Access to Competence Development Among Nurses in Telenursing services: Does It Matter? – a comparative cross-sectional study with an embedded mixed-method approach

Access to Competence Development Among Nurses in Telenursing services: Does It Matter? – a comparative cross-sectional study with an embedded mixed-method approach | 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 Access to Competence Development Among Nurses in Telenursing services: Does It Matter? – a comparative cross-sectional study with an embedded mixed-method approach Annica Björkman, Karin Myrberg¹, Anna Carin Wahlberg, Maria Engström¹ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8831065/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background The nursing profession is continually adapting to changing population health needs and rapid medical advancements, underscoring the importance of ongoing competence development. Nurses have a professional responsibility to maintain updated knowledge; however, participation in continuing professional development (CPD) is often constrained by high workloads, staffing shortages, limited resources, and insufficient organizational support. Telenursing represents an expanding area of practice shaped by technological change and may require increased CPD to ensure safe and high-quality care. Despite this, previous research indicates that nurses in these services often work under demanding conditions and have restricted opportunities for professional development. Given the relevance of CPD for competence maintenance, well-being, and care quality, further evidence is needed regarding its availability, its association with work-related outcomes, and nurses’ specific CPD needs. Aim The study aimed to compare nurse-rated quality of working life and satisfaction with given care among nurses who had participated in CPD during the previous year and those who had not. A further aim was to explore nurses’ preferences and perceived needs related to CPD activities. Methods A cross-sectional survey was conducted among nurses in Sweden’s national healthcare advisory service (SHD 1177), involving participants from fourteen regions. Data were collected through a web-based questionnaire in autumn 2023. Of 465 invited nurses, 187 responded (40.2%). Quality of working life and satisfaction with given care were assessed using validated instruments. Access to CPD was measured with a single item, and CPD needs and preferences were collected through free-text responses. Results Nurses with access to CPD reported significantly higher levels of emotional thriving compared with those without CPD. They also gave significantly higher ratings for ‘management and colleagues’ and ‘growth opportunities’. No significant group differences emerged for satisfaction with given care. Desired CPD components included strengthened clinical knowledge, opportunities for reflective and self-directed learning, and improved communication skills. Conclusion Access to CPD was associated with more positive work-related outcomes, including higher thriving and stronger perceptions of managerial and collegial support. These findings highlight the importance of regular competence development to support sustainable telenursing services. Telenursing nurses continuous professional development quality of working life satisfaction with care thriving workforce sustainability 1. Introduction The role of nurses is continually evolving in response to shifting demographic health challenges and ongoing medical advancements (1). To meet these demands, nurses have a professional responsibility to keep their knowledge up to date and engage in lifelong learning (2,3). However, barriers such as heavy workloads, insufficient staffing, lack of funding, and limited managerial support can impede participation in Continuous Professional Development (CPD) (4,5). Telephone advice nursing, here after called telenursing exemplifies how technological advancements are evolving in the nursing profession. Since telenursing as a novel care delivery method may require increased CPD, it is notable that nurses often work under demanding conditions with restricted access to professional development (6–8). Given the critical role of CPD in maintaining competence and enhancing quality of working life, understanding its availability, associated factors, and the specific needs and preferences of nurses is essential. 2. Background CPD in nursing has been defined as: “a life-long process of active participation by nurses in learning activities that assist in developing and maintaining their continuing competence, enhancing their professional practice and supporting achievement of their career goals” (9). It is a continuous process of enhancing knowledge, skills, and attitudes to improve their ability to provide high-quality patient care (10). The need for continuous development of knowledge and skills encompasses diverse areas such as clinical practice, administration, and research (2). Some studies have documented the positive impact of CPD on patient outcomes (11), professional growth (12) and organizational performance (13) and found related to person-centered care (14). Despite the importance of CPD for nurses, there are several challenges in this area. First, there are methodological limitations in examining the effects on patient outcomes. There is also a growing awareness that the knowledge and competencies acquired through CPD are not necessarily automatically transferred into practice and that this application is influenced by contextual factors (15). Among the challenges mentioned in a scoping review by Hakvoort and colleagues(4) are the lack of nursing staff development plans, limited career paths, inadequate staffing levels, and insufficient support from colleagues, managers, and employers. Additionally, nurses experience a disconnect between educational activities and their practical application. A meta synthesis (5) showed how the most common perceived barriers to CPD were poor staffing levels, heavy workloads, lack of funding and lack of study time. On the other hand, continuous learning is central in a knowledge intensive sector such as health care, and higher nurse competence have been found related to less stress symptoms among nurses (16) and a more person-centered care (17). However, methodological challenges remain in demonstrating direct effects on patient outcomes, and there is increasing recognition that the knowledge and competencies gained through CPD are not always readily applied in practice, as their transfer is shaped by contextual factors (15). Nurses have a professional responsibility to maintain up-to-date competencies and require lifelong learning to effectively operate in an evolving and highly demanding healthcare environment (3). CPD participation is mandatory for nurses in many countries, such as the UK and the US, whereas in others, including Sweden, it is not required. Motivations for engaging in CPD vary, with younger nurses focusing on career advancement and older nurses prioritizing patient care ((18)Organizational culture shapes the possibility and conditions for nurses CPD as they are depending on organizational support and culture (5,19). Common barriers to effective CPD include a lack of staff development plans, limited career pathways, inadequate staffing, insufficient managerial and peer support (4), as well as poor staffing, heavy workloads, lack of funding, and insufficient study time (5). Nevertheless, continuous learning is crucial in the knowledge-intensive healthcare sector, and higher nurse competence has been linked to reduced stress symptoms and more person-centered care (20). Telenursing Telenursing includes all kind of care where nurses, deliver nursing services, triage care seekers need of care and give self-care advice via remote telecommunications such as telephone, video consultations and chat/text consultations (21). Telenursing is a rapidly expanding field (21). It is emerging as a critical strategy for optimizing healthcare resources and improving access to appropriate care (22). Within the publicly financed primary care system, a national nurse-led telenursing service has become increasingly important in some European countries for managing patient flow and addressing workforce shortages (23). Telenursing helps manage patient flows by guiding care-seekers before they seek unscheduled care, reducing unnecessary emergency visits and easing the burden on healthcare services. Nurses have reported to having a demanding work where they are exposed to cognitive fatigue and no opportunity for recovery during the work shift (7,8). Nurses working in telenursing