The Perspective of Rehabilitation Nurses on Physical Exercise in the Rehabilitation of Older People in the Community: A Qualitative Study

Comment 1: Title has two sentences, please revise, and make a reflective title.

Answer 1: Thank you for your suggestion. We agree with this comment, and we have changed the title which traduces the content and the method of this study. This change can be found on page 1 of the article, line 3 to 5.

Comment 2: Line 29; 5 categories? If the author is implying themes, if not please explain which categories are being referred to.

Answer 2: Thank you for your comment. We agree that the presentation of results should be clear and concise. We have made changes to the abstract on page 1, line 29 to 35.

Comment 3: Although the introduction provides a thorough background, it could benefit from a more explicit statement of the study's specific objectives and research questions.

Answer 3: Thank you for your suggestion. We agree with this comment and have chosen to introduce three specific objectives that allow the object of study to be measured more concisely. This change can be found on page 3, line 102 to 110.

Comment 4: Although the introduction outlines the importance of implementing exercise programs for the elderly, it could benefit from making explicit the research gap or the specific contribution this study intends to make to the existing body of knowledge.

Answer 4: Thank you for your suggestion. We agree with the comment and have decided to introduce a paragraph explaining the contribution of this study to the field of science and specialization. This change is expressed on page 3, from line 111 to 116.

Comment 5: There is some repetition of information, particularly in the discussion of terms such as "physical activity" and "physical exercise". Try to consolidate and streamline the explanations for a more concise and focused introduction.

Answer 5: Thank you for your comment on the terms "physical activity and physical exercise". We agree with the need for a concise and focused approach. In this sense, we have taken care to differentiate the terms physical activity and physical exercise, using the "International Exercise Recommendations in Older Adults (ICFSR): Expert Consensus Guidelines" (2021) and in agreement with the suggestions made, we have taken care to use the term "exercise program" whenever we characterize physical exercise as a planned and structured activity. This change can be found on page 2, line 77 up to page 3, on line 81 and then between lines 85 and 87 on page 3.

Comment 6: Section 2.3: please have supplementary material in the interview guide material. How the study data was analyzed, the methods should clearly describe. Please review this recent article which has an important key aspect of qualitative research that can be covered and explained https://www.mdpi.com/2227-9032/11/19/2665. What was the analysis approach? Thematic analysis? Grounded theory?

Answer 6: Thank you for your suggestions regarding data analysis. We agree with the concern to make the analysis approach used explicit in the article. The answer to this question is explained in section 2.4 (Data processing and analysis). We used thematic analysis, along the lines of Laurence Bardin, a French author whose original work on content analysis was published in 1977. On page 5, from line 164 to line 176, we took care to concisely present the data analysis procedures used, using content analysis, more specifically thematic analysis. In this process, we were concerned to present the corpus of analysis, the coding units, with the necessary explanation of what is meant by theme according to Laurence Bardin, given that we are dealing with a thematic analysis, in addition to the process of categorization. We agree that the categorization process needs to be better explained and so we have supplemented the information introduced, the change to which can be seen on page 5, lines 176 and 179.

Comment 7: The study has poor rigor. Please have a section on rigor as well.

Answer 7: Thank you for your suggestions regarding rigor. Although the end of section 2.4 deals with the rigor of research, we agree with this comment and have therefore created section 2.5  referent to Rigor and Trustworthiness of the Research, which responds more concisely to the criteria of rigor and quality of qualitative research. This change is visible on page 5 of the revised manuscript, from line 182 to 198.

Comment 8: Please focus on the methodical aspect about methods, and I believe authors can have a short paragraph about ethics instead of several paragraphs.

Answer 8: Thank you for your comments. We agree with the need to be methodical in the approach to ethical aspects and to explicitly highlight the different procedures that lend credibility to the concerns about the ethical aspects of this study. With the changes made to the article, the ethical aspects correspond to section 2.6.

Comment 9: Please review the results, as the readability of the article is very poor in its current version. Some improvements could be made by limiting the number of quotes, such as those in lines 406-425. They could potentially be turned into a table or limited to the best quotes.

Some of the quotes used are unclear. Examples can be found in lines 429, 487 and 544. These are just a few examples of many. Make sure the interview statements are complete and understandable.

Answer 9: Thank you for your suggestions. We agree with this comment and have removed the registration units (the quotes referred to by the reviewer correspond to registration units/themes in Bardin's thematic analysis) that were not clear enough. What is marked in yellow corresponds to the text that has remained intact.

Comment 10: The discussion covers a wide range of information from various studies. Consider organizing the information into more defined paragraphs to make it easier for the reader to follow the flow of arguments.

It would be beneficial to make explicit how the findings of the studies discussed can be applied in practical settings, especially for health professionals and policy makers.

Although the discussion focuses predominantly on the positive effects of structured exercise programs for the elderly, consider briefly addressing some of the challenges associated with such programs.

It would be useful to briefly address the methodologies employed in these studies. This could provide context for the credibility and reliability of the findings.

Potential areas for future research in this field could be incorporated into the discussion.

Answer 10: Thank you for your suggestions. We agree that the discussion covers a wide range of information related to the categories defined in the analysis and the indicators that emerged in the thematic analysis (in the results). Most of the studies presented highlight the methodology used. It has been added on page 17, line 655, on page 18, line 699 and on page 19, line 722. The discussion very briefly addresses some of the challenges arising from this study, on page 20, line 788 to 790 and line 801 to 809.

