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Nursing Abroad: 10 Programs That Will Change Your Life and Career

Have you ever dreamed of traveling the world while pursuing your passion for nursing? If so, you are not alone. Many nursing students and professionals choose to study or work abroad to gain valuable skills, experience different cultures, and make a positive impact on global health. Nursing abroad can also boost your career prospects, as employers value nurses who have international exposure and cross-cultural competence. Whether you want to study, volunteer, or work as a nurse overseas, there is a program for you!

Introduction

Nursing is a noble and rewarding profession that allows you to make a positive difference in the lives of others. But did you know that nursing can also be an exciting and enriching way to explore the world? By participating in nursing abroad programs, you can gain valuable skills, experience different cultures, and broaden your horizons. In this article, we will introduce you to 10 of the best nursing abroad programs that will change your life and career for the better.

In this Article:

Why Study Nursing Abroad?

Studying nursing abroad can offer you many benefits, both personally and professionally. Here are some of the reasons why you should consider studying nursing abroad:

Enhance your resume: Studying nursing abroad can make you stand out from other candidates in the competitive job market. You can demonstrate your adaptability, flexibility, and cross-cultural competence to potential employers. You can also learn new techniques, methods, and best practices from other healthcare systems and professionals.

Expand your network: Studying nursing abroad can help you build connections with people from different backgrounds, perspectives, and fields. You can make friends with fellow students, mentors, teachers, and patients. You can also join professional associations and organizations that can support your career development and advancement.

Improve your language skills: Studying nursing abroad can improve your communication skills in another language. You can practice your listening, speaking, reading, and writing skills in a natural and immersive environment. You can also learn medical terminology and jargon that are specific to your field and location.

Discover new cultures: Studying nursing abroad can expose you to new cultures, traditions, values, and beliefs. You can learn about the history, geography, politics, and society of your host country. You can also experience the food, music, art, and festivals of your host culture.

Grow as a person: Studying nursing abroad can challenge you to step out of your comfort zone and overcome difficulties. You can develop your confidence, independence, resilience, and problem-solving skills. You can also discover more about yourself, your interests, your goals, and your values.

How to Choose a Nursing Abroad Program?

There are many factors to consider when choosing a nursing abroad program that suits your needs and preferences. Here are some of the questions you should ask yourself before applying:

What are your goals?:

Think about what you want to achieve from studying nursing abroad. Do you want to earn credits for your degree? Do you want to gain practical experience in a clinical setting? Do you want to conduct research or volunteer in a community project? Do you want to learn a new language or culture?

Where do you want to go?:

Think about where you want to study nursing abroad. Do you have a preference for a certain region, country, or city? Do you want to go somewhere that is similar or different from your home country? Do you want to go somewhere that has a high or low demand for nurses? Do you want to go somewhere that has a good or bad reputation for healthcare quality?

How long do you want to stay?

: Think about how long you want to study nursing abroad. Do you want to go for a semester, a year, or longer? Do you want to go for a short-term program during the summer or winter break? Do you want to go for a full-time or part-time program?

How much can you afford?:

Think about how much money you have or need to study nursing abroad. Do you have enough savings or income to cover the costs of tuition, fees, travel, accommodation, insurance, and living expenses? Do you qualify for any scholarships, grants, loans, or financial aid? Do you need to work or fundraise while studying abroad?

What are the requirements?:

Think about what requirements you need to meet for studying nursing abroad. Do you have the academic qualifications and grades to be accepted by your chosen program or university? Do you have the language proficiency and test scores to communicate effectively in your host country? Do you have the health clearance and vaccinations to travel safely and legally?

Ten programs that will reshape your life and career

Embarking on a journey as a nurse abroad can be a transformative venture, both professionally and personally. Here’s a comprehensive guide on ten programs that will reshape your life and career:

1. Volunteer Nursing Abroad Programs:

Programs like the one offered by African Impact are ideal for those seeking to volunteer as nurses abroad. Volunteers have commended the program for its eye-opening experiences in home-based care and the chance to aid those most in need in South Africa.

2. International Travel Nursing:

As an International Travel Nurse , you can traverse the globe, providing care to patients in various countries, especially where your skills are highly sought after. This profession allows you to work independently or even establish your practice in certain regions, offering a hands-on approach with diverse patient cases daily.

3. Advanced Nursing Education Abroad:

Earning a Doctor of Nursing Practice degree abroad can propel your career to new heights. With the right preparation, this path can offer remarkable rewards, as it equips you with the requisite education and experience to instigate changes in healthcare globally.

4. Overseas Nursing Degree Programs:

It’s feasible to pursue a nursing degree abroad, even if your ambition is to work in the US. However, it’s imperative to ensure that the overseas education is tantamount to a US nursing degree, which also necessitates passing the NCLEX exam, akin to US nursing graduates.

5. Building a Nursing Career Abroad:

Fostering a successful nursing career abroad requires meticulous preparation, dedication, and continuous learning. Upholding ethical and legal standards while interacting with patients, coworkers, and employers enhances treatment standards, making the experience professionally and personally rewarding.

6. Nursing Internships Abroad:

Engaging in international nursing internships can be a substantial step toward advancing your career while exploring different parts of the world.

7. Specialized Nursing Programs Abroad:

Some programs abroad offer specialized training in areas like pediatric nursing, oncology, or gerontology, providing a unique opportunity to hone skills in a specific field.

8. Cultural Competence Programs:

Programs focusing on cultural competence can be invaluable, aiding in understanding and respecting the diverse cultural backgrounds of patients.

9. Language Immersion Programs:

Language immersion programs for nurses can be beneficial, especially in regions where language barriers exist, ensuring effective communication with patients.

10. Global Health Initiatives:

Participating in global health initiatives as a nurse can provide a broader perspective on healthcare challenges and solutions worldwide.

Each of these programs or pathways offers a distinct set of experiences and learning opportunities, aiding in not only advancing your nursing career but also enriching your life on a personal level. Through these programs, nurses can develop a global perspective, acquire new skills, and contribute significantly to healthcare improvement worldwide.