settings report high levels of various stressors (e.g., higher demands, role conflicts, and work-private life conflicts, lower possibility to influence work, lower feedback and quality of leadership), stress reactions and long-term consequences (e.g., lower job satisfaction and quality of sleep, higher intention to leave and burnout-symptoms) (7,24–27). Common stressors also include limited opportunities for professional development, high workloads, time pressure, overtime, and long working hours (28). Working as a nurse is demanding, knowledge intensive and implies the need for constant knowledge and competence development. Nurses’ ability to develop their competencies is to a large extent influenced by their work environment (29). As healthcare continuously evolves, with new guidelines, medications, and treatments introduced regularly, nurses must adapt by continually learning new skills (5). Nurses' competence has also been found to have a considerable impact on the quality of care and is closely associated with work performance, satisfaction and reduced intention to leave (6,30) . In a recent study, we found that good access to structural empowerment, such as opportunities for development and growth, increases nurses’ thriving, which in turn improves work–personal life balance and job performance, while reducing stress symptoms and turnover intentions. Thriving (a sense of learning and vitality) acted as a mediator in the relationships between structural empowerment and these positive outcomes (31). However, there is limited research on how access to CPD influences nurses’ quality of working life and satisfaction with care, and on their preferences and needs regarding CPD activities. Addressing this knowledge gap is essential for informing strategies that support nurses’ professional development and help optimize both staff wellbeing and patient care. Aim The aim of the study was to compare nurse-rated quality of working life and satisfaction with given care between nurses with CPD at work during the last year and those without. An additional aim was to investigate nurses’ preferences and perceived needs regarding CPD activities in the workplace. 3. Methods Design The study used a descriptive comparative cross-sectional design with an embedded mixed-method approach. Study Setting and Sampling This study was conducted in Sweden, where telenursing service is organized in regional call-centers (7) staffed by registered nurses. The work environment for these nurses resembles that of a typical call center. Aline with the rest of the Swedish nursing workforce, there is no mandatory requirement for nurses to complete a specific number of hours of CPD . The inclusion criteria were all nurses employed at SHD 1177 – the Swedish national nurse-led telephone healthcare advice service (n=465) and they were invited to answer the web survey conducted in November 2023. Exclusion criteria were nurses on long-term sick leave or maternity leave. Of those invited, 187 nurses completed the survey, yielding a response rate of 40.2%. Among the respondents 180 (96.3 %) provided a free-text response on the question, “What kind of CPD do you desire?”. For nursing studies, an effect size of small to medium has been suggested. With an effect size 0.40 to 0.50 and a power of 0.80, the required sample size would be 99 to 64 people in each group (32). In the present study, of the 180 respondents, 124 nurses reported having access to competence development and 56 did not. Measures The web survey consisted of validated instruments with the opportunity for free-text responses. Emotional thriving was measured using a 4-item scale developed by Adair et al.,(33), with five-grade response alternatives. Telenursing working conditions (TWC) were measured using a scale developed specifically for telenursing service (7), with construct validity found acceptable using explorative factor analyses (unpublished data). The 14-item scale consists of three factors: ‘management and colleagues’ (three items), ‘preconditions’ (six items) and ‘barriers’ (five items) with responses on a seven-point Likert scale. Growth opportunities were measured with a six-item factor from the Safety, Communication, Operational Reliability and Engagement (SCORE) scale (34), addressing areas such as personal growth, independent thoughts and actions, and feelings of achievement; responses were given on a five-point scale. Job satisfaction was measured using the four-item Brief Index of Affective Job Satisfaction scale (35) with response options ranging from 1 (strongly disagree) to 5 (strongly agree). Satisfaction with given care was measured using the eight-item Satisfaction with Given Care scale (36), with seven-point Likert response options. All instruments have shown good psychometric properties. Access to CPD was measured with a Yes/No question, accompanied by an option for free-text responses, and participants could suggest more than one area. These free-text responses were used for directed and summative content analysis (37). Data Analysis Quantitative variables were analyzed using descriptive and comparative statistics (Chi-square test and Mann-Whitney U Test). Visual inspection of histograms for the outcome variables showed non-normal distribution. Effect size was computed for Mann-Whitney U Test (38) According to Funder and Ozer, an r of .10 indicates a small effect and .20 a medium effect (39). Among the participants, 180 provided free-text responses, which included 122 mentions or suggestions related to their desired CPD in the surveys. The free-text responses comprised six pages (2 524 words). They were analyzed using directed content analysis, a method in which coding starts from predetermined categories based on existing theory or prior research, allowing new categories to emerge as needed (37). Two authors (A.B. and K.M.) independently familiarized themselves with the data and generated initial codes. These codes were then organized into potential themes, which were reviewed and refined through iterative discussions. After consensus was reached, five distinct themes were identified. The process was reflexive, with an emphasis on transparency and rigor, and all coding and theme development were conducted manually to ensure close engagement with the data. Following the directed analysis, a summative content analysis was applied (37). This involved counting and summarizing mentions within each category to provide an overview of the most frequently expressed needs. This combined approach offered both qualitative insights and quantitative descriptions of the data. 4. Results Sample A majority of the participants were women (n=169), mean age was 53 years, and they had, in average, worked 25 years as a registered nurse. In general, they had received a median of two CDP days during the past year. There were no statistically significant differences in demographic data between the two groups (CPD yes vs. no). For a description of participants, see Table 1. Table 1 Participant demographic Total samplen=180 Yes CPD, n=124 No CPD, n=56 P-value Competence development, days, mean (SD) 3.8 (3.8) Md 2.0, Q1-3 1.6;4.0 3.8 (3.8) Md 2.0, Q1-3 1.6;4.0 0 Sex, female/male, n (%) 169/10 (93.9/5.6) 116/7 (93.5/5.6) 53/3 (94.6/5.4) 1.000 a Age, years mean (SD), min-max 53.1 (11.1) 27–72 52.2 (10.8) 27–72 55.0 (11.6) 28–71 0.121 b Years working as a RN, mean (SD), min-max 24.7 (12.2), 2–49 24.1 (11.8) 3–49 26.2 (13.0) 2–48 0.290 c Specialist education, yes/no, n (%) 98/81 (54.4/45.0) 66/57 (53.2/46.0) 32/24 (57.1/42.9) 0.747 a Working full/part time, n (%) 54/126 (30.0/70.0) 35/89 (28.2/71.8) 19/37 (33.9/66.1) 0.484 a When the sum does not add 180 there are internal missing data. Abbreviations: CPD Continuous Professional Development, SD standard deviation, RN registered nurse, a Chi-Square test, b independent samples T-test, c Mann-Whitney U Test Nurse-rated quality of working life and satisfaction with given care Comparing the groups with access to CPD or not during the year, the CPD group reported statistically significantly higher mean scores for thriving compared to those without. Effect Size (ES) reported as r was -.20 for the Emotional thriving scale. The CPD group also reported statistically significantly higher mean scores for ‘Structural working conditions’ (total score), and in the factor ‘Management and Colleagues’ with ES of r= -.16 and r=-.20 respectively. For ‘Growth opportunities’ the CPD group reported statistically significantly higher mean score than the than the without group (ES r =-.16). These ES can be described as small to medium. For the other variables ‘Job satisfaction’, ‘Nurse satisfaction with given care’ and the factors ‘preconditions’ and ‘obstacles’, the results were non-significant (Table 2). Table 2 Comparison of working life variables and nurse-rated satisfaction with given care (NSC) between the groups competence development during the year yes (n=124) and no (n=56), Mann-Whitney U Test CPD Yes CPD No P-value Effect size r Total sample n=178-180 Mean (SD) Mean (SD) Emotionel Thriving 3.9 (0.7) 3.6 (0.9) . 