaction by Domain and Contract Type; C. Job Satisfaction by Domain and Surgical Volume. Low surgical volume \u0026lt;10 major surgeries per year. All numbers show averages. Vertical lines show averages by color. Domains ordered from lowest to highest satisfaction.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7805783/v1/f27bf8a8fa45ee3e7bc896cd.png"},{"id":97145355,"identity":"76cadcbe-2532-4c6d-81bf-33979ca0447c","added_by":"auto","created_at":"2025-12-01 10:13:46","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1511928,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7805783/v1/163d1067-c045-423e-9f28-27dc15c70dd0.pdf"},{"id":97113694,"identity":"b1051af8-1906-44b7-83c8-e7348a424d9c","added_by":"auto","created_at":"2025-12-01 06:55:26","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":26374,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTableandFig.docx","url":"https://assets-eu.researchsquare.com/files/rs-7805783/v1/59ab2d8829d944b22ac52b78.docx"},{"id":97113696,"identity":"362bd37e-2a20-4560-9c7b-9b8002509795","added_by":"auto","created_at":"2025-12-01 06:55:26","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22779,"visible":true,"origin":"","legend":"","description":"","filename":"AAQuestinnaireQualEng.docx","url":"https://assets-eu.researchsquare.com/files/rs-7805783/v1/c92c703b8618a9e5b4150a7c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Task Shifting and Sustainability: Nonphysician anesthetist satisfaction and role in the field - a mixed method cross sectional analysis in primary and secondary hospitals of Nepal","fulltext":[{"header":"Introduction","content":"\u003cp\u003eA healthcare system is completely dependent on its workforce; having the right number of people with the right skills in the right place at the right time (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Yet, there continues to be a growing global shortage of healthcare professionals (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The WHO estimates that for every 1,000 people there are 2.9 physicians in high income countries (HICs), compared to only 0.9 in LMICs (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). On top of global pressures, low- and middle- income countries (LMICs) face even greater shortages due to discrepancies of pay and quality of life between their own country and host countries, accelerated by active recruitment by HICs to supplement their own shortages and various personal and systemic push and pull factors (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). If these trends continue, the progress towards equitable primary health care systems will remain out of reach as LMICs fall farther behind (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eNepal has long struggled with healthcare worker retention, especially in rural and remote areas due to its mountainous terrain, where it is estimated that 2.4\u0026nbsp;million people will not have access to necessary surgical care during their lives (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Despite challenges, efforts to improve healthcare access have shown substantial progress, reducing the maternal mortality rate from 379 per 100,000 in 2000 to 151 per 100,000 in 2021 (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). However, challenges remain. A survey conducted by the International Labour Organization found that 50% of responding medical and nursing students planned to migrate abroad, motivated mostly by better salaries, better living conditions, and better working environments (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn an attempt to address the healthcare worker shortage, Nepal has employed task-shifting of lower level health cadres to provide specialized services, typically reserved for specialists (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The Nick Simons Institute (NSI) has partnered closely with the Ministry of Health and Population (MoHP) to develop a myriad of healthcare cadres including the Advanced Skilled Birth Attendant (ASBA) to train medical officers to provide Cesarean sections (CSs), or the Anesthesia Assistants (AA) to train lower level health cadres to provide anesthesia under the supervision of an anesthesiologist or, more often, a family physician or MDGP (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOne study found that six AAs were conducting 8,000 operations annually at a rural 160-bed mission hospital annually in 2008 (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In 2014, 14 AAs reported an annual caseload of 50\u0026ndash;788 per each (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). And while Nepal\u0026rsquo;s specialist Surgeon-Anesthesiologist-Obstetrician (SAO) density was only 0.4 per 100,000 population, the density of non-specialist SAOs led by MDGPs and supported by AAs was found to be eight times higher, with a density of 3.1 per 100,000. However, this is still significantly below the Lancet Commission on Global Surgery\u0026rsquo;s 2030 target of 20 per 100,000 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). This suggests that AAs play key roles in Nepal\u0026rsquo;s surgical workforce. However, they remain poorly studied with little known about their job satisfaction or retention in rural areas.\u003c/p\u003e\u003cp\u003eThis paper aims to fill this gap by exploring the roles of AAs in the field and better understanding the factors associated with job satisfaction. This research can inform the MoHP\u0026rsquo;s development of the National Surgical, Obstetric, and Anesthesia Plan and provide insights into task shifting and staff retention strategies in other low-resource settings.\u003c/p\u003e"},{"header":"Methods","content":"\n\u003ch3\u003eQuantitative Methods\u003c/h3\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eData Collection and Preparation\u003c/h2\u003e\u003cp\u003eAAs working in governmental hospitals were assessed using Spector\u0026rsquo;s Job Satisfaction Scale (JSS) (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The JSS survey was formatted to a Google Forms survey that was emailed to all AAs working at Primary and Secondary A government hospitals during November 2024 to December 2024 (n\u0026thinsp;=\u0026thinsp;95). This included AAs working at health facilities that may not have had a functional operating theater and were not utilizing their skills to best represent actual satisfaction of the workforce. Ninety-six percent of AAs responded to the survey (n\u0026thinsp;=\u0026thinsp;91). Retrospective surgical data for the 2022/23 fiscal year was retrieved from the Health Management Information System (HMIS) database. Population data by year was retrieved from the national census and province-wise HDI was obtained from the Nepal Human Development Reports.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eThe survey data was downloaded as a CSV file, which was imported and analyzed in R. Job satisfaction obtained via a 6-point Likert scale was categorized using Spector\u0026rsquo;s JSS guidelines into dissatisfied, ambivalent, and satisfied (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The data was dichotomized based on the median satisfaction score for further analysis. The primary outcome was overall satisfaction, which was assessed against relevant hospital-level variables (hospital level, hospital governance, geography, Minimum Service Standards (MSS) score similar to a hospital quality or accreditation score, and provision of surgery) and individual characteristics (education, work experience, course, and employment contract) collected through the survey. Age and sex were not available for analysis.\u003c/p\u003e\u003cp\u003eBivariate analysis through crosstab using chi-square test was used to identify the association between Job Satisfaction and demographic and environmental factors. Significant independent variables where p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 considered significant were then further analyzed by job satisfaction domain.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eQualitative Method\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData Collection and Preparation\u003c/h2\u003e\u003cp\u003eQualitative data was purposely sampled from seven government hospitals representing each province, hospital level, and governance. Three hospitals had Anesthesiologists, three hospitals had other consultants, and one hospital had an ASBA in the OT team during the survey. Topic guides were developed iteratively throughout data collection to guide the Focus Group Discussion (FGD), Key Informants interviews (KII) and In-depth Interviews (IDI). IDI with Medical Superintendents, Anesthesiologist and directors, KII with AAs and FGD with OT team and department heads of the hospitals were conducted. Further, KIIs were completed with four directors of the Provincial Health Directorate and MoHP, Kathmandu (See Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eInterviews were transcribed and translated into English. A thematic content analysis method was applied to analyze the data, whereby the research team read a sample of the transcripts. A descriptive report of the preliminary analysis was written by one research team member, after which the research team independently generated themes from the data and came to a consensus through discussion. The data were coded according to themes and Atlas-ti was used for theme generation.