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Nursing students intention to work abroad - a public health policy issue in Serbia: Milena Santric-Milicevic

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M Santric-Milicevic, B Matejic, Z Terzic, V Vasic, U Babic, Nursing students intention to work abroad - a public health policy issue in Serbia: Milena Santric-Milicevic, European Journal of Public Health , Volume 24, Issue suppl_2, October 2014, cku161–147, https://doi.org/10.1093/eurpub/cku161.147

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Out-migration of nurses from less developed countries continues to exacerbate. In a country with poor economy and limited job opportunities students’ out-migration is not commonly understood as a problem rather is perceived as a solution for high unemployment of young health professionals. Attainment of a health care system intermediate objectives and goals may be challenged by lasting nurse shortages and inequity in distribution of nursing care. Study objectives were to identify the prevalence of intention to work abroad, to point to the predictors of intention to work abroad and predictors of having a firm plan to leave and work in a foreign country. Total of 719 nurse students attending the final years of state college and specialist studies in school year 2012/2013 voluntarily completed the questionnaire designed with regard to similar surveys carried out in pre EU accession period in Poland. Data were analysed with descriptive and multivariate regression analyses. 69.7% (501) respondents have considered working abroad. Among them majority was college nurses (70%), average age 22 years, females (80%), single (93%), from urban residence, unemployed (80%), with no foreign country’ professional experience, but with a relative or friend abroad. Most respondents speak one foreign language and prefer to work abroad right upon graduation permanently or temporarily. A firm plan to work abroad already had 13% nurses. Single nurses and those friend or relative abroad were more likely to consider working abroad than their counterparts (Odds Ratios were 2.3 and 1.7 respectively). The likelihood to consider working abroad was decreasing by 29% with the improvement in financial situation. Having someone abroad was associated with 4.8 fold higher likelihood for having a firm plan to go. Also associated were previous professional experience in foreign country, and financial improvement (5.4- fold and 2-fold higher likelihood). Serbia has no explicit policy to address nurse out-migration nor nurse student’ intention to leave. The high prevalence of intention to work abroad suggests putting the issue of student’ out-migration on policy agenda. Factors associated to work abroad instead in country are relevant to be understood, analyzed and effectively addressed in a short- and long-term multidimensional approach (labor, education, socioeconomic and health policy).

Key messages

Students consider work abroad in need for better quality of life, better work conditions, and higher salaries. They are ready to leave alone and overcome language and administrative barriers.

Serbian managers’ myopia posees difficulties to plan and maintain “the right number of nurses with the right skills, in the right place at the right time, doing right things … at right costs”.

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Top 4 Reasons Nurses Should Explore Working Abroad

Blog   |  April 13, 2023 by 1NURSE

Working as a nurse is a challenging and rewarding career, and the opportunity to work abroad can add an extra dimension of excitement and growth. Whether you are a seasoned nurse or just starting out in your career, working abroad can provide new experiences, professional development opportunities, and a chance to expand your horizons. In this article, we will explore some of the reasons why nurses should consider working abroad, the benefits of doing so, and the steps you can take to make your dream of working abroad a reality.

Expand Professional Horizons

One of the primary reasons why nurses should consider working abroad is the opportunity to expand their professional horizons. Working in a foreign country allows you to gain exposure to new healthcare systems, technologies, and approaches to patient care. This exposure can help you to develop new skills and knowledge, making you a more well-rounded and versatile nurse. Additionally, working abroad can help you to develop a broader perspective on healthcare and the challenges faced by patients and healthcare providers globally.

Opportunity For Growth

Another reason why nurses should consider working abroad is the opportunity to grow personally and professionally. Working abroad can be a life-changing experience, exposing you to new cultures, languages, and ways of life. This exposure can help you to develop greater cultural awareness, a more global perspective, and a more open and tolerant outlook on life. Additionally, working abroad can provide opportunities for professional growth, allowing you to advance in your career and develop new skills and knowledge.

Financial Benefits

Working abroad also provides financial benefits. Nurses who work abroad often earn higher salaries than they would in their home country, and they also have the opportunity to save more money due to lower living expenses in some countries. Additionally, many countries offer attractive benefits packages, including health insurance, paid time off, and retirement plans, further increasing the financial benefits of working abroad.

Travel And Explore

For many nurses, the chance to travel and see the world is another compelling reason to work abroad. Whether you are interested in exploring exotic destinations or simply want to experience different cultures, working abroad can provide a unique opportunity to do so. You will have the chance to immerse yourself in a new country and culture, making friends, and building memories that will last a lifetime.

Making the decision to work abroad can seem daunting, but the process is much simpler than many nurses realize. The first step is to research the countries and healthcare systems that interest you, taking into account factors such as the language, culture, cost of living, and opportunities for professional development. Next, you will need to familiarize yourself with the immigration and work requirements for the country you have selected. Many countries have specific visa requirements for healthcare workers, and you will need to ensure that you meet these requirements before making your move.

Once you have completed your research, it is time to start the job search. There are many online resources that can help you to find job opportunities abroad, including job boards, staffing agencies, and professional organizations. You can also network with other nurses who have worked abroad, reaching out to nursing organizations, hospitals, and clinics for information and advice.

In conclusion, working abroad as a nurse is a unique and exciting opportunity that provides many benefits. From professional development and personal growth to financial benefits and the chance to travel, there are many reasons why nurses should consider exploring work abroad. With a little bit of research and preparation, you can turn your dream of working abroad into a reality and embark on an adventure that will change your life.

Connect with your co-nurses and nurse employers here

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Working overseas

This is a guide for RCN members considering working overseas - whether in paid employment or as a volunteer. It covers topics such as research, language, qualification and registration requirements, attending interviews and what to consider before accepting a job offer. 

Do your research 

Check with the  International Council for Nurses  (ICN) and the specific nurses' association in the country where you intend to work for information on the minimum requirements and regulatory framework in place.

Obtain background information on nursing and health care in overseas countries. Learn about the culture, religious beliefs and laws of the country that you are travelling to. This will help prepare you for differences of culture and legislation, minimising the risk of you running into difficulties during your stay.

If you're interested in working within the European Union or European Economic Area, go to  www.europa.eu  where you'll find information on living and working in the EU/EEA.  

Country profiles can also be found at the  Foreign, Commonwealth & Development Office  (FCDO) and the  World Health Organisation

Carry out a 'working overseas'  literature search  of the RCN's Library of eBooks and eJournals.