006 -.20 3.8 (0.8) Job satisfaction 3.6 (0.8) 3.4 (0.9) .362 - .07 3.5 (0.8) Telenursing work conditions 5.2 (0.7) 4.9 (0.8) . 026 -.16 5.2 (0.8) -Management & Colleagues 5.8 (1.2) 5.3 (1.2) . 006 -.20 5.6 (1.2) -Preconditions 6.2 (0.6) 6.0 (0.8) .205 -.09 6.1 (0.7) -Obstacles a 4.2 (1.3) 4.5 (1.3) .099 .12 4.3 (1.3) Growth Opportunities 63.6 (18.5) 55.2 (24.7) . 027 -.16 61.0 (20.9) NSC 5.9 (0.6) 5.9 (0.7) .595 .04 5.9 (0.7) Abbreviations: CPD Continuous Professional Development, CI Confidence intervals; SD standard deviation, NSC Nurse Satisfaction with given Care a higher scores indicating more obstacles. Nurses’ preferences and perceived needs regarding CPD activities The thematic analysis revealed five different themes, all describing what kind of CPD activities the participants desired. See Table 3 for details. Table 3, description of themes Themes n % of total Clinical knowledge 52 42.6% Reflective and Self-Directed Learning 30 24.6% Communication Skills 17 13.9% Technical and Documentation Skills 13 10.7% Cross-Institutional Exposure 10 8.2% n = 122 mentions Clinical knowledge Participants expressed a strong need for continuous education through regular lectures and updates on clinical guidelines relevant to telenursing. Commonly mentioned areas included pediatrics, psychiatry, ophthalmology, allergies, and seasonal infections—considered essential for accurate assessments and efficient daily work. Opportunities for skills development were also mentioned as important for introducing variation into an otherwise repetitive work environment, supporting both competence and job satisfaction. Reflective and Self-Directed Learning Structured feedback through supervised call reviews was described as a valuable tool for professional development. Respondents also emphasized the importance of having dedicated time for professional tasks beyond direct patient contact. Suggestions included setting aside weekly time slots or designated administrative days for reviewing updated guidelines, completing documentation, and engaging in self-directed learning. Communication Skills The participants expressed a desired training for managing emotionally challenging interactions, such as conversations involving suicidal ideation and handling aggressive or dissatisfied callers—situations frequently encountered in practice. The growing use of digital tools, including chat and video consultations, highlighted the need for comprehensive training in giving care via written communication in the context of nursing. Additionally, participants identified gaps in English language proficiency for healthcare contexts, noting difficulties with medical terminology and effective communication. Technical and Documentation Skills Several participants highlighted the need for training in effective documentation strategies, expressing interest in learning how to document essential information concisely without producing overly lengthy entries. They also emphasized the importance of developing their IT-related competencies. There was notable interest in gaining deeper insight into decision support tools, especially newly introduced advisory systems. Responses stressed the value of understanding the underlying logic and hierarchical structure of these tools. Cross-Institutional Exposure . There was a strong interest in job shadowing and clinical observation in other healthcare settings. Participants suggested visits to primary care centers, child health clinics, emergency departments, ambulance services, and emergency dispatch centers. These experiences were viewed as valuable for broadening clinical understanding and enhancing professional competence. Discussion Access to CPD is seen by nurses as an indication of being valued by the organization (5). In our study, access to CPD was associated with several positive outcomes, including increased thriving, higher ratings of ‘management and colleagues’ and growth opportunities. Thriving, as increased in our study, has in an integrative review by Goh et al (40), been found linked to improved health, well-being, job performance, work attitudes, and professional development. Given the high demands placed on nurses (7,8), it is critically important that nurses are provided with the necessary conditions to experience and maintain thriving, a sense of learning and vitality, in their professional roles. One way to support thriving is by ensuring access to CPD, given its numerous positive effects, including enhanced knowledge and skills, increased professional confidence, and expanded opportunities for career advancement. Furthermore, nurses with CPD reported higher growth opportunities such as personal development, feelings of achievement, and independence in actions. Keeping up-to-date with healthcare developments is also crucial for safe, effective patient care (5). However, in our study, nurses with CPD during the year did not report higher satisfaction with given care compared to those without. Our results also showed the nurses in the CPD group rated higher satisfaction with management and colleagues, e.g., more time to discuss and reflect with colleagues, possibly reflecting a learning-oriented organizational climate where they continuously discuss, support, train and give feedback to each other during daily work. They see the workplace as a learning organization and develop a learning climate. For the factors barriers and preconditions, our results were non-significant. These are also aspects not supposed to be changed by CPD. Our findings suggest that successful implementation of digital care requires not only technical competence, but also pedagogical support. The nurses reported a need for further skill development in delivering care through the digital tools, such as adapting communication strategies for chat and video consultations—an area that has become increasingly relevant with the introduction of new features in the Swedish SHD 1177 service. To maintain high-quality care in this rapidly evolving context, systematic education and training in digital care delivery are essential (41). In our study, the participating nurses also identified structured feedback on their own calls and management of emotionally challenging interactions as important for professional development. These findings are consistent with previous research indicating that delivering telenursing care without adequate training can lead to discomfort and uncertainty for both nurses and patients, thereby compromising care quality and communication (41). Rutledge and Gustin (41) further argue that nurses must be prepared for the expanding role of telehealth and emphasize that education for nurses should incorporate communication training, reflecting the preferences expressed by participants in our study. Advanced communication skills are required, especially when traditional visual or verbal cues are missing, as in telephone or chat consultations (42,43). Haakvort et al. (44) highlight the importance of individualized approaches, as factors influencing professional growth differ throughout a nurse’s career. The role of a nurse in telenursing settings is both knowledge-intensive and complex, constantly requiring the development of new professional, methodological, personal, and social competencies. The field of telenursing is constantly evolving and transforming. While most nurses were motivated to engage in CPD, it is of utmost importance that healthcare organizations recognize nurses’ individual goals and provide resources that support these varied needs. Methodological considerations The design of the study was cross-sectional, which limits cause and effect associations. Validated instruments were used which is a strength. The numbers of participants in the group of nurses without CPD (N=56) might be considered a bit small, which could reduce the statistical power of the analyses. The participants were predominantly women, which aligns with national statistics showing that women constitute approximately 88–90 % of all registered nurses in Sweden, while men represent only about 10–12 % of the nursing workforce(45). Conclusions Nurses’ access to CPD appears to relate to emotional thriving, higher ratings of management and colleagues, and opportunities for growth, but not to job satisfaction, satisfaction with given care and certain structural factors. Abbreviations CPD - continuing professional development Declarations Ethics approval and consent to participate The study was approved by the Swedish Ethical Review Authority Dnr 2023-01378-02. All participants received written study information, completing and returning the questionnaire indicated tacit informed consent. Consent for publication Not applicable Availability of data and materials The data presented, aggregated data, during the current study are available from the corresponding author upon reasonable request. Signing a data sharing agreement will be necessary. Individual data are unavailable due to General Data Protection Regulations (GDPR) and in accordance with the ethics application. Clinical trial number Not applicable Competing interests The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article. Funding This study was funded by AFA insurance. Open access funding provided by University of Gavle Authors' contributions Three of the authors (AB, ACW and ME) contributed to the conception and design of the study. Data collection was performed by AB and analyses by ME, AB and KM. 