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eDescriptive Analysis\u003c/h2\u003e\u003cp\u003eThe JSS Google Forms survey received 91 responses from 88 different government hospitals. Basic demographics of respondents were assessed and are reported in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDemographics of AA Survey Respondents (n\u0026thinsp;=\u0026thinsp;91).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003en\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eWork Experience\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;3 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(41.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;3 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(58.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eContract\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eContract\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(50.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePermanent (Loksewa)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(49.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eCurrent Health Facility\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(52.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary A Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(43.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary B Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(2.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTertiary Hospital\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(2.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHospital Governance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLocal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(23.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProvincial\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(76.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eCSSP Supported hospitals\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(46.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhased Out\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(22.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(30.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNSI-supported AA Staff\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(33.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(67.0%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHospital MSS Scores\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (\u0026plusmn;\u0026thinsp;s.d.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74.3%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026plusmn;\u0026thinsp;14.0%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHospitals providing any major surgery\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(94.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(5.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of Major Surgeries\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean (\u0026plusmn;\u0026thinsp;s.d.)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e180\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026plusmn;\u0026thinsp;203\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eAvailability of Anesthesiologists or consultants\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnesthesiologist\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(7.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConsultant*\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(83.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eASBA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(3.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNo Surgeon\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(5.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003eAnesthesia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSpinal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(98.80%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIntravenous Anesthesia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(96.40%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLocal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(63.90%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegional Block\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(62.70%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGeneral\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(24.10%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eJob Satisfaction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(52.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e(47.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e*Consultant: Hospitals with Consultants (MDGP, Orthopaedic, Surgeon etc) during the study period.\u003c/p\u003e\u003cp\u003eWork experience was well distributed, suggesting long term impact on the healthcare workforce. AAs were also more likely to be working at lower-level hospitals, with a majority serving at either Primary hospitals (52.3%) or Secondary A hospitals (43.2%). Further, only 7.7% of AAs were working with an anesthesiologist, suggesting that MDGPs are providing the majority of the supervision, making AAs the primary provider of anesthesia in rural settings.\u003c/p\u003e\u003cp\u003eOf the 91 respondents, 98.8% of AAs provided spinal anesthesia and 96.4% intravenous anesthesia, while general anesthesia was less frequently provided (24.1%). Additionally, 68.3% AAs worked alongside an MDGP, while 50.0% collaborated with gynecologists, 43.9% with orthopedic surgeons, and 40.2% with general surgeons. Besides OT departments, the majority of AA\u0026rsquo;s work took place in emergency rooms (ER) (79.6%), with occasional cases handled in the outpatient department (OPD) (35.2%), and other wards (18.5%). This suggests that AAs are utilizing their training and contributing to wider hospital functioning beyond anesthesia alone.\u003c/p\u003e\u003cp\u003eTen AAs (10.9%) did not have a functional operating theater (OT) at their current placement, limiting the use of their skills. The greatest hindering factor was the lack of a surgeon (n\u0026thinsp;=\u0026thinsp;9), followed by shortages in medicine, equipment (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), OT facilities (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e), and insufficient community support (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eJob Satisfaction\u003c/h3\u003e\n\u003cp\u003eThe job satisfaction levels among the participants showed a slight inclination towards dissatisfaction with 53% of the respondents reported being dissatisfied with their jobs, while 47% expressed satisfaction suggesting a pretty even split in satisfaction from respondents, with average satisfaction of 60% (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eJob Satisfaction by domain (n\u0026thinsp;=\u0026thinsp;91)\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAAs reported mixed feelings across nine job satisfaction dimensions assessed in the JSS. Lowest satisfaction was with fringe benefits (46%), followed by Operating Conditions (51%), and Pay (52%). Supervision received relatively positive feedback, with more than two thirds of respondents (70%) having a positive view of their supervisor. The highest satisfaction was with Nature of Work (83%), followed by Coworkers (74%), and Supervision (70%), although these had several outliers.\u003c/p\u003e\u003cp\u003eThe bivariate analysis of job satisfaction among AAs reveals a significant association between the type of service and job satisfaction (Supplemental Table \u003cspan refid=\"MOESM2\" class=\"InternalRef\"\u003eS2\u003c/span\u003e), with AAs hired on a contract basis being significantly more likely to be satisfied compared to their permanent counterparts (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). NSI-supported AAs (p\u0026thinsp;=\u0026thinsp;0.004) were also more likely to be satisfied while CSSP supported hospitals were borderline significant (p\u0026thinsp;=\u0026thinsp;0.056). However, there is significant overlap between AAs supported by NSI and contract employees as 100% NSI-supported employees are hired on a contract basis, making up 63% of all contract employees of respondents. Finally, AAs at hospitals that performed more than 10 major surgeries per year were more likely to be satisfied with their position (p\u0026thinsp;=\u0026thinsp;0.029). Significant results are disaggregated by domain in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, with contract type being selected in lieu of NSI contract.\u003c/p\u003e\u003cp\u003eNo other significant associations were found between job satisfaction and other variables such as years of experience, availability of higher supervisors, type of hospital, or hospital governance. Overall, the contract type and utilization of skills stand out as the most influential factor in determining job satisfaction among the variables studied.\u003c/p\u003e\u003cp\u003eIn summary, while some AAs are satisfied with their roles, particularly those that are supported by NSI and/or on contract, significant dissatisfaction persists concerning pay, promotion, and operating conditions. This suggests a need for targeted interventions to improve job satisfaction across the board.