Communication plays a key role in the provision of health care. To effectively care for patients and practice safely, you should check if you need a basic knowledge of the language of the country where you will be working or if there will be an interpretation service available to you.

Some 'British' and 'American' hospitals abroad welcome applications for employment from UK-trained nurses and midwives. However, the working language of these hospitals is generally the language of the country in which they are located (except in the case of British Military hospitals which have their own nursing staff).

Qualifications and experience

The UK nursing qualification which is generally transferable in every other country is the 'Registered Nurse: Adult'. Not all countries have equivalents to the UK qualifications in mental health, learning disability, children’s nursing, health visiting and the enrolled nurse. If there is no equivalent to your nursing qualification in the country you would like to visit then you will not be able to work there as a qualified nurse. Please check the full qualification requirements for your chosen country with that country's regulatory body (see useful information below).

There is no formal mechanism for recognising UK post-registration qualifications such as, for example, intensive care nursing but employers may take them into account.

Overseas employers and recruitment companies will be specific about the experience and qualifications required for a particular role (whether paid employment or voluntary work).

The Nursing and Midwifery Council (NMC) has some really useful information on the portability of qualifications overseas, both inside the EU and outside the EU.

Many countries/employers have specific requirements around previous experience. For example, employers in the Middle East usually require at least two years’ post-registration experience for nursing roles. Voluntary Service Overseas (VSO) outline different experience requirements for a range of voluntary opportunities in health care - not all of which require NMC registration.

It is in your own best interests to gain at least six months to one year's experience in the UK after registration before working abroad as a nurse. It will be an opportunity to consolidate your pre-registration education, access preceptorship and make the transition from being a student to being a registered accountable practitioner. A prospective overseas employer will be able to request a reference relating to your ability as a qualified nurse. It will also be easier for you to provide references to overseas employers if you already have experience.

Professional registration

Most countries have their own nurse registration or licensing authorities. The NMC advises that you should always register with the appropriate regulator in the country in which you are practising.

European Union

Information about the impact of Brexit can be found on the NMC website .

Outside the EU

Nurse registration processes vary enormously from country to country and can be lengthy and time-consuming. The process may involve passing an examination or assessment, i.e. submitting an application including records of your nursing education and qualifications. For example, you will have to pass the English language proficiency test to register to work in Australia.

You may find that your nursing education does not fully meet the requirements of the nurse registration authority in the country where you wish to work. Making up this shortfall requires negotiation by an individual nurse with a UK university. These programmes are not universally available in all universities and courses may incur a fee. You would also normally be expected to complete the course in your own time, so use annual leave or negotiate unpaid leave for this.

Nurse registration authorities in other countries may require transcripts of your training and proof ('verification') of current NMC registration. Please contact the registering body directly for more information about their registration process. 

The NMC can provide verification of registration via NMC Online . If the verification requires translation you will be responsible for arranging this.  

In addition to your verification of registration, you may also need a transcript of your training. Please contact the organisation where you completed your training for this.

Finding a job

You can find vacancies through advertisements in nursing journals such as Nursing Standard and Nursing Times. These vacancies are placed by overseas employers or their recruiting agencies. Some countries regularly run recruitment events in the UK. To subscribe to the Nursing Standard log on to  www.nursing-standard.co.uk . 

Overseas employers or recruitment agents often have detailed procedures for processing your application, interviewing you and making arrangements for you to take up your post. It is still your responsibility to:

• find out all you need to know in order to decide whether you want the job
• assess whether you are competent to do it
• confirm that you meet the legal requirements involved such as work permits and registration as a nurse in the host country.

If you decide to send speculative letters enquiring about work overseas you will need to prepare a detailed  curriculum vitae (CV)  that can easily be understood by someone unfamiliar with UK nursing qualifications, scope of practice and abbreviations. Our careers service can only offer personalised feedback on CVs if you are planning on working in the UK.

Your covering letter will need to make it clear whether you need the employer to obtain a work permit on your behalf.

An interview for work abroad may be very different to interviews for work in your own country. A thorough interviewer will look for evidence that you have the personal qualities needed to cope with and successfully complete work in a foreign country, perhaps working in a foreign language. If the interview is successful, an informal job offer may be made to you. Responsible employers and recruiters will give you time to consider before making a definite commitment. The employment contract checklist below in this guide will help you to evaluate job offers and contracts of employment.

Take at least 24 hours to reflect on the offer before you accept it - take your time to research the country, check your contract and ensure that you are happy with the details.

Taxation and salary deductions

As taxation is a complicated matter you should seek professional advice about your obligations at home and abroad. Contact  Her Majesty's Revenue and Customs  for further information.

Please note: if you are not paying UK tax whilst abroad you cannot claim tax relief on your RCN subscription during this time.

Visas and work permits

You should always check visa requirements when planning to undertake work abroad. This is a complicated issue which varies from country to country. Further information can be found at  www.gov.uk/foreign-travel-advice .

Work permits are usually obtained by the employer from the immigration authorities of the host country. Where work permits are a requirement, you will be unable to take up paid employment in that country if you cannot find an employer who is able to obtain a work permit for you.

Employment contracts: a checklist

This checklist may help you evaluate the contents of any contract of employment (or contract for voluntary work) before committing yourself. You must also ensure that any agreements made between you and the prospective employer/recruiter are confirmed in writing.

• Never sign a contract until all the blank spaces have been completed.
• Never sign a contract that is in a foreign language that you do not understand.
• Never place any reliance on verbal promises. How would you be able to prove the commitment later?
• Always ask for copies of any documents referred to within the contract and ensure that you understand these before agreeing.

1. Pre-employment agreement

You may be asked to sign a document which covers the period between accepting the job offer in the UK and taking up employment in the host country. It may commit the employer or recruiter to providing a language or examination revision course, facilitating your application to take an examination, or even paying for you to fly abroad to take the examination. In addition, it usually includes details of any financial penalty you would incur if you withdrew your application.

Think carefully before you commit yourself, as it may be expensive to change your mind later. Be clear about the kind of post you would be willing to accept and the length of time you are willing to wait for a placement. Please ensure that all of this information is contained within the pre-employment agreement.