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Lenhard W, Lenhard A, Psychometrica. 2022. Computation of effect sizes. Funder DC, Ozer DJ. Evaluating Effect Size in Psychological Research: Sense and Nonsense. Adv Methods Pract Psychol Sci. 2019;2(2):156–68. Goh Z, Eva N, Kiazad K, Jack GA, De Cieri H, Spreitzer GM. An integrative multilevel review of thriving at work: Assessing progress and promise. Journal of Organizational Behavior. Volume 43. John Wiley and Sons Ltd; 2022. pp. 197–213. Rutledge CM, Gustin T. Preparing Nurses for Roles in Telehealth: Now is the Time! OJIN: The Online. J Issues Nurs. 2021;26(1). Gustafsson SR, Wahlberg AC. The telephone nursing dialogue process: an integrative review. BMC Nurs. 2023;22(1). Sharkiya SH. Quality communication can improve patient-centred health outcomes among older patients: a rapid review. BMC Health Serv Res. 2023;23(1). Hakvoort L, Dikken J, Cramer-Kruit J, van Nieuwenhuyzen KM, van der Schaaf M, Schuurmans M. Factors that influence continuing professional development over a nursing career: A scoping review. Nurse Education in Practice. Volume 65. Elsevier Ltd; 2022. The Swedish Occupational. Register with occupational statistics. Uneven gender distribution in most major professions. 2023. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 27 Apr, 2026 Reviews received at journal 01 Apr, 2026 Reviews received at journal 20 Mar, 2026 Reviewers agreed at journal 12 Mar, 2026 Reviewers agreed at journal 12 Mar, 2026 Reviewers invited by journal 05 Mar, 2026 Editor invited by journal 11 Feb, 2026 Editor assigned by journal 10 Feb, 2026 Submission checks completed at journal 10 Feb, 2026 First submitted to journal 09 Feb, 2026 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. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8831065","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":603320772,"identity":"02f8f088-ed71-4306-a0b2-fb22c0936637","order_by":0,"name":"Annica Björkman","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAq0lEQVRIiWNgGAWjYPACmwQ2UrWkka7lcALxavlnNz98XLnnfB4f/wLmDx+I0SJx55ix4Zlnt4vZJB6wSc4gypobCWaSDQduJ7ZJHGBj5iFGh/yN9O8/Gw6cA2lh/vyHGC0GN3LMGBsOHEhs429gkCbKXYY3coqBDksG2sLYJtlDjBa5G+kbPzYcsEuc33/48IcfRFkDBxKJDaRpAMbQAVJ1jIJRMApGwUgBAHvlNjgXjGRxAAAAAElFTkSuQmCC","orcid":"","institution":"University of Gävle","correspondingAuthor":true,"prefix":"","firstName":"Annica","middleName":"","lastName":"Björkman","suffix":""},{"id":603320775,"identity":"be940f9a-1656-468b-b41c-7070aaae516e","order_by":1,"name":"Karin Myrberg¹","email":"","orcid":"","institution":"University of Gävle","correspondingAuthor":false,"prefix":"","firstName":"Karin","middleName":"","lastName":"Myrberg¹","suffix":""},{"id":603320778,"identity":"815c8ffc-4845-4cff-bb00-2f2829b35ccf","order_by":2,"name":"Anna Carin Wahlberg","email":"","orcid":"","institution":"Karolinska Institutet","correspondingAuthor":false,"prefix":"","firstName":"Anna","middleName":"Carin","lastName":"Wahlberg","suffix":""},{"id":603320781,"identity":"35fed271-d43b-4e55-8f4b-c82b42c4a3c8","order_by":3,"name":"Maria Engström¹","email":"","orcid":"","institution":"University of Gävle","correspondingAuthor":false,"prefix":"","firstName":"Maria","middleName":"","lastName":"Engström¹","suffix":""}],"badges":[],"createdAt":"2026-02-09 13:38:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8831065/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8831065/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104348930,"identity":"8514371b-8b55-415b-9885-1dcfc9f364ff","added_by":"auto","created_at":"2026-03-10 18:40:03","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":701150,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8831065/v1/f54a001a-f869-47d8-9350-c48d482e3ec7.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Access to Competence Development Among Nurses in Telenursing services: Does It Matter? – a comparative cross-sectional study with an embedded mixed-method approach","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe role of nurses is continually evolving in response to shifting demographic health challenges and ongoing medical advancements (1). To meet these demands, nurses have a professional responsibility to keep their knowledge up to date and engage in lifelong learning (2,3). However, barriers such as heavy workloads, insufficient staffing, lack of funding, and limited managerial support can impede participation in Continuous Professional Development (CPD) (4,5). Telephone advice nursing, here after called telenursing exemplifies how technological advancements are evolving in the nursing profession. Since telenursing as a novel care delivery method may require increased CPD, it is notable that nurses often work under demanding conditions with restricted access to professional development (6\u0026ndash;8). Given the critical role of CPD in maintaining competence and enhancing quality of working life, understanding its availability, associated factors, and the specific needs and preferences of nurses is essential.\u003c/p\u003e"},{"header":"2. Background ","content":"\u003cp\u003eCPD in nursing has been defined as: “a life-long process of active participation by nurses in learning activities that assist in developing and maintaining their continuing competence, enhancing their professional practice and supporting achievement of their career goals” (9). It is a continuous process of enhancing knowledge, skills, and attitudes to improve their ability to provide high-quality patient care (10). The need for continuous development of knowledge and skills encompasses diverse areas such as clinical practice, administration, and research (2). Some studies have documented the positive impact of CPD on patient outcomes (11), professional growth (12) and organizational performance (13) and\u003cs\u003e\u0026nbsp;\u003c/s\u003efound related to person-centered care (14). Despite the importance of CPD for nurses, there are several challenges in this area. First, there are methodological limitations in examining the effects on patient outcomes. There is also a growing awareness that the knowledge and competencies acquired through CPD are not necessarily automatically transferred into practice and that this application is influenced by contextual factors (15). Among the challenges mentioned in a scoping review by Hakvoort and colleagues(4) are the lack of nursing staff development plans, limited career paths, inadequate staffing levels, and insufficient support from colleagues, managers, and employers. Additionally, nurses experience a disconnect between educational activities and their practical application. \u0026nbsp; A meta synthesis (5) \u0026nbsp; showed how the most common perceived barriers to CPD were poor staffing levels, heavy workloads, lack of funding and lack of study time. On the other hand, continuous learning is central in a knowledge intensive sector such as health care, and higher nurse competence have been found related to less stress symptoms among nurses (16) and a more person-centered care (17). However, methodological challenges remain in demonstrating direct effects on patient outcomes, and there is increasing recognition that the knowledge and competencies gained through CPD are not always readily applied in practice, as their transfer is shaped by contextual factors (15).