\u003c/p\u003e\n\u003ch3\u003eJob Satisfaction by Hospital Context\u003c/h3\u003e\n\u003cp\u003eJob satisfaction varied significantly across contract types in multiple domains, as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Loksewa (permanent) staff reported significantly lower mean satisfaction scores in domains regarding motivation, including Contingent Rewards (p\u0026thinsp;=\u0026thinsp;0.013), Fringe Benefits (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and Pay (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Pay and Fringe benefits showed the greatest magnitude of difference between contract types, with contract employees being 19% and 16% more satisfied, on average. This suggests that systems for motivating the permanent staff are insufficient and lead to higher dissatisfaction compared to non-permanent contract staff. Inversely, it may suggest that NSI\u0026rsquo;s support via a contract employment is successful at improving satisfaction in these domains. Notable disparities were also observed in Nature of Work (p\u0026thinsp;=\u0026thinsp;0.017), Communication (p\u0026thinsp;=\u0026thinsp;0.005), Supervision (p\u0026thinsp;=\u0026thinsp;0.016).\u003c/p\u003e\u003cp\u003eAAs at hospitals with more than 10 major surgeries a year reported significantly greater satisfaction (61%) compared to AAs at hospitals with less than 10 major surgeries annually (55%) (p\u0026thinsp;=\u0026thinsp;0.029). However, when broken up by domain, only pay (p\u0026thinsp;=\u0026thinsp;0.020) and supervision (p\u0026thinsp;=\u0026thinsp;0.006) were significant as shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eNo significant differences were found in Operating Conditions, Coworkers, or Opportunities for Promotion (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05), suggesting similar experiences in these domains regardless of contract type.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDomains of Job Satisfaction by Contract Type (n\u0026thinsp;=\u0026thinsp;91) and Surgical Volume at Hospitals (n\u0026thinsp;=\u0026thinsp;88). Welch Two Sample t-test used for analysis.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJob Satisfaction Domains.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMean JSS Score by Domain (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eAbsolute Difference\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003edf\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cem\u003eContract Type\u003c/em\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eContract\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLoksewa (Permanent)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e64.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e84.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.005 **\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperating Conditions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e49.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e82.89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.362\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoworkers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e78.85\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.138\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFringe benefits\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e84.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001 ***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNature of Work\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e87.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e78.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.017 *\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e60.69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.96\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e85.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001 ***\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOpportunities for Promotion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e52.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e84.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.462\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eContingent Rewards\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e58.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e85.90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.013 *\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupervision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e74.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e85.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.016 *\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eSurgical Volume\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;10 Surgeries per year\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e\u0026ge;\u0026thinsp;10 Surgeries per year\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e8.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e21.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.071\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperating Conditions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e57.64\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e17.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.059\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoworkers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e74.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e15.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFringe benefits\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e37.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.82\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e16.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.074\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNature of Work\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e84.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.211\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e42.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e11.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.020 *\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOpportunities for Promotion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.754\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eContingent Rewards\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e50.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.499\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupervision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e56.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e15.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e19.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.006 **\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eQualitative Analysis\u003c/h2\u003e\u003cp\u003eQualitative results explore key themes related to AA\u0026rsquo;s satisfaction, including their role in peripheral and larger hospitals, perception towards AA, surgical care before and after their deployment, continuity of emergency surgical care, working environment and challenges. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarises the characteristics of hospitals and interview types included in qualitative analysis.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of Respondent Hospitals and Directors (n\u0026thinsp;=\u0026thinsp;29). Focus Group Discussion (FGD), Key Informant Interview (KII), In Depth Interview (IDI).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCategory\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFGD (n\u0026thinsp;=\u0026thinsp;7)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eKII (n\u0026thinsp;=\u0026thinsp;8)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eIDI (n\u0026thinsp;=\u0026thinsp;14)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"6\" rowspan=\"7\"\u003e\u003cp\u003eProvince\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKoshi\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGandaki\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBagmati\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMadhesh\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLumbini\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eKarnali\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSudurpashchim\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHospital Level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSecondary A\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eHospital Governance\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProvince\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLocal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eGeographical Region\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHills\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHimal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTerai\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eDirectors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProvince\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFederal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ePerceived Role and Value of AAs\u003c/p\u003e\u003cp\u003eAcross both rural and urban hospitals, AAs are widely recognized as essential members of the surgical team. Their contributions vary by context, but their value is consistently emphasized by clinicians, hospital leaders, and the AAs themselves who find satisfaction in their work.