2. Job description

The job description should be detailed enough to give you a good idea of what the job involves.

Your nursing education and experience to date should have provided you with the necessary knowledge to undertake the role. If not, will this be covered in any orientation/induction programme?

3. Orientation/induction programme

This is a crucial part of any overseas post and should include information about the new workplace, the whole health care system and nursing practices within the country.

You should ask for written confirmation of the following:

• How long will the induction last?
• Does it include training in tasks which you may not have done before?
• Will you be on full pay during the programme and is the programme included in the time period of your contract.

4. Probationary period

• Is there a probationary period?
• What support will you get?
• How do the termination of contract arrangements differ during this period?
• Does the employer have the right to terminate the contract without any reason and with immediate effect during this time? If so, would you still be entitled to benefits such as a paid flight home?

5. Premature termination of the contract

• If you terminate your contract early then you may face a penalty such as having to pay for your own flight home or having to reimburse the employer/recruiter for your outward airfare. Under these circumstances, would your employer give you a reference and would you be given a copy of the reference for your records?
• Does the contract state the nursing specialty and site you will be working in?
• Does the contract allow the employer to change this without your agreement? Could you be required to work for the employer in any part of the host country?

7. Salaries (if applicable)

• Will you be paid the same salary as a nurse originating from the host country?
• Is the salary you have been offered on a scale or is it a fixed salary?
• What will your net salary be?
• Where will the salary be paid - in the UK, host country or part in both? If you intend to send money back to the UK on a regular basis e.g. to meet mortgage repayments, remember that currency fluctuations could affect the amount of sterling you receive.

8. Hours of work and overtime

• The exact hours of work should be written into your contract. The working week is longer than 37.5 hours in many countries.
• Does the contract state that you may be asked to do overtime?
• What shift pattern will you work and does it include breaks?

9. Annual leave and time off

• Annual leave entitlement varies widely from country to country and may be much less than you have been used to. Public holidays may or may not be included
• Will you be allowed to take your annual leave when you want, or do you have to take it after a waiting period (common in Australia) or at the end of your contract? Are you entitled to emergency or compassionate leave?

10. Length of contract

• The commencement and termination date should be clearly stated on the contract. If you are signing a standard contract for permanent employment used by the host country employer, there may be no termination date. In this situation the termination date of your work permit would apply.
• Is there a possibility of renewing the contract if both sides wish to do this? Would this involve a change of work permit? Would an increase of salary be offered?

11. Health care and health insurance

• Does the employer/recruiter provide you with private health insurance as part of the employment package? If not, will you be required to arrange your own? How much does this cost?
• Is a UK passport holder entitled to use the public health service on the same terms as residents of the country?
• Does your health insurance cover the cost of repatriating you to the UK if necessary and who decides whether this is necessary?
• Consider taking out personal injury accident insurance subject to the conditions of cover being applicable to your working situation.

12. Professional indemnity

Members who undertake overseas work should ensure that they have adequate indemnity and insurance cover. 

Please see our Indemnity scheme terms and conditions  for more information. 

The RCN scheme does cover the overseas work of volunteers in certain countries to the extent that a clinical negligence claim might be brought against them.

However, there are other considerations about how a volunteer is supported, particularly if working in a dangerous environment. Any member considering volunteering should give careful thought as to what will happen if they need support with their own health whilst overseas, for example. Volunteers can be given support from organisations that arrange volunteer activity.

If you are involved in an incident overseas that you think might lead to a patient or colleague making a claim against you, you must contact us as soon as possible. You must never admit responsibility for an incident or submit a written statement about it until we have agreed for you to do so.

13. Other considerations:

You should also check your contract for the following:

• sickness policy and entitlement
• grievance/disciplinary procedures and trade union representation
• language training
• accommodation
• transportation for work
• responsibility of costs of the return airfare from the UK to the host country
• overseas employment contracts are usually interpreted according to the laws of the host country

Finally, look into the cost of living in that country and the  laws of the host country beforehand.

Joining a union and/or nursing association

The RCN is not a trade union outside of the UK, Channel Islands and Isle of Man and we do not have representatives in other countries. Although we may be able to provide general advice to help you deal with an employment problem we are unable to offer formal advice or representation for matters arising in your host country. Please note UK law is applicable in the UK only and you will be bound by the laws of your chosen country.

We strongly recommend   that you join a trade union or professional association as soon as you arrive in your chosen country just in case you require employment relations or legal advice. Employees of the UK armed forces are not permitted to join a trade union but may join a professional association such as the RCN.

Contact details of national nurses' associations which are members of the International Council (ICN) can be obtained from the  ICN website .

If you choose not to become a member of a trade union or professional association and you subsequently need legal or employment relations support you should contact the national nurses' association of that country. They may be able to help or recommend an organisation that can. Please be aware that not all organisations will be able to provide advice and support if you were not in membership at the time of the incident for which you require support.

The RCN is able to offer support to members working for Soldiers, Sailors, Airmen and Families Association (SSAFA) working within military establishments in Europe. SSAFA recognises the RCN as a trade union. If you require employment advice, please contact us.

If you wish to maintain your RCN membership you will continue to have access to number of member benefits, for example:

The best method of paying your RCN subscription while abroad is via direct debit from your UK bank account. You can also make an annual payment by credit card.

Personal safety and wellbeing

More information is available in our Wellbeing, Self Care and Resilience subject guide and on our Health, safety and wellbeing  page. 

If you are currently taking any medication it is useful to check the government website for information on what you need to do when abroad .

Ensure that you are following the guidance in relation to COVID-19 – both in the country you are travelling to and upon your return to the UK. Guidance in this area often changes at short notice so it is important update yourself regularly.

Conflict zones

Conditions may be physically stressful and emotionally overwhelming. Expect long working days, the strain of working with people who are traumatized, and insufficient supplies. Make sure you are taking care of your emotional and physical health too.

Ukraine crisis

The best way to support ukrainians.

The best way to help Ukrainians is to donate directly to credible international and Ukrainian organisations that are working around the clock to help those displaced by the conflict. For primary care professionals looking at how to meet the health needs of patients from Ukraine, we recommend reading Arrivals from Ukraine: advice for primary care .