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNurses have a professional responsibility to maintain up-to-date competencies and require lifelong learning to effectively operate in an evolving and highly demanding healthcare environment (3). CPD participation is mandatory for nurses in many countries, such as the UK and the US, whereas in others, including Sweden, it is not required. Motivations for engaging in CPD vary, with younger nurses focusing on career advancement and older nurses prioritizing patient care ((18)Organizational culture shapes the possibility and conditions for nurses CPD as they are depending on organizational support and culture \u0026nbsp; (5,19). Common barriers to effective CPD include a lack of staff development plans, limited career pathways, inadequate staffing, insufficient managerial and peer support (4), as well as poor staffing, heavy workloads, lack of funding, and insufficient study time (5). Nevertheless, continuous learning is crucial in the knowledge-intensive healthcare sector, and higher nurse competence has been linked to reduced stress symptoms and more person-centered care (20).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTelenursing\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTelenursing includes all kind of care where nurses, deliver nursing services, triage care seekers need of care and give self-care advice via remote telecommunications such as telephone, video consultations and chat/text consultations (21). Telenursing is a rapidly expanding field (21). It is emerging as a critical strategy for optimizing healthcare resources and improving access to appropriate care (22).\u0026nbsp;Within the publicly financed primary care system, a national nurse-led telenursing service has become increasingly important in some European countries for managing patient flow and addressing workforce shortages (23).\u0026nbsp;Telenursing helps manage patient flows by guiding care-seekers before they seek unscheduled care, reducing unnecessary emergency visits and\u0026nbsp;easing the burden on healthcare services. \u0026nbsp;Nurses have reported to having a demanding work where they are exposed to cognitive fatigue and no opportunity for recovery during the work shift (7,8). Nurses working in telenursing settings report high levels of various stressors (e.g., higher demands, role conflicts, and work-private life conflicts, lower possibility to influence work, lower feedback and quality of leadership), stress reactions and long-term consequences (e.g., lower job satisfaction and quality of sleep, higher intention to leave and burnout-symptoms) (7,24–27). \u0026nbsp;Common stressors also include limited opportunities for professional development, high workloads, time pressure, overtime, and long working hours (28).\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWorking as a nurse is demanding, knowledge intensive and implies the need for constant knowledge and competence development. \u0026nbsp; Nurses’ ability to develop their competencies is to a large extent influenced by their work environment (29). \u0026nbsp;As healthcare continuously evolves, with new guidelines, medications, and treatments introduced regularly, nurses must adapt by continually learning new skills (5). \u0026nbsp;Nurses' competence has also been found to have a considerable impact on the quality of care and is closely associated with work performance, satisfaction and reduced intention to leave (6,30) .\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn a recent study, we found that good access to structural empowerment, such as opportunities for development and growth, increases nurses’ thriving, which in turn improves work–personal life balance and job performance, while reducing stress symptoms and turnover intentions. Thriving (a sense of learning and vitality) acted as a mediator in the relationships between structural empowerment and these positive outcomes (31). However, there is limited research on how access to CPD influences nurses’ quality of working life and satisfaction with care, and on their preferences and needs regarding CPD activities. Addressing this knowledge gap is essential for informing strategies that support nurses’ professional development and help optimize both staff wellbeing and patient care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAim\u003c/strong\u003e The aim of the study was to compare nurse-rated quality of working life and satisfaction with given care between nurses with CPD at work during the last year and those without. An additional aim was to investigate nurses’ preferences and perceived needs regarding CPD activities in the workplace.\u0026nbsp;\u003c/p\u003e"},{"header":"3. Methods","content":"\u003cp\u003e\u003cstrong\u003eDesign\u0026nbsp;\u003c/strong\u003eThe study used a descriptive comparative cross-sectional design with an embedded mixed-method approach.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Setting and Sampling\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was conducted in Sweden, where telenursing service is organized in regional call-centers (7) staffed by registered nurses. The work environment for these nurses resembles that of a typical call center.\u0026nbsp;Aline with the rest of the Swedish nursing workforce, there is no mandatory requirement for nurses to complete a specific number of hours of CPD\u003cstrong\u003e.\u0026nbsp;\u003c/strong\u003eThe inclusion criteria were all nurses employed at \u003cem\u003eSHD\u003c/em\u003e \u003cem\u003e1177\u003c/em\u003e – the Swedish national nurse-led telephone healthcare advice service (n=465) and they were invited to answer the web survey conducted in November 2023. Exclusion criteria were nurses on long-term sick leave or maternity leave. Of those invited, 187 nurses completed the survey, yielding a response rate of 40.2%. Among the respondents 180 (96.3 %) provided a free-text response on the question, “What kind of CPD do you desire?”. For nursing studies, an effect size of small to medium has been suggested. With an effect size 0.40 to 0.50 and a power of 0.80, the required sample size would be 99 to 64 people in each group (32). In the present study, of the 180 respondents, 124 nurses reported having access to competence development and 56 did not.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe web survey consisted of validated instruments with the opportunity for free-text responses. Emotional thriving was measured using a 4-item scale developed by Adair et al.,(33), with five-grade response alternatives. Telenursing working conditions (TWC) were measured using a scale developed specifically for telenursing service \u0026nbsp;(7), with construct validity found acceptable using explorative factor analyses (unpublished data). The 14-item scale consists of three factors: ‘management and colleagues’ (three items), ‘preconditions’ (six items) and ‘barriers’ (five items) with responses on a seven-point Likert scale. Growth opportunities were measured with a six-item factor from the Safety, Communication, Operational Reliability and Engagement (SCORE) scale (34), addressing areas such as personal growth, independent thoughts and actions, and feelings of achievement; responses were given on a five-point scale. \u0026nbsp;Job satisfaction was measured using the four-item Brief Index of Affective Job Satisfaction scale (35) with response options ranging from 1 (strongly disagree) to 5 (strongly agree). Satisfaction with given care was measured using the eight-item Satisfaction with Given Care scale (36), with seven-point Likert response options. All instruments have shown good psychometric properties. Access to CPD was measured with a Yes/No question, accompanied by an option for free-text responses, and participants could suggest more than one area. These free-text responses were used for directed and summative content analysis (37).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative variables were analyzed using descriptive and comparative statistics (Chi-square test and Mann-Whitney U Test). Visual inspection of histograms for the outcome variables showed non-normal distribution. Effect size was computed for Mann-Whitney U Test (38) According to Funder and Ozer, an r of .10 indicates a small effect and .20 a medium effect (39).