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eRural and Peripheral Hospitals\u003c/h2\u003e\u003cp\u003eIn rural and peripheral hospitals, AAs are often the enablers of any surgical services at all, making cesarean sections and emergency surgeries possible. As one health worker at a remote primary hospital described, \u003cem\u003e\u0026ldquo;Last week AA went for the exposure visit, in his absence we had to refer surgical cases to another hospital. So, there is no possibility of surgeries without AA even if we hire multiple surgeons.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eLarger Hospitals\u003c/h2\u003e\u003cp\u003eIn larger or Secondary A hospitals, AAs enhance capacity by providing around-the-clock coverage and enabling multiple surgeries to take place concurrently. An anesthesiologist working alongside an AA shared, \u003cem\u003e\u0026ldquo;Based on the situation in Nepal, I have found that the role of an anesthesia assistant is crucial. I previously worked at a provincial hospital, one of the largest in western Nepal, where there was a significant need for anesthesia assistants to run multiple OT simultaneously. Emergency care services were being provided even in my absence.\u0026rdquo; However, one AA is not enough. At least four should be available with four shifts.\u0026rdquo;\u003c/em\u003e Similarly, a Me.Su. noted a shift in recognition, \u003cem\u003e\u0026ldquo;A surgeon is mandatory to perform surgery, and the presence of AA is necessary\u0026hellip; After stopping surgery due to the lack of AA, the importance of AA is now understood by all.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003ePerception of AAs\u003c/h2\u003e\u003cp\u003eAAs are also praised for their dedication, professionalism, and teamwork. A surgeon at a primary hospital noted, \u003cem\u003e\u0026ldquo;They are very dedicated to their work with no compromise. They are working 24 hours, seven days, and are always available whenever we need.\u003c/em\u003e\u0026rdquo; Their clinical competencies are well-regarded, as an Anesthesiologist at a Secondary A hospital said, \u003cem\u003e\u0026ldquo;The AA working in our hospital is really good at her job. She gives general anesthesia in my presence\u0026hellip; There have been no errors from her side ever since I worked here.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eSatisfaction\u003c/h2\u003e\u003cp\u003eWhile some AAs express concern about long working hours and limited support, most describe their work as meaningful, with high levels of intrinsic motivation tied to service delivery, particularly for underserved populations. This highlights the component of equity that AAs provide, ensuring affordable and accessible life-saving services in rural Nepal. An AA at a Primary hospital said, \u003cem\u003e\u0026ldquo;Talking about job satisfaction, I am happy. We perform 55\u0026ndash;60 CS per month. Many cases come with uterine rupture and with our effort their life is saved. The patients visiting this hospital are mainly poor. The rich patients go to private hospitals or urban areas. The patients visiting these 15 bedded hospitals are from surrounding municipalities and referred cases from neighboring districts. These cases bring me satisfaction.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eSurgical Services Before and After AA Deployment\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eBefore AA Deployment\u003c/h2\u003e\u003cp\u003eBefore the deployment of AAs, many district hospitals, especially primary-level facilities, were unable to provide even basic surgical services. Operations were limited by poor infrastructure, lack of equipment, and a shortage of trained personnel.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I joined this hospital seven years ago; I heard that before that some surgeons have worked here and performed some surgeries, but service was not regular, when I joined the condition of the OT set up was very poor, there was limited surgical equipment and sets.\u0026rdquo;\u003c/em\u003e AA, Secondary A Hospital\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eAfter AA Deployment\u003c/h2\u003e\u003cp\u003eThe introduction of AAs marked a turning point. In many hospitals, they were instrumental in initiating and expanding cesarean sections, general surgeries, and even laparoscopic procedures. As one clinician reported, \u003cem\u003e\u0026ldquo;We have been performing all the surgeries: General, Orthopedics, and Gynecology. Today we are starting laparoscopy.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhile the scope of services continues to vary based on available human and material resources, AAs have enabled a clear expansion in surgical capacity. A director from the Ministry of Health and Population reflected, \u003cem\u003e\u0026ldquo;We do not have exact data\u0026hellip; but with an overview from MoHP, the rate of surgery is higher in higher-level hospitals and less in peripheral hospitals. Nevertheless, some peripheral hospitals are performing well despite limited infrastructure and HR.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eBarriers\u003c/h2\u003e\u003cp\u003eProvincial health leaders emphasized the lingering barriers, particularly infrastructure, equipment, and trained staff, and the need for systemic investments to sustain and scale up surgical services. A provincial Director said, \u003cem\u003e\u0026ldquo;We have many barriers to start surgical services\u0026mdash;like infrastructure, equipment, skilled HR like MDGP, AA etc. We cannot imagine hospitals without surgery.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Currently some of the surgeons like MDGP, Surgeon, Gynecologist started to work in some of the hospitals however we are not in the condition to deploy Anesthesiologists to all the district level hospitals to support surgeons and surgeons cannot perform alone. So AA is the only option that we have for now, we have deployed one anesthesia assistant to each hospital via various resources, however the number is not sufficient, if he/she must leave the hospital the service is interrupted, so there should be at least two AA in the hospital to fill the gap.\u0026rdquo;\u003c/em\u003e - Provincial Director\u003c/p\u003e\u003cp\u003eThe federal government has begun to respond, with planning underway to address gaps more strategically. The \u003cem\u003e\u0026ldquo;MoHP is developing a National Anesthesia and Surgical Obstetric Plan\u0026hellip; a 5-year plan in which we will design necessary HR and other necessities for emergency surgeries.\u0026rdquo;\u003c/em\u003e, stated an MoHP Director\u003c/p\u003e\u003cp\u003eOverall, the deployment of AAs is widely seen as a foundational step in improving surgical access in Nepal\u0026rsquo;s peripheral hospitals. However, continued support across all levels of government is needed to translate this early success into a fully functional and equitable surgical system.\u003c/p\u003e\u003cp\u003eAAs Role in Emergency and Surgical Continuity\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec19\" class=\"Section2\"\u003e\u003ch2\u003eReferrals\u003c/h2\u003e\u003cp\u003eBuilding on their critical role in expanding surgical capacity, AAs are also central to maintaining emergency services and reducing patient referrals, especially in remote and resource-constrained settings. Their presence has not only enabled surgeries to occur, but has also ensured continuity of care during emergencies, where delays can be fatal. In many hospitals, AAs have become the de facto frontline providers for stabilizing patients and managing critical cases that would otherwise be referred to distant tertiary centers. As an AA at one of the most remote districts shared, \u003cem\u003e\u0026ldquo;Referrals have decreased significantly as we provide emergency surgical and medical services from here. only case that need specialist services are refereed from here\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eWhen AAs are unavailable, hospitals are forced to refer even routine emergencies. A Me.Su. shared a stark example, \u003cem\u003e\u0026ldquo;AAs are the backbone of peripheral hospitals. Last week, when our AA was unavailable, we had to call a helicopter to refer a pregnant woman. This shows their importance in reducing referrals and saving lives.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eEven in better-equipped hospitals, the absence of general anesthesia machines, CT scanners, or ICUs limits service delivery. In such cases, AAs do their best to triage and manage patients before referral.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Cases that need ICU set up, complicated cases that need multispeciality services are referred\u0026rdquo;\u003c/em\u003e- AA at a Primary hospital.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Nowadays most of the cases are managed here, complex cardiac cases that need specialized set up are referred from here.