Managing stress during the crisis

As a health care professional, you may already experience burnout from COVID-19 and the demands a two-year-long pandemic has placed on you, your family, and your colleagues. It's tempting to "doomscroll" through bad news or feel guilty about working in relative comfort while nursing colleagues and civilians in Ukraine are suffering.

Instead, focus on what you can do. For example, donating now or in the future. Remember, that you can help spread the word and encourage others to donate time or money in support of Ukraine. Above all, take care of yourself so that you can continue taking care of others.

Volunteering in Ukraine

There are currently limited options for volunteering in Ukraine. There are some organisations in surrounding countries where you may find options. You may also want to investigate what your employer is doing.

Please be sure to reach out to these organisations directly to get the most up-to-date information on volunteering before you decide to travel. 

Be sure to verify any organisation, especially ones you aren't already familiar with. Unfortunately, while human suffering like the humanitarian crisis in Ukraine can elicit profound compassion and the desire to help, it also attracts scammers who prey on this.

The FCDO advise against all travel to Ukraine. For up-to-date information please visit the FCDO website .

NMC revalidation and working overseas

 Revalidation with the NMC applies to all nurses and midwives, regardless of the role or sector in which they are operating and across all fields of practice.

If you are a nurse or midwife practising overseas and want to maintain your UK registration, you will have to comply with the revalidation process  every three years and continue to pay your annual retention fee to the NMC. 

If you are working overseas (or have worked overseas for part of your three year renewal period) as a nurse or midwife you can meet the practice hours on the basis of your registration with the NMC. The NMC advises that you should always register with the appropriate regulator in the country in which you are practising.

If you work wholly overseas you can seek confirmation from your line manager where you undertake your work. If you do not have a line manager, you will need to decide who is best placed to provide your confirmation. The NMC advises that wherever possible your confirmer is a nurse or midwife regulated where you practise, or another regulated healthcare professional. The  NMC online confirmation tool  provides further guidance about who can act as your confirmer.

If you are asked to provide ‘verification’ information to support your revalidation application, in relation to practice hours you need to provide information about whether you are registered with the appropriate regulating body.

It is important that the NMC has an up to date address for you and you should  register with NMC online  to ensure that you know your revalidation date and that the NMC can send you relevant information.

More information is available from the NMC on ' How to revalidate '.

Pensions and wills

Nurses in the NHS pension scheme who leave the scheme may have their pension benefits frozen. If you are moving to a new non-NHS employer, whether in the UK or abroad, you should seek independent advice as to whether you are able to transfer your membership into your new employer’s scheme.

Contact the relevant NHS pension agency for further details about the options available as follows:

England and Wales: NHS Business Services Authority  www.nhsbsa.nhs.uk

Northern Ireland: Health and Social Care Northern Ireland  www.hscni.net

Scotland: Scottish Public Pensions Agency  www.sppa.gov.uk

For further information, or if you have a non-NHS pension please go to:

The Pension Service

Money and Pensions Service

The Pensions Regulator

Quilter Financial Advisers can provide free financial advice to members planning employment abroad. This is particularly useful if you have financial commitments in the UK such as a mortgage, pension, savings plan etc.

It is a good idea to make a will particularly if you have dependants and financial commitments. The legal situation is very complicated if a person dies overseas without having made a will. You could take advantage of the RCN’s will writing service. For further information, please see our will writing  page.

Returning to the UK

Your nursing career is a long-term investment. We recommend that you plan your return to practice in the UK before you leave. You will need to consider how to present your overseas experience in a positive light to UK employers and to demonstrate that you are broadly in touch with general developments in nursing and health care in the UK. The RCN has a number of resources which may help you when you return to the UK. These include:

• RCN careers service **
• RCN jobs bulletin
• The Nursing Standard
• RCN Agenda for Change advice guide
• RCN Contract advice guide

Add any qualifications you have obtained overseas both to your CV and your personal professional portfolio. If you have completed education equivalent to a qualification for another part of the register (for example, as a midwife) you may apply to the NMC to have the qualification registered. Your application may be assessed through the 'overseas' route and compared to the UK course and you might be required to undertake supplementary training in the UK. When you return to the UK and are planning further study, you may be able to obtain credit for this study through schemes such as Assessment of Prior Learning (APL) and Assessment of Prior Experiential Learning (APEL). General information concerning APL/APEL is available from  UCAS .

The NMC is not involved with recognition of academic qualifications such as first or higher degrees. You can check the comparability of degrees obtained overseas with UK ENIC - the UK National Information Centre for the recognition and evaluation of international qualifications and skills.

**Please note: the Careers service can only check CVs for members working within the UK and are unable to provide advice about working overseas.

Useful contacts for popular destinations

The NMC have published some guidance regarding nurses who are or who may want to work in the EU following Brexit.

You can contact these organisations directly for advice:

Working outside the EU

Australian Nursing & Midwifery Council

Australian Nursing Council

Australian High Commission

British High Commission Canberra

Ministry of Health

Bahrain Embassy

British Embassy Bahrain

Canadian Nurses Association

Canadian High Commission

British High Commission

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Embassy of the United States

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Global Health

The u.s. is hiring nurses from abroad, depleting some countries' health care systems.

Adrian Florido

Ashish Valentine

Amy Isackson

NPR's Adrian Florido chats with New York Times reporter Stephanie Nolen about how U.S. hospitals are relying on global recruitment to address staff shortages.

Copyright © 2022 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by an NPR contractor. This text may not be in its final form and may be updated or revised in the future. Accuracy and availability may vary. The authoritative record of NPR’s programming is the audio record.

What to Know About Working as an International Travel Nurse

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• International Travel Nursing Explained
• Global Demand
• International Travel Nurse Salary
• International Travel Nurse Benefits
• How To Become

Are you ready to earn your online nursing degree?

As countries across the world experience nursing shortages, international nursing job opportunities will continue to expand. According to The World Health Organization (WHO), one in eight nurses finds employment in a country other than the one where they were born or received training. The field of international travel nursing provides opportunities for nurses to see the world while using their training to help others.

If you are a current or aspiring nurse, international travel nursing can offer you competitive salaries and benefits working in a variety of clinical experiences with diverse populations. Learn more about international travel nursing, how to prepare for and find jobs, and what countries offer the highest pay.