\u003c/p\u003e\n\u003cp\u003eAmong the participants, 180 provided free-text responses, which included 122 mentions or suggestions related to their desired CPD in the surveys. The free-text responses comprised six pages (2 524 words). They were analyzed using directed content analysis, a method in which coding starts from predetermined categories based on existing theory or prior research, allowing new categories to emerge as needed (37). Two authors (A.B. and K.M.) independently familiarized themselves with the data and generated initial codes. These codes were then organized into potential themes, which were reviewed and refined through iterative discussions. After consensus was reached, five distinct themes were identified. The process was reflexive, with an emphasis on transparency and rigor, and all coding and theme development were conducted manually to ensure close engagement with the data. Following the directed analysis, a summative content analysis was applied (37). This involved counting and summarizing mentions within each category to provide an overview of the most frequently expressed needs. This combined approach offered both qualitative insights and quantitative descriptions of the data.\u003c/p\u003e"},{"header":"4. Results","content":"\u003cp\u003e\u003cstrong\u003eSample\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA majority of the participants were women (n=169), mean age was 53 years, and they had, in average, worked 25 years as a registered nurse. In general, they had received a median of two CDP days during the past year. There were no statistically significant differences in demographic data between the two groups (CPD yes vs. no). For a description of participants, see Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Participant demographic\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal samplen=180\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eYes CPD, n=124\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo CPD, n=56\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCompetence development, days, mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.8 (3.8) Md 2.0, Q1-3 1.6;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.8 (3.8) Md 2.0, Q1-3 1.6;4.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSex, female/male, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e169/10 (93.9/5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e116/7 (93.5/5.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53/3 (94.6/5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e1.000\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAge, years mean (SD), min-max\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e53.1 (11.1) 27–72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52.2 (10.8) 27–72\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e55.0 (11.6) 28–71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.121\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eYears working as a RN, mean (SD), min-max\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.7 (12.2), 2–49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.1 (11.8) 3–49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e26.2 (13.0) 2–48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.290\u003csup\u003e\u0026nbsp;c\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSpecialist education, yes/no, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e98/81 (54.4/45.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e66/57 (53.2/46.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e32/24 (57.1/42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.747\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eWorking full/part time, n (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e54/126 (30.0/70.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e35/89 (28.2/71.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e19/37 (33.9/66.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e0.484\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWhen the sum does not add 180 there are internal missing data.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAbbreviations: CPD Continuous Professional Development, SD standard deviation, RN registered nurse, \u003csup\u003ea\u003c/sup\u003e Chi-Square test, \u003csup\u003eb\u0026nbsp;\u003c/sup\u003eindependent samples T-test, \u003csup\u003ec\u003c/sup\u003eMann-Whitney U Test\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNurse-rated quality of working life and satisfaction with given care\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eComparing the groups with access to CPD or not during the year, the CPD group reported statistically significantly higher mean scores for thriving compared to those without. Effect Size (ES) reported as r was -.20 for the Emotional thriving scale. The CPD group also reported statistically significantly higher mean scores for ‘Structural working conditions’ (total score), and in the factor ‘Management and Colleagues’ with ES of r= -.16 and r=-.20 respectively. For ‘Growth opportunities’ the CPD group reported statistically significantly higher mean score than the \u0026nbsp;than the without group (ES r =-.16). These ES can be described as small to medium. For the other variables ‘Job satisfaction’, ‘Nurse satisfaction with given care’ and the factors ‘preconditions’ and ‘obstacles’, the results were non-significant (Table 2). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Table 2 Comparison of working life variables and nurse-rated satisfaction with given care (NSC) between the groups competence development during the year yes (n=124) and no (n=56), Mann-Whitney U Test\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCPD Yes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eCPD No\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eEffect size r\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal sample n=178-180\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean (SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eEmotionel Thriving\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.9 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.6 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003cstrong\u003e006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.8 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eJob satisfaction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.6 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.4 (0.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.362\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e- .07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e3.5 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTelenursing work conditions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.2 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.9 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003cstrong\u003e026\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.2 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-Management \u0026amp; Colleagues\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.8 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.3 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003cstrong\u003e006\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.6 (1.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-Preconditions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.2 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.0 (0.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.205\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-.09\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e6.1 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-Obstacles\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.2 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.5 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.099\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e4.3 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eGrowth Opportunities\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e63.6 (18.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e55.2 (24.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.\u003cstrong\u003e027\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e-.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e61.0 (20.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNSC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.9 (0.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.9 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.595\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e5.9 (0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAbbreviations: CPD Continuous Professional Development, CI Confidence intervals; SD standard deviation, NSC Nurse Satisfaction with given Care \u003csup\u003ea\u003c/sup\u003e higher scores indicating more obstacles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNurses’ preferences and perceived needs regarding CPD activities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe thematic analysis revealed five different themes, all describing what kind of CPD activities the participants desired. See Table 3 for details.