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

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.