International Travel Nursing At a Glance

What Is International Travel Nursing?

Registered nurses (RNs) from various clinical backgrounds and specialties can find well-paid positions as international travel nurses in settings throughout the world. Rather than apply directly to overseas medical facilities, they find placements by working with recruiters from independent staffing agencies.

The recruiter finds the best placement based on skills, prior work experience, and preferred destinations. Once the nurse agrees to commit to the placement, the agency arranges the salary and benefits package. Depending on the contract, benefits include housing stipends, direct deposit and currency transfer fees, referral bonuses, meal or travel reimbursements, and paid time off.

While travel nurses working in the U.S. usually take assignments that last six months or less, international travel nursing jobs require longer commitments. International nursing jobs in Europe and Australia require nurses to work at least a year. Nurses placed in Middle Eastern countries often take contracts that last a minimum of two years.

Several organizations, including the Red Cross, United Planet, Project Hope, and International Volunteer HQ, offer volunteer opportunities in international nursing . While these travel nurses do not earn a salary, they gain valuable experience while providing essential healthcare services to people who may not otherwise have access. These international nursing volunteers take on crucial roles during public health emergencies and natural disasters as part of medical relief teams.

The duties of an international travel nurse are as varied as the destinations where they work. They provide services to patient populations from infancy through old age. Depending on the setting, they may have the same responsibilities as American RNs e.g., performing tests, administering medications and vaccinations, monitoring vital signs, and compiling reports.

Because international nurses work in an array of environments, from well-equipped modern hospital facilities to rudimentary clinics in underserved, remote communities, their responsibilities depend on the needs of the patients in these settings. Those who work in emergency or epidemic situations must adjust to rapidly changing and stressful conditions.

Work Environment

International travel nurses will find employment anywhere experiencing nursing shortages. These nurses work in urban and rural areas, in hospitals, doctors’ offices, outpatient care centers, and community clinics. Nurses with surgical, intensive care, emergency room, and labor and delivery specialties are in particularly high demand. Staffing agencies work with nurses to find placements that best fit their training and interests.

Which Countries Need International Travel Nurses?

Nursing shortages are a global phenomenon. According to the WHO’s 2020 State of the World’s Nursing Report , nurses make up the largest occupational group in the healthcare industry, accounting for 59% of all health professionals. The global nursing shortfall had grown to almost six million, even before the onset of the COVID-19 pandemic. These shortages have been driven by several trends, including the decline in the number of nurses entering the profession, retirements, and increasing demands for healthcare from the growing world population.

The opportunities for U.S. trained nurses to work overseas have never been better. International nursing jobs run the gamut from well-paying clinical positions at state-of-the-art facilities in modern urban areas to remote clinics or refugee camps in developing nations.

Low and lower middle-income countries in Africa, Southeast Asia, the Eastern Mediterranean region, and parts of Latin America experience the most severe nursing shortages. Among the more affluent nations, the United Kingdom, Canada, Australia, New Zealand, and the United Arab Emirates face the highest need for nurses.

How Much Do International Travel Nurses Make?

While international travel nurses typically earn more than full-time RN staff, salary ranges vary significantly based on education and skill levels, specialties, years of experience, and placement location. According to the online employment service ZipRecruiter , the majority of international travel nurses earn between $60,500 and $106,000. Each travel nurse agency handles compensation differently. Some offer housing and travel benefits as part of the contract while others provide nurses with stipends to make their own arrangements.

RNs should consider several factors when searching for international travel nurse jobs. While some countries may not match U.S. salary levels, they offer a lower cost of living, making essentials like housing, food, and utilities more affordable. Middle Eastern nations like Saudi Arabia and the United Arab Emirates offer the most attractive compensation packages that include tax-free salaries, free air travel, free furnished housing, and 30-day annual vacations.

The Benefits of Becoming an International Travel Nurse

RNs choose international travel nursing for several reasons, including the chance to travel the world, earn top salaries, expand their careers, or serve others in high-need regions. International travel nurses often cite these professional and personal benefits:

How To Become an International Travel Nurse

International travel nurses follow the same educational pathway as nurses preparing for careers as staff RNs in the U.S. Although each country or employer may have specific requirements for a preferred degree, specialty area, and years of experience, travel agencies typically recruit nurses who hold an undergraduate nursing degree and have passed the NCLEX-RN examination.

While licensed practical nurses and RNs with an associate degree may find international positions, most travel agencies represent overseas employers who strongly prefer BSN degree-holders with a valid RN license. Nurses should also have certification in Basic Life Support and Advanced Cardiac Life Support. Most agencies require applicants who have completed at least one year of clinical experience .

While not required for all international nursing jobs, specialized certifications in high-demand areas such as labor and delivery, intensive care, and emergency medicine may lead to better-paid placements.

Working as an International Travel Nurse

​​In addition to completing a nursing degree and obtaining a valid RN license, international travel nurses will need to acquire additional credentials to work abroad.

Nurses need to have a valid passport and work with their travel agency to find out about work permits, visas, and other forms of sponsorship required by the country where they intend to work. Overseas employers may request birth certificates, immunization records, criminal background checks, and transcripts that verify educational qualifications. Gathering the necessary documentation may take several months.

Nurses must have a basic knowledge of a country’s language to provide patient care and communicate with staff. Most placements require international travel nurses to demonstrate a working knowledge or conversational ability in the country’s primary language.

Some employers may require nurses to take a test to verify their language ability. Many English-speaking countries like Canada and the United Kingdom require work visa applicants to take an English-language test to demonstrate their fluency, even if English is their native tongue.

English-speaking travel nurses sometimes get around the language barriers by restricting their employment choices to English-speaking countries or international healthcare organizations that have adopted English as their official language. Certain facilities in the Middle East, for example, require English as the work language for all staff and for all medical documentation.

International travel nursing jobs can offer tremendous personal, professional, and financial rewards, but the process requires research and planning. The most successful international travel nurses have invested the time to learn as much as possible about qualifications, how to choose a travel agency, and what to expect when working abroad.

Reviewed by:

Brandy Gleason, MSN, MHA, BC-NC, is a nursing professional with nearly 20 years of varied nursing experience. Gleason currently teaches as an assistant professor of nursing within a prelicensure nursing program and coaches graduate students. Her passion and area of research centers around coaching nurses and nursing students to build resilience and avoid burnout.