\u003c/p\u003e\n\u003cp\u003eTable 3, description of themes\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"347\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e% of total\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eClinical knowledge\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e52\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e42.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eReflective and Self-Directed Learning\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e24.6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCommunication Skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13.9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eTechnical and Documentation Skills\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10.7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCross-Institutional Exposure\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e8.2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003en = 122 mentions\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eClinical knowledge\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eParticipants expressed a strong need for continuous education through regular lectures and updates on clinical guidelines relevant to telenursing. Commonly mentioned areas included pediatrics, psychiatry, ophthalmology, allergies, and seasonal infections—considered essential for accurate assessments and efficient daily work. Opportunities for skills development were also mentioned as important for introducing variation into an otherwise repetitive work environment, supporting both competence and job satisfaction.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eReflective and Self-Directed Learning\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eStructured feedback through supervised call reviews was described as a valuable tool for professional development. Respondents also emphasized the importance of having dedicated time for professional tasks beyond direct patient contact. Suggestions included setting aside weekly time slots or designated administrative days for reviewing updated guidelines, completing documentation, and engaging in self-directed learning.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCommunication Skills\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe participants expressed a desired training for managing emotionally challenging interactions, such as conversations involving suicidal ideation and handling aggressive or dissatisfied callers—situations frequently encountered in practice. The growing use of digital tools, including chat and video consultations, highlighted the need for comprehensive training in giving care via written communication in the context of nursing. Additionally, participants identified gaps in English language proficiency for healthcare contexts, noting difficulties with medical terminology and effective communication.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTechnical and Documentation Skills\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eSeveral participants highlighted the need for training in effective documentation strategies, expressing interest in learning how to document essential information concisely without producing overly lengthy entries. They also emphasized the importance of developing their IT-related competencies. There was notable interest in gaining deeper insight into decision support tools, especially newly introduced advisory systems. Responses stressed the value of understanding the underlying logic and hierarchical structure of these tools.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCross-Institutional Exposure\u003c/em\u003e\u003cem\u003e.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThere was a strong interest in job shadowing and clinical observation in other healthcare settings. Participants suggested visits to primary care centers, child health clinics, emergency departments, ambulance services, and emergency dispatch centers. These experiences were viewed as valuable for broadening clinical understanding and enhancing professional competence.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eAccess to CPD is seen by nurses as an indication of being valued by the organization (5). In our study, access to CPD was associated with several positive outcomes, including increased thriving, higher ratings of ‘management and colleagues’ \u0026nbsp;and growth opportunities. Thriving, as increased in our study, has in an integrative review by Goh et al (40), been found linked to improved health, well-being, job performance, work attitudes, and professional development. Given the high demands placed on nurses (7,8), it is critically important that nurses are provided with the necessary conditions to experience and maintain thriving, a sense of learning and vitality, in their professional roles. One way to support thriving is by ensuring access to CPD, given its numerous positive effects, including enhanced knowledge and skills, increased professional confidence, and expanded opportunities for career advancement. Furthermore, nurses with CPD reported higher growth opportunities such as personal development, feelings of achievement, and independence in actions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eKeeping up-to-date with healthcare developments is also crucial for safe, effective patient care (5). However, in our study, nurses with CPD during the year did not report higher satisfaction with given care compared to those without.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur results also showed the nurses in the CPD group rated higher satisfaction with management and colleagues, e.g., more time to discuss and reflect with colleagues, possibly reflecting a learning-oriented organizational climate where they continuously discuss, support, train and give feedback to each other during daily work. They see the workplace as a learning organization and develop a learning climate. For the factors barriers and preconditions, our results were non-significant. These are also aspects not supposed to be changed by CPD.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur findings suggest that successful implementation of digital care requires not only technical competence, but also pedagogical support. \u0026nbsp;The nurses reported a need for further skill development in delivering care through the digital tools, such as adapting communication strategies for chat and video consultations—an area that has become increasingly relevant with the introduction of new features in the Swedish SHD 1177 service. To maintain high-quality care in this rapidly evolving context, systematic education and training in digital care delivery are essential (41).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn our study, the participating nurses also identified structured feedback on their own calls and management of emotionally challenging interactions as important for professional development. These findings are consistent with previous research indicating that delivering telenursing care without adequate training can lead to discomfort and uncertainty for both nurses and patients, thereby compromising care quality and communication (41). Rutledge and Gustin (41) further argue that nurses must be prepared for the expanding role of telehealth and emphasize that education for nurses should incorporate communication training, reflecting the preferences expressed by participants in our study. Advanced communication skills are required, especially when traditional visual or verbal cues are missing, as in telephone or chat consultations (42,43). Haakvort et al. (44) highlight the importance of individualized approaches, as factors influencing professional growth differ throughout a nurse’s career. The role of a nurse in telenursing settings is both knowledge-intensive and complex, constantly requiring the development of new professional, methodological, personal, and social competencies. The field of telenursing is constantly evolving and transforming. While most nurses were motivated to engage in CPD, it is of utmost importance that healthcare organizations recognize nurses’ individual goals and provide resources that support these varied needs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethodological considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe design of the study was cross-sectional, which limits cause and effect associations. Validated instruments were used which is a strength. The numbers of participants in the group of nurses without CPD (N=56) might be considered a bit small, which could reduce the statistical power of the analyses. The participants were predominantly women, which aligns with national statistics showing that women constitute approximately 88–90 % of all registered nurses in Sweden, while men represent only about 10–12 % of the nursing workforce(45).