\u0026rdquo;\u003c/em\u003e Anesthesiologist, Secondary A\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eDespite system constraints, AAs serve as a stabilizing force in Nepal\u0026rsquo;s district hospitals. Their presence ensures continuity of care, timely emergency response, and reduced financial and physical burden on patients who would otherwise need to travel long distances, preventing catastrophic health expenditures.\u003c/p\u003e\u003cp\u003eWork Environment and Challenges\u003c/p\u003e\u003cp\u003eWhile AAs are highly valued for their contributions, their ability to function effectively is often limited by structural and systemic challenges. These include inadequate equipment, resource delays, overwork, and bureaucratic barriers. These issues compromise both the quality of care and the wellbeing of the providers themselves.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eSupportive but Constrained Settings\u003c/h2\u003e\u003cp\u003eIn some facilities, AAs report positive relationships with colleagues and opportunities to apply their skills. However, these are often tempered by practical limitations. One AA shared, \u003cem\u003e\u0026ldquo;I am inspired and motivated through this hospital to implement the skills I learned. But due to the lack of anesthesia machines and anesthesiologists, we are not able to implement our skills in general anesthesia.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003cp\u003eHospital leaders, too, expressed frustration about the disconnect between motivation and means. A Superintendent said, \u003cem\u003e\u0026ldquo;The provincial government sends medicine and HR to provincial hospitals. But in local-level hospitals, we must get permission for everything\u0026mdash;HR, supplies. There is no autonomy. We are stuck.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec21\" class=\"Section2\"\u003e\u003ch2\u003eSupply Chain and Infrastructure Gaps\u003c/h2\u003e\u003cp\u003eA common thread across interviews was the persistent delay or absence of essential supplies. These disruptions significantly affect surgical and emergency services. An AA at a Secondary A hospital said,\u003cem\u003e\u0026ldquo;Medicines are delayed for almost a month. Our suggestions to purchase from other sources are seen as corruption, which is wrong. Medicines should always be available.\u0026rdquo;\u003c/em\u003e These logistical delays are not just operational, but they undermine morale and disrupt continuity of care.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eExcessive Workload and Role Creep\u003c/h2\u003e\u003cp\u003eAAs are frequently responsible for multiple clinical areas, often beyond their formal training. AAs were found to be handling multiple roles beyond anesthesia, such as emergency resuscitation and patient care. Further, the growing number of surgical cases, particularly in orthopedic and caesarean surgeries, without a corresponding increase in AAs is contributing to increased workload.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Besides AA, I work as OT in-charge, I\u0026rsquo;m on call for emergencies, I do resuscitation, intubation, IV access for difficult cases.\u0026rdquo;\u003c/em\u003e - AA, Primary Hospital\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWorkload pressures are particularly intense in busier, high-level hospitals and both anesthesiologists and hospital leadership echoed the need for increased staffing.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Usually we have 120\u0026ndash;130 orthopedic cases, 80\u0026ndash;90 surgery cases, and 25\u0026ndash;30 CS cases per month. It\u0026rsquo;s too much.\u0026rdquo;\u003c/em\u003e - AA, Secondary A Hospital\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The workload is so much that two people cannot handle it. We\u0026rsquo;re on call 24 hours and doing major cases frequently\u0026mdash;it\u0026rsquo;s hectic.\u003c/em\u003e\u0026rdquo; (Anesthesiologist, Secondary A, Gandaki)\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Due to 8\u0026ndash;10 surgeries per day, both the AA and anesthesiologist are overloaded. One more AA is definitely needed.\u0026rdquo;\u003c/em\u003e - Me.Su., Secondary A\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eRetention and Career Progression\u003c/p\u003e\u003cp\u003eThe demanding working environment, combined with limited recognition and unclear career pathways, presents significant challenges to the long-term retention of AAs in Nepal\u0026rsquo;s public hospitals. While many AAs are committed to serving rural communities, the absence of financial incentives, opportunities for growth, and professional legitimacy undermines motivation over time.\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eFinancial Incentives and Motivation\u003c/h2\u003e\u003cp\u003eAAs frequently work long hours with minimal compensation. While many express satisfactions in saving lives, this is not always enough to sustain retention. This is known by leadership, as Me.Su. at a Primary Hospital shared, \u003cem\u003e\u0026ldquo;If they are working for many hours, then they need to be motivated with some extra benefits. If their expectations cannot be met, it is very difficult to retain anyone.\u003c/em\u003e\u0026rdquo; A Provincial director shared, \u003cem\u003e\u0026ldquo;Currently, health workers are overburdened with minimal pay. With this condition, they cannot work for a long time.\u0026rdquo;.\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eCareer Stagnation and Policy Frustration\u003c/h2\u003e\u003cp\u003eDespite undergoing specialized training, many AAs remain at the same civil service level as before. This is a recurring source of frustration, especially for those with advanced qualifications, Even AAs with bachelor\u0026rsquo;s and master\u0026rsquo;s degrees face limitations.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We study three years PCL, gain two years\u0026rsquo; experience, train for one more year, and still must work in a fifth-level position. Policymakers did not think about our careers.\u0026rdquo; -\u003c/em\u003e AA, Primary Hospital\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I was fifth level as a nurse, and after doing the AA course, I\u0026rsquo;m still fifth level. There is no growth. Sometimes I think of changing my profession.\u0026rdquo;\u003c/em\u003e- AA, Secondary A,\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There is huge discrimination. We\u003c/em\u003e [anesthesia graduates] \u003cem\u003ecan only reach the seventh level. Entry for all the graduates is limited to the fifth level. This must be addressed.\u0026rdquo;\u003c/em\u003e - AA\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFurther, the lack of a professional post for AAs despite their training exacerbates the issue:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;AA is seen as a training, not an academic course. But there is no designated post for it. Unless we make this an academic program, it\u0026rsquo;s hard to create appropriate posts.\u003c/em\u003e \u0026rdquo; - Director, Federal MoHP\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eLimited Incentives to Enter the Field\u003c/h2\u003e\u003cp\u003eHealth Assistants and nurses often see little value in pursuing the one-year AA course because it does not offer promotion or improved status as one Me.Su. shared, \u003cem\u003e\u0026ldquo;HA or Staff Nurses already at fifth level see no benefit in taking the AA course. After completing it, they stay at the same level. There should be a provision for sixth-level posting.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e\u003cp\u003eThis disconnect between training, recognition, and advancement discourages future enrolment and weakens retention in the long term.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eTriangulation of Results\u003c/h2\u003e\u003cp\u003eResults from the quantitative and qualitative portions were then triangulated using JSS domains to identify areas of convergence and divergence. Almost all areas had strong convergence, with qualitative data providing insight into why domains were seen negatively or positively. Communication, operating conditions, coworkers, nature of work, opportunities for promotion, and contingent rewards had strong convergence. In contrast, fringe benefits, pay, and supervision at least partially diverged, shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eTriangulation Matrix of Quantitative and Qualitative Findings by Job Satisfaction Domain.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDomain\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eQuantitative Findings\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eQualitative Findings\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eConvergence/ Divergence\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eModerate satisfaction overall (Contract: 64.5%; Permanent: 53.6%, p\u0026thinsp;=\u0026thinsp;0.005).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAAs report unclear expectations from leadership; poor vertical communication, especially under local governance.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eConvergence\u003c/b\u003e: Both sources identify communication challenges, especially under bureaucratic hospital systems.