Gleason is a paid member of our Healthcare Review Partner Network. Learn more about our review partners here .

Page last reviewed November 8, 2021

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• Open access
• Published: 27 September 2024

Patient mistreatment, emotional exhaustion and work-family conflict among nurses: a moderated mediation model of social sharing of negative work events and perceived organizational support

• Wei Yan 1 ,
• Zeqing Cheng 1 ,
• Di Xiao 2 ,
• Huan Wang 3 , 4 ,
• Li Li 6 &
• Caiping Song 7  

BMC Medical Education volume  24 , Article number:  1041 ( 2024 ) Cite this article

Metrics details

Nursing literature suggested that patient mistreatment has significant impacts on nurses’ emotions and job burnout. Yet, further research is needed to understand the underlying mechanism and the spillover effect on nurses’ families. Leveraging the goal progress theory, this study aimed to examine the association between patient mistreatment, nurses’ emotional exhaustion, and work-family conflict, as well as the mediating role of social sharing of negative work events and the moderating role of perceived organizational support.

During the COVID-19 pandemic in China, a cross-sectional study was conducted with a sample of 1627 nurses from the Hematology Specialist Alliance of Chongqing from October to November 2022. Questionnaires were administered to measure patient mistreatment, perceived organizational support, social sharing of negative work events, emotional exhaustion, and work-family conflict. Hierarchical linear regression and conditional processes were used for statistical analyses.

Patient mistreatment was positively associated with emotional exhaustion ( β  = 0.354, p  < 0.001) and work-family conflict ( β  = 0.314, p  < 0.001). Social sharing of negative work events played a partial mediating role in the relationship between patient mistreatment and emotional exhaustion (effect = 0.067, SE = 0.013), and work-family conflict (effect = 0.077, SE = 0.014). Moderated mediation analysis found that the mediation effect was stronger when the perceived organizational support was high.

Our findings reveal the amplifying effect of social sharing of negative work events on nurses’ emotional exhaustion and work-family conflict. Perceived organizational support strengthens the positive effect of patient mistreatment on the social sharing of negative work events, thus resulting in increased emotional exhaustion and work-family conflict. We also discuss practical implications, limitations, and directions for future research.

Peer Review reports

Introduction

With the outbreak of COVID-19, workplace violence in medical organizations have intensified, putting tremendous pressure on healthcare workers [ 1 , 2 ]. A survey of 522 Chinese nurses found that 55% of respondents had experienced workplace violence in the past 12 months, including verbal and physical aggression [ 3 ]. Workplace violence directly affected nurses’ job performance and organizational citizenship behavior [ 4 , 5 ], reduced their quality of life [ 6 ], and increased their psychological distress and turnover intention [ 7 , 8 ]. Among these, the behavior of patients and their families abusing nurses through insults, unreasonable demands, or physical attacks was described as patient mistreatment [ 9 ]. Previous research has confirmed that when nurses were mistreated by patients, they may experience persistent work meaninglessness, emotional exhaustion and depression [ 10 , 11 , 12 ], which further predicted their career withdrawal behavior and turnover intention [ 12 ].

Additionally, the negative impact of experiencing abuse from service users may spread from service providers to their families [ 13 ]. Research on customer mistreatment has shown that abusive stress events encountered by front-line service providers in the workplace can detrimentally affect their role performance in the family domain [ 14 ], consume additional resources, and lead to work-family conflict [ 15 ].

Some studies indicate that after experiencing negative events, individuals tend to share negative events with their families or friends to alleviate negative emotions [ 16 , 17 ]. However, whether social sharing of negative work events can attenuate emotional exhaustion and reduce work-family conflict remains undetermined [ 18 ]. In this study, we examine the mediating effect of social sharing of negative work events between patient mistreatment and emotional exhaustion and work-family conflict.

One common solution for employees to address workplace violence was to seek organizational support [ 19 , 20 ]. However, evidence from several studies suggested that organizational support didn’t mitigate the relationship between workplace violence and stress [ 21 , 22 , 23 ], suggesting that the benefit of organizational support is controversial. Thus, this study explores the moderating role of perceived organizational support (POS) in the effect of patient mistreatment on emotional exhaustion and work-family conflict via social sharing of negative work events.

It can be observed that existing literature on the functional mechanism of patient mistreatment and its spillover impact on nurses’ family domain remains rare and far from unanimous. Therefore, this study establishes and tests a theoretical model of the effects of patient mistreatment on nurses’ emotional exhaustion and work-family conflict and explores the underlying mechanism and boundary condition of this relationship. To be more specific, we aim to answer the following questions: Does patient mistreatment increase nurses’ emotional exhaustion and work-family conflict through social sharing of negative work events? Could perceived organizational support intensify the mediating effect of social sharing of negative work events?

Patient mistreatment, emotional exhaustion and work-family conflict

Similar to customer mistreatment, patient mistreatment occurs when nurses experience unfair interpersonal treatment from patients and their families, such as various forms of verbal attacks, including anger, cursing, shouting, and rudeness [ 24 , 25 ]. Patient mistreatment adversely affects the quality of medical service and work performance of nurses, and imposes threats to their mental health. Previous studies have shown that employees exhibit negative emotions such as emotional dysregulation, declining morale, and post-traumatic stress disorder [ 7 , 18 , 26 ] when frequently or intensely exposed to interpersonal mistreatment. Negative job attitudes predict subsequent burnout, withdrawal, and service-destroying behaviors [ 27 , 28 , 29 , 30 ]. Drawing on the goal progress theory [ 31 ], we argue that patient mistreatment interrupts the service achievement process, and the failure of achieving service goals triggers a constantly cognitive rumination process that could result in continuous emotional exhaustion [ 32 , 33 , 34 ]. Research has also shown that individuals who experience customer abuse in the workplace may transfer their negative emotions to family members [ 14 ]. This causes the harmful effects of customer mistreatment to spread throughout the area of employees’ family life [ 35 ]. Hence, it can be expected that:

Patient mistreatment is positively correlated with emotional exhaustion.

Patient mistreatment is positively correlated with work-family conflict.