Comment 1: The authors of the report state that nurses have to design and implement programs aimed at the elderly in order to keep them healthy and maintain their quality of life. This is a well-known truth that should also be enriched with the statement that it is also a task for rehabilitation physicians and physiotherapists, in fact well performed by them all over the world. The article includes more well-known statements that cannot be recognized as novel, for example, Summary, lines 21-23 ..." Structured exercise and general physical activity play an important role in maintaining an active lifestyle, improving health, preventing disease and helping to maintain quality of life for older people." ... . Furthermore, the aim of the study (lines 23-24) for the authors is..." To investigate the importance of implementing physical exercise programs for the elderly in the community, taking into account the perspective of the Rehabilitation Specialist Nurse. is difficult to estimate, as such tasks are always faced by nursing specialists, the question arises: what did the authors intend to investigate?

Answer 1: Thank you for your suggestion. We agree with your comment regarding the statement that nurses, doctors, and physiotherapists must design and implement programs in order to keep older person healthy and maintain their quality of life. However, the object of this study focuses on the intervention of rehabilitation nurses in relation to physical exercise programs in the rehabilitation of elderly people in the community. We can't ignore the fact that in Portugal there is a specialty area in nursing, rehabilitation nurses, whose professionals, due to their skills, have an intervention in a community context that is very appropriate and close to the elderly population. The work between the different professionals is one of partnership and complementarity, but in clinical contexts in the community, the development of these programs and projects is often in the direct responsibility of the nurses.

We agree with the comment regarding the objective and have decided to make a change in the abstract, with the reformulation of the aim of the study and in the introduction with the definition of specific objectives. This change can be found on page 1, lines 23 and 24 and page 3, lines 102 to 110.

Comment 2: The methodology was based on questionnaires and reports with nine rehabilitation nurses from various regions of Portugal who have experience in implementing physical exercise programs with the elderly, which seems to be subjective and free in evaluation as well as in drawing conclusions. Five categories were studied: "Physical exercise program for the elderly in the community", "Importance of physical exercise in the rehabilitation of the elderly in the community", "People's adherence to the programs", "Health gains from implementing these strategies" and "Gains from group activities" and the conclusions were easy to predict that (cit.) ..."Nurses recognize the importance of using structured physical exercise programs adapted to the elderly, bringing advantages in the rehabilitation and maintenance of active aging". ... There is no rational explanation for the data analysis accepted by the authors, based solely on expertise, which does not consider inter-observer reliability.

Answer 2: Thank you for your comment. We agree with the use of these participants with experience in implementing physical exercise programs with the elderly in the community. In this sense, we opted for a qualitative approach because we felt it would be more appropriate to understand the phenomenon under study, valuing the meaning of the experience lived by these participants and taking an interest in understanding the object of study from the perspective of the subjects involved.  We didn't intend to carry out an extensive study, but rather an in-depth one. Hence, the criterion that determined the number of subjects was data/findings saturation.

We should also emphasize that this study was conceived from a naturalistic and interpretivist perspective, whose scientific efforts were directed towards understanding the phenomenon under study, which corresponds to contextual knowledge. We assume that reality is multiple and that this object of study is unique, seen from the perspective of these nurses and not predictable, as is the case with a positivist approach.

The results of the analysis were not based on the expertise of the researchers, seen in the pejorative sense of the term. They are the reflection of rigorous, high-quality work, compatible with what is recommended in qualitative research and in line with the criteria of credibility, transferability, dependability, and confirmability. A change was made to the article, with the creation of section 2.5 about Rigor and Trustworthiness of the Research, visible on page 5 of the revised manuscript, from line 182 to 198.

Comment 3: The discussion is not very comprehensive; the research results are compared with those obtained in some centers outside Portugal; only 27 refs. are provided.

Answer 3: Thank you for your suggestion. We believe that the discussion covers a wide range of information related to the categories defined in the analysis and the indicators that emerged in the thematic analysis (in the results). We used studies carried out by researchers from the scientific area in question and from other areas, with similar skills (some from Portugal and others from other countries). With regard to the number of references, we tried to use as many authors and studies as possible in order to lend credibility to the interpretation of the findings that emerged from the analysis process. As a result of the improved discussion, two more references were added, bringing the total to 29. This change can be seen on page 23, lines 908 to 912.

Comment 4: Poor quality English

Answer 4: Thank you for your comment. Although AJE's highly qualified native English-speaking editors are involved in the translation process, we will endeavor to improve the quality of the text.

Comment 1: The authors responded minimally to comments, particularly in the methods and discussion sections, and made minimal changes to the manuscript.

Answer 1: We appreciate the suggestions regarding methodology and discussion. We agree with the concern to improve the methodology. Therefore, we tried to make the data analysis process clearer and more complete. These changes are visible on page 6, between lines 213 to 219.

In the discussion of the data and in order to frame the results of the studies discussed with practical environments, we introduced changes on page 19, line 726 to 730, on page 20, line 765 to 769 and on page 21, line 824 to 827. We briefly discuss some challenges associated with these physical exercise programs on page 22, line 859 to 867.

We added some references, visible on page 22, line 855 to 858 and on pages 24 and 25, lines 971 to 978.

Comment 2: Accept the text in its current form. Some minor corrections to the literature list are necessary, as marked in yellow in the attached pdf file.

Answer 1: We appreciate your suggestions for improving references. We agree with the need to present references. The changes are visible on pages 23 to 25, from lines 903 to line 978.