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperating Conditions\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLowest rated domain overall; not significantly different by contract type or volume of surgery.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAAs cite lack of equipment, delayed supplies, and poor infrastructure, especially in local-level hospitals.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eConvergence\u003c/b\u003e: Strong alignment on the impact of poor working conditions.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoworkers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh satisfaction across all groups (Contract: 76.5%, Loksewa: 70.8%).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAAs described strong team cohesion and mutual respect with OT staff and surgeons. This was reflected by team and supervisor attitudes towards AAs.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eConvergence\u003c/b\u003e: Consistent reports of collegial relationships and supportive team dynamics.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFringe Benefits\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLowest satisfaction, especially among Loksewa staff (38.0% vs. Contract: 54.0%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNot a major theme in interviews, though some mentioned lack of housing or living support indirectly.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003ePartial Divergence\u003c/b\u003e: Quantitative data showed very low satisfaction, especially among permanent staff, but qualitative data did not highlight this as a major concern.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNature of Work\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVery high satisfaction (Contract: 87.2%, Loksewa: 78.3%, p\u0026thinsp;=\u0026thinsp;0.017).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAAs find meaning in emergency care, maternal health, and surgical work, especially in underserved areas and serving the poor.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eConvergence\u003c/b\u003e: Both methods show intrinsic motivation and pride in clinical service.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAmong the lowest-rated domains. Significantly lower satisfaction for Loksewa (42.0%; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and low surgical volume (42.4%; p\u0026thinsp;=\u0026thinsp;0.020)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStrong qualitative dissatisfaction: \"\u003cem\u003eWe are working so much but paid so little\u003c/em\u003e\"; linked to burnout.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eConvergence\u003c/b\u003e: Reinforced concern about pays across both data types.\u003c/p\u003e\u003cp\u003e\u003cb\u003ePartial Divergence\u003c/b\u003e: AAs with higher surgical volume are less dissatisfied with pay, suggesting skills utilisation may eliminate some pay dissatisfaction.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOpportunities for Promotion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow ratings overall but no significant difference by group.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStrong qualitative theme: AAs report stagnant roles, lack of recognition, and no incentive to enroll in AA courses.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eConvergence\u003c/b\u003e: Clear and aligned across sources. AAs do not see a way forward in their careers.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eContingent Rewards\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLow satisfaction (Contract: 58.2%, Loksewa: 48.7%, p\u0026thinsp;=\u0026thinsp;0.013).\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAAs feel overlooked; effort not rewarded unless tied to external support such as NSI incentives.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003eConvergence\u003c/b\u003e: Strong alignment in perceived lack of reward structure and aligned with poor pay.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSupervision\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigher satisfaction among contract staff (74.7%, p\u0026thinsp;=\u0026thinsp;0.016) and higher surgical volume hospitals (71.9%; p\u0026thinsp;=\u0026thinsp;0.006)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMixed views: AAs trust immediate supervisors (MDGPs) but feel unsupported and frustrated institutionally.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003ePartial Divergence\u003c/b\u003e: Quantitatively, supervision scored relatively high, especially for contract staff and hospitals with higher volumes of surgeries. However, some AAs expressed frustration at lack of institutional support, unclear hierarchies, or autonomy under local governments. This suggests a differentiation between direct clinical supervision and system-level management.\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFringe benefits were rated the lowest for any domain. However, this theme did not emerge in the interviews suggesting that although AAs may be very dissatisfied by fringe benefits, or lack-there-of, they are not top-of-mind to AAs and thus may not have a large influence on overall satisfaction. Further, although Pay showed strong convergence, strongly reinforcing concerns about low pay, there was partial divergence. AAs with higher surgical volume were less dissatisfied with pay, suggesting skills utilisation may eliminate some pay dissatisfaction and make AAs more satisfied overall. Finally, supervision saw the greatest divergence with themes emerging differentiating between local, direct, medical supervision, and system-level and institutional supervision. Overall, AAs were highly satisfied with supervision but themes in the qualitative interviews highlighted strong dissatisfaction with a lack of institutional support, unclear hierarchies or autonomy under local governments in interviews. This suggests a differentiation between direct clinical supervision, which was more positive, and system-level management. Further, AAs at hospitals with a lower surgery volume were significantly less satisfied with supervision (p\u0026thinsp;=\u0026thinsp;0.006), suggesting they may be unhappy with the lack of skill utilisation.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eFive billion people lack access to safe and affordable surgical care, with the majority residing in low- and middle-income countries (LMICs), where 9 out of 10 individuals are without basic surgical services (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Further, only 6% of surgical procedures are performed in these countries despite comprising 48% of the global population (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Of the nearly half a million specialists/physician anesthesiologists globally, only 12% reside in LMICs (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Expectedly, this has been associated with a high perioperative morbidity and mortality rate and it is estimated that one quarter of maternal deaths could be prevented with access to surgical and anesthesia care in LMICs (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). The Anesthesia Assistant (AA) is a task-shifting program to train health assistants and nursing staff to perform anesthesia under supervision by the Nick Simons Institute and the Government of Nepal\u0026rsquo;s MoHP. This paper\u0026rsquo;s mixed-methods approach clarifies the important role that AAs play in surgical access across Nepal, highlighting challenges and opportunities to improve retention of healthcare workers and surgical access.\u003c/p\u003e\u003cp\u003eAAs were repeatedly described as the \u0026ldquo;\u003cem\u003ebackbone\u003c/em\u003e\u0026rdquo; of the healthcare system and playing a \u0026ldquo;\u003cem\u003evital role in the team\u003c/em\u003e\u0026rdquo; across hospitals. They frequently enabled major surgery at lower-level hospitals, serving poor and remote populations, such as CSs or orthopedics, where surgeries would otherwise have been impossible. As one respondent noted, \u0026ldquo;\u003cem\u003eIf an AA was available, the poor people would not have to spend a lot of money.\u0026rdquo;\u003c/em\u003e Another AA shared, \u0026ldquo;\u003cem\u003eThe patients visiting this hospital are mainly poor. The rich patients go to private hospitals or urban areas\u0026hellip; These cases bring me satisfaction.