\u003c/p\u003e"},{"header":"Conclusions ","content":"\u003cp\u003eNurses\u0026rsquo; access to CPD appears to relate to emotional thriving, higher ratings of management and colleagues, and opportunities for growth, but not to job satisfaction, satisfaction with given care and certain structural factors.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eCPD -\u0026nbsp;\u003c/strong\u003econtinuing professional development\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Swedish Ethical Review Authority Dnr 2023-01378-02. All participants received written study information, completing and returning the questionnaire indicated tacit informed consent.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data presented, aggregated data, during the current study are available from the corresponding author upon reasonable request. Signing a data sharing agreement will be necessary. Individual data are unavailable due to General Data Protection Regulations (GDPR) and in accordance with the ethics application.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was funded by AFA insurance. Open access funding provided by University of Gavle\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThree of the authors (AB, ACW and ME) contributed to the conception and design of the study. Data collection was performed by AB and analyses by ME, AB and KM. All authors (AB, KM, ACW and ME) were substantially involved in interpretation of the results, drafting and revising the manuscript critically for important intellectual content. All authors (AB, KM, ACW and ME) have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work, ensuring that any questions related to accuracy or integrity are appropriately investigated and resolved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank all participating nurses at 1177 SHD and their managers for dedicating their time to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eORCID iDs:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAnnica Bj\u0026ouml;rkman - https://orcid.org/0000-0001-9513-3102\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMaria Engstr\u0026ouml;m https://orcid.org/0000-0002-9912-5350\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnna Carin Wahlberg https://orcid.org/0000-0002-0532-8721\u003c/p\u003e\n\u003cp\u003eKarin Myrberg https://orcid.org/0000-0002-7934-0109\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eHamukoto R, Ashipala DO, Muhora PN, Amadhila J, Hamukoto. 2025. 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The telephone nursing dialogue process: an integrative review. BMC Nurs. 2023;22(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSharkiya SH. Quality communication can improve patient-centred health outcomes among older patients: a rapid review. BMC Health Serv Res. 2023;23(1).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHakvoort L, Dikken J, Cramer-Kruit J, van Nieuwenhuyzen KM, van der Schaaf M, Schuurmans M. Factors that influence continuing professional development over a nursing career: A scoping review. Nurse Education in Practice. Volume 65. Elsevier Ltd; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThe Swedish Occupational. Register with occupational statistics. Uneven gender distribution in most major professions. 2023.\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-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Telenursing, nurses, continuous professional development, quality of working life, satisfaction with care, thriving, workforce sustainability","lastPublishedDoi":"10.21203/rs.3.rs-8831065/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8831065/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe nursing profession is continually adapting to changing population health needs and rapid medical advancements, underscoring the importance of ongoing competence development. Nurses have a professional responsibility to maintain updated knowledge; however, participation in continuing professional development (CPD) is often constrained by high workloads, staffing shortages, limited resources, and insufficient organizational support. Telenursing represents an expanding area of practice shaped by technological change and may require increased CPD to ensure safe and high-quality care. Despite this, previous research indicates that nurses in these services often work under demanding conditions and have restricted opportunities for professional development. Given the relevance of CPD for competence maintenance, well-being, and care quality, further evidence is needed regarding its availability, its association with work-related outcomes, and nurses\u0026rsquo; specific CPD needs.\u003c/p\u003e\u003ch2\u003eAim\u003c/h2\u003e \u003cp\u003eThe study aimed to compare nurse-rated quality of working life and satisfaction with given care among nurses who had participated in CPD during the previous year and those who had not. A further aim was to explore nurses\u0026rsquo; preferences and perceived needs related to CPD activities.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA cross-sectional survey was conducted among nurses in Sweden\u0026rsquo;s national healthcare advisory service (SHD 1177), involving participants from fourteen regions. Data were collected through a web-based questionnaire in autumn 2023. Of 465 invited nurses, 187 responded (40.2%). Quality of working life and satisfaction with given care were assessed using validated instruments. Access to CPD was measured with a single item, and CPD needs and preferences were collected through free-text responses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNurses with access to CPD reported significantly higher levels of emotional thriving compared with those without CPD. They also gave significantly higher ratings for \u0026lsquo;management and colleagues\u0026rsquo; and \u0026lsquo;growth opportunities\u0026rsquo;. No significant group differences emerged for satisfaction with given care. Desired CPD components included strengthened clinical knowledge, opportunities for reflective and self-directed learning, and improved communication skills.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eAccess to CPD was associated with more positive work-related outcomes, including higher thriving and stronger perceptions of managerial and collegial support. These findings highlight the importance of regular competence development to support sustainable telenursing services.\u003c/p\u003e","manuscriptTitle":"Access to Competence Development Among Nurses in Telenursing services: Does It Matter? – a comparative cross-sectional study with an embedded mixed-method approach","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-10 18:39:37","doi":"10.21203/rs.3.rs-8831065/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-27T16:52:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-01T23:59:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-20T08:01:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52930486999028287116857369171943534989","date":"2026-03-12T12:32:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"76526167084830669239292778373041496986","date":"2026-03-12T11:36:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-05T11:21:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-02-11T10:57:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-10T12:03:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-10T12:02:44+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nursing","date":"2026-02-09T13:20:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nursing","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurs","sideBox":"Learn more about [BMC Nursing](http://bmcnurs.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurs/default.aspx","title":"BMC Nursing","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"9510cb93-e47d-45ae-9aee-cb6689a18570","owner":[],"postedDate":"March 10th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T14:08:18+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-10 18:39:37","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8831065","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8831065","identity":"rs-8831065","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}