\u003c/em\u003e\u0026rdquo; These narratives highlight how AAs help mitigate both geographic and financial barriers to care, two core dimensions of inequity in LMIC health systems (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Their presence reduces the risk of catastrophic health expenditures and promotes timely access to essential services. In this way, AAs contribute not only to surgical scale-up, but to the broader goals of universal health coverage and social protection in rural Nepal. At higher level hospitals, AA played a supportive role, enabling concurrent surgeries and 24 hour coverage of the emergency room, allowing for shared shifts and reduced load on a single staff member. This reflects findings from other task-shifting initiatives in Nepal, such as ASBAs, who were associated with reduced burnout and improved morale through shared shifts and distributed workload (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOverall, AAs were nearly evenly split, with 47% reporting satisfaction and 53% dissatisfaction. The domains with the greatest satisfaction were nature of work (83%), coworkers (74%), and supervision (70%). Other research found that interpersonal relationships, work climate, and supportive supervision were the most important influences on satisfaction of rural healthcare workers in LMICs (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). The poorest satisfaction domains were fringe benefits - or the lack thereof (46%), operating conditions (51%), and pay (52%). These results echo existing research, which found main motivating factors to be interpersonal, while discouraging factors included low salaries and poor working conditions in Viet Nam (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Another study of surgeons in east, central, and southern Africa found that addressing working conditions and equality of promotion opportunities was necessary to reduce burnout and improve retention (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). These findings suggest that job satisfaction among AAs in Nepal is not driven by a single continuum from dissatisfaction to satisfaction, but by two distinct sets of influences. This aligns with Herzberg\u0026rsquo;s Two-Factor Theory, which distinguishes between motivators, such as the nature of the work and coworker relationships, which actively promote satisfaction. This is in contrast to hygiene factors, such as poor working conditions, low pay, and weak promotion pathways, which primarily \u003cem\u003eprevents\u003c/em\u003e dissatisfaction (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThis pattern is reflected in our findings: while a functional operating theater is necessary to avoid frustration, it does not appear to enhance satisfaction. In contrast, saving maternal lives and working within cohesive operating theater teams clearly fueled intrinsic motivation. AAs working in hospitals performing\u0026thinsp;\u0026ge;\u0026thinsp;10 major surgeries annually were significantly more satisfied (p\u0026thinsp;=\u0026thinsp;0.006), suggesting that opportunities for skills utilization reduce dissatisfaction while also enhancing motivation. As one AA shared: \u0026ldquo;\u003cem\u003eWe perform 55\u0026ndash;60 CS per month\u0026hellip; with our effort their life is saved\u0026hellip; These cases bring me satisfaction\u003c/em\u003e.\u0026rdquo; Skills utilization also appeared to buffer dissatisfaction with poor pay (p\u0026thinsp;=\u0026thinsp;0.020), suggesting that professional fulfillment can partially offset other frustrations. Inversely, a study in the Philippines found that increasing pay, when working conditions remained poor, did not improve healthcare workers satisfaction (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Ultimately, well-functioning hospitals may contribute to a positive feedback loop, improving both workforce satisfaction and staff retention in parallel.\u003c/p\u003e\u003cp\u003eDespite undergoing specialized training, AAs reported feeling stuck in low-level civil service positions with no formal post, limited pathways for promotion, and no regulatory recognition. This frustration was universally echoed across interviews and reflected in low satisfaction scores in the Opportunities for Promotion domain. Although a higher level cadre, MDGPs cited similar frustration around limited career opportunities, a significant barrier to rural retention nearly 20 years ago in 2008 (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Further, permanent (Loksewa) staff were consistently more dissatisfied across nearly all domains (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), similar to findings in the ASBA study (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The absence of professional growth not only demotivates current AAs but deters future candidates from entering the field. The structural reality stands in sharp contrast to the swell of support and positive feedback from hospital staff, describing the AAs as essential to surgical services across settings. This mismatch must be addressed at the structural level to ensure that AAs are provided pathways to success as a reflection of their role on the ground, as described in a systematic review that found that task-shifting can be effective and affordable \u0026ldquo;\u003cem\u003eif accompanied by health system re-structuring\u0026rdquo;\u003c/em\u003e (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Similarly, another qualitative systematic review of midwifery, called for \u003cem\u003e\u0026ldquo;legal protections and liabilities and the regulatory framework\u0026rdquo;\u003c/em\u003e, reiterating the need for systematic changes to support task-shifted cadres (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). Despite their strong intrinsic motivation, AAs face systemic barriers that threaten long-term retention and performance, similar to task-shifted cadres elsewhere (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). Addressing institutional shortcomings, including delayed supplies, bureaucratic rigidity, and lack of clarity in governance, is critical to sustaining this vital cadre and ensuring the resilience of Nepal\u0026rsquo;s rural surgical system (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAlthough this study aimed to include as many AAs as possible, the response rate only reflected a portion of AAs in the field, limiting generalizability. Furthermore, only seven hospitals were selected for qualitative interviews. Given dramatically different environments and the impact they have on satisfaction, results should be interpreted with caution. Finally, AAs are a new cadre with evolving structures around their role, which may limit generalizability to other healthcare cadres that are more established, such as nurses or MDGPs. However, there may be useful insights to other new task-shifted cadres.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eAnesthesia Assistants are a vital, task-shifted workforce supporting surgical access across Nepal\u0026rsquo;s rural hospitals. They reduce geographic and financial barriers, enable emergency care, and are widely recognized by hospital teams for their contributions. While many find meaning in their work, systemic challenges including low pay, poor infrastructure, and lack of career growth limit satisfaction. These findings highlight the need for dual strategies that both sustain intrinsic motivation and address structural barriers. Strengthening institutional support and formalizing career pathways will be essential to protect and expand this critical cadre.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAA Anesthesia Assistant\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eASBA Advance Skilled Birth Attendant\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eCS Caesarean Section\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eCSSP Curative Service Support Program\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eCSV Comma Separated Values\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eCT Computed Tomography\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eER Emergency\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eFGD Focus Group Discussion\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eHIC High Income Countries\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eHR Human Resource\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eICU Intensive Care Unit\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eIDI In-depth Interview\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eJSS Job Satisfaction Survey\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eKII Key Informant Interview\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eLMIC Low and Middle Income Countries\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eMDGP Medical Doctorate in General Practice\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eMoHP Ministry of Health and Population\u003c/p\u003e\n\n\u003cp\u003eMSS Minimum Service Standard \u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eNSI Nick Simons Institute\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eOPD Out Patient Department\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eOT Operation Theater\u003cbr\u003e \u003c/p\u003e\n\u003cp\u003eSAO Surgeon-Anesthesiologist-Obstetrician\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003eEthical Consideration\u003c/p\u003e\n\u003cp\u003eThe research was conducted in accordance with Declaration of Helsinki - Ethical Principles for Medical Research Involving Human Participants. Ethical approval was obtained from the Nepal Health Research Council (reg no. 1002) based on National Ethical Guidelines for Health Research in Nepal and the administrative approval was taken from MoHP prior to conduction of the study (See supplemental materials). Written informed consent was taken from all the study participants. Voluntary participation was considered for the study. \u0026nbsp;Data were de-identified prior to analysis to protect the privacy and confidentiality of participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDisclosure Statement\u003c/p\u003e\n\u003cp\u003eNo potential conflict of interest was reported by the authors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Funding Statement\u003c/p\u003e\n\u003cp\u003eWhile the Nick Simons Foundation provides regular funding to the Nick Simons Institute, the research outcomes presented in this paper have no effect on the funding received. The authors did not receive grants directly supporting this work. The funders had no role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. None of the authors\u0026rsquo; affiliations or organizations have any financial interest in the outcomes of the research publications.\u003c/p\u003e\n\u003cp\u003eAuthor Contributions\u003c/p\u003e\n\u003cp\u003eJP conceptualized the study, completed the initial literature review, and collected primary quantitative and qualitative data. JP analyzed and interpreted the qualitative data and developed descriptive statistics of the quantitative data with technical support from RR, RB and AK. AK cleaned and analyzed the data, completed the quantitative analysis and interpretation and created Figure 1. Triangulation was done by AK. JP drafted the first manuscript with support from BS. The manuscript was revised by AK, with support from JP, RR, AA, RB, ABK, MKS, SS. All authors reviewed and approved the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgement\u003c/p\u003e\n\u003cp\u003eWe like to express our sincere gratitude to the Nick Simons Institute for providing the platform and support to conduct this research. We are also thankful to the Ministry of Health and Population, as well as the Provincial Ministries of Health, and the Directors of Health Directorates from all seven provinces, for their valuable support and facilitation.\u003c/p\u003e\n\u003cp\u003eWe deeply appreciate the assistance of Mr. Arjun Ghimire and Mr. Khurshid Ahmed in the data collection process. Finally, we extend our heartfelt thanks to all Anesthesia Assistants and Medical Superintendents from the respective hospitals for their cooperation and participation, which made this study possible. We are grateful to Pravin Paudel for his contribution and inputs during the proposal development and data analysis phase of this study. \u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDžakula A, Relić D, Michelutti P. Health workforce shortage \u0026ndash; doing the right things or doing things right? Croat Med J. 2022;63(2):107\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLiu JX, Goryakin Y, Maeda A, Bruckner T, Scheffler R. Global Health Workforce Labor Market Projections for 2030. Hum Resour Health. 2017;15(1):11.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOlayemi E, Asare EV, Benneh-Akwasi Kuma AA. Guidelines in lower-middle income countries. Br J Haematol. 2017;177(6):846\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eInternationale A, editor. Migration of health workers from Nepal. 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Global Anesthesia Workforce Crisis: A Preliminary Survey Revealing Shortages Contributing to Undesirable Outcomes and Unsafe Practices. World J Surg. 2010;34(3):438\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHenker R, Taki M. Challenges to Global Access to Anesthesia and Surgical Care. In: Thomas SL, Rowles JS, editors. Nurse Practitioners and Nurse Anesthetists: The Evolution of the Global Roles [Internet]. Cham: Springer International Publishing; 2023 [cited 2024 Aug 8]. pp. 313\u0026ndash;29. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/978-3-031-20762-4_25\u003c/span\u003e\u003cspan address=\"10.1007/978-3-031-20762-4_25\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJacobs B, Ir P, Bigdeli M, Annear PL, Van Damme W. 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Retention of general practitioners in rural Nepal: a qualitative study. Aust J Rural Health. 2008;16(4):201\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJoshi R, Alim M, Kengne AP, Jan S, Maulik PK, Peiris D, et al. Task Shifting for Non-Communicable Disease Management in Low- and Middle-Income Countries \u0026ndash; A Systematic Review. PLoS ONE. 2014;9(8):e103754.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eColvin CJ, de Heer J, Winterton L, Mellenkamp M, Glenton C, Noyes J, et al. A systematic review of qualitative evidence on barriers and facilitators to the implementation of task-shifting in midwifery services. Midwifery. 2013;29(10):1211\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBradley S, McAuliffe E. Mid-level providers in emergency obstetric and newborn health care: factors affecting their performance and retention within the Malawian health system. Hum Resour Health. 2009;7(1):14.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCoales K, Jennings et al. Hannah, Afaq, Saima, Arsh, Aatik, Bhatti, Mujeeb, Siddiqui, Faraz,. Perspectives of health workers engaging in task shifting to deliver health care in low-and-middle-income countries: a qualitative evidence synthesis. Global Health Action. 2023;16(1):2228112.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Task shifting, Anesthesia Assistant, Job Satisfaction","lastPublishedDoi":"10.21203/rs.3.rs-7805783/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7805783/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe lack of skilled healthcare workers and poor retention in rural areas limits access to surgical care globally, with the greatest disparities in low- and middle-income countries. In Nepal, the one-year Anesthesia Assistant (AA) program trains non-physician cadres to provide anesthesia to address this gap.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA cross-sectional satisfaction survey using Spector\u0026rsquo;s Job Satisfaction Survey (JSS) was distributed to all AAs working in Primary and Secondary government hospitals, yielding 91 responses from 88 hospitals. Bivariate analyses using chi-squared and t-tests examined associations between job satisfaction and respondent or facility characteristics. Additionally, qualitative data were collected through 7 focus group discussions, 8 key informant interviews, and 14 in-depth interviews with AAs, hospital staff, and policymakers at seven purposively sampled government hospitals.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAAs were nearly evenly split in overall job satisfaction (47% satisfied, 53% dissatisfied). Highest satisfaction was reported in domains related to the nature of work and coworker relationships, while the lowest satisfaction scores were related to pay, fringe benefits, and operating conditions. Significant associations were found between satisfaction and contract status, NSI support, and the availability of surgical services. Qualitative findings reinforced the importance of supportive teams and meaningful work, while highlighting structural barriers such as limited career progression, poor working conditions, and inadequate institutional support.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAAs play a critical role in expanding access to surgical care in rural Nepal yet face persistent structural challenges that threaten retention. Strategies to improve satisfaction must address both intrinsic motivators and systemic barriers, including formal career pathways and improved working environments, to sustain this essential workforce.\u003c/p\u003e","manuscriptTitle":"Task Shifting and Sustainability: Nonphysician anesthetist satisfaction and role in the field - a mixed method cross sectional analysis in primary and secondary hospitals of Nepal","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-01 06:55:22","doi":"10.21203/rs.3.rs-7805783/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-28T06:26:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-27T07:54:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"182267024552436832374633171445177682289","date":"2026-04-16T17:06:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-25T11:33:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"75063360704173679355440486955185278866","date":"2025-11-25T08:35:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"295862472867292151174587070708150277716","date":"2025-11-25T08:23:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-22T08:10:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"289432660800794690735279666073545383332","date":"2025-11-22T07:31:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"245630013211036813993382433093002094913","date":"2025-11-20T08:54:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-11-20T08:15:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-18T12:50:01+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-10-27T10:45:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-27T09:47:48+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-10-27T09:44:56+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"841aae65-ba7d-4c50-878a-8ba51d5a7852","owner":[],"postedDate":"December 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-13T17:08:34+00:00","versionOfRecord":[],"versionCreatedAt":"2025-12-01 06:55:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7805783","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7805783","identity":"rs-7805783","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}