Patient mistreatment and social sharing of negative work events

Empirical evidence showed that individuals tend to share negative experiences with peers and friends in search of emotional support and to reduce burnout [ 18 , 36 ], which may occur from a few hours to several months after the event. This kind of sharing of negative sentiments in a relatively trusted environment can be generalized as social sharing of negative work events [ 18 ]. The more frequently nurses experience mistreatment, the stronger their intentions of social sharing will grow. Accordingly, we propose the following hypothesis:

Patient mistreatment is positively correlated with social sharing of negative work events.

The mediating role of social sharing of negative work events

Social sharing involves confronting negative emotions and expressing them verbally in a safe environment [ 37 ]. However, social sharing of negative work events may be a maladaptive coping strategy that employees adopt when facing patient mistreatment, falling under the domain of social cognitive rumination [ 18 , 38 ]. According to the goal progress theory, social sharing further promotes repetitive discussions or rehearsals of negative events [ 39 ]. It can engulf nurses in work rumination, affecting their subsequent work engagement [ 40 ]. Employees who are deeply immersed in negative work events for a long time may find it difficult to detach themselves from work and are unable to address the emotional needs generated by rumination [ 41 ]. Jeon (2021) also found that emotional rumination caused by work communication resulted in more emotional exhaustion [ 42 ]. Huang (2022) demonstrated that when peers engage in co-rumination due to negative events, it exacerbated working pressure, negative moods and psychological problems [ 43 ]. We believe that sharing negative events within a social context leads to a more negative view of patient mistreatment, thus aggravating emotional exhaustion after work [ 44 ] and causing further depletion of nurses’ cognitive and emotional resources [ 45 ].

Additionally, when employees focus on negative work events for extended periods, they invest a significant amount of time and energy into uncompleted work goals, thereby disrupting the time that could be allocated to family activities, often leading to disappointment and frustration for both employees and their families [ 46 , 47 ]. It is documented that individuals subjected to severe customer mistreatment have fewer resources available to meet family needs, thereby increasing work-family conflict (WFC) [ 48 ]. The repetitive thinking triggered by negative work events makes it difficult for individuals to sufficiently engage in family roles, thus resulting in negative emotions spilling over from workplace into family life [ 14 , 49 , 50 , 51 , 52 ]. Park and Kim (2019) also articulated that the harmful effects of customer mistreatment extended into the personal life domain [ 35 ]. Thus, we propose the following hypotheses:

Social sharing of negative work events plays a mediating role between patient mistreatment and emotional exhaustion.

Social sharing of negative work events plays a mediating role between patient mistreatment and work-family conflict.

The moderating role of perceived organizational support

Perceived organizational support refers to the overall perception of employees regarding the organization’s willingness to help them, value their contributions, and care about their overall well-being [ 53 ]. It is commonly believed to be helpful in dealing with the problems such as work frustration and burnout [ 54 , 55 ]. POS meets the socio-emotional needs of respect, belonging, emotional support and recognition in the workplace [ 56 ], providing a safer and more trusted environment in which employees are more likely to share negative events with colleagues or peers [ 57 ]. We propose that:

H4. Perceived organizational support moderates the relationship between patient mistreatment and social sharing of negative work events, and this positive relationship is stronger when perceived organizational support is high (vs. low).

As elaborated in H3, patient mistreatment could be perceived by nurses as a failure of personal service goals, indicating that nurses have not successfully fulfilled their obligations and job requirements. This brings huge psychological and role pressure [ 58 , 59 , 60 ]. Perceived stress leads to negative emotional focus and cognitive rumination, which manifests as recursive thinking and sharing of negative work events, thus triggering job burnout [ 61 ]. Combining Hypotheses 1, 2, 3a, 3b and 4, we propose that the mediating effect of social sharing of negative work events will be moderated by perceived organizational support:

H5a . Perceived organizational support moderates the indirect influence of.

patient mistreatment on emotional exhaustion through social sharing of negative work events, and the indirect influence is stronger when the level of perceived organizational support is high (vs. low).

H5b. Perceived organizational support moderates the indirect influence of.

patient mistreatment on work-family conflict through social sharing of negative work events, and the indirect influence is stronger when the level of perceived organizational support is high (vs. low).

We summarize our conceptual model in Fig.  1 .

Conceptual model

Study design and setting

This study exploited a cross-sectional design to investigate the relationship between patient mistreatment, emotional exhaustion, and work-family conflict among Chinese nurses during the COVID-19 pandemic after the lockdown was imposed in mainland China. During the pandemic, our participants performed heavy work tasks and experienced psychological stress.

Participants and data collection

Collaborating with the Chongqing Hematology Specialist Alliance, we initiated a call for research on patient mistreatment and obtained a convenient sample. Clinical nurses were invited to participate in the survey through one-to-one contact. The inclusion criteria were as follows: (1) possession of a nursing practice license; (2) working as a clinical nurse; and (3) informed consent and voluntary participation. The exclusion criteria were as follows: (1) nurses with further education; (2) interns; (3) trainees; and (4) off-duty nurses (on leave, sick leave, or out for studying). To prevent COVID-19 risk, we used an online electronic questionnaire for ease of operation.

A small-scale pilot survey was conducted before the formal survey to ensure the rationality of questions and the accuracy of expressions. An anonymous cross-sectional online survey was conducted via the questionnaire website of Wenjuanxing (link: https://www.wjx.cn/ ) from October 9 to November 1, 2022. Finally, we obtained a sample of 1627 valid responses.

The measurement used was originally published in English; therefore, we adopted Brislin’s (1986) suggestion and translated the scale forward and backward to ensure Chinese equivalence and prevent semantic bias problems [ 62 ].

• Patient mistreatment

We measured patient mistreatment using the 18 items developed by Wang et al. (2011) [ 63 ]. Some minor modifications were made to suit the hospital environment since the original scale was designed to assess customer mistreatment. Sample items included “Patients demanded special treatment” and “Patients took their bad temper out on you”. The respondents reported the frequency with which they had experienced mistreatment from their patients within the last three months. Each item was measured on a 5-point Likert scale (“0” = never and “4” = all of the time). The alpha coefficient was 0.95.

• Social sharing of negative work events

We used the four items developed by Baranik et al. (2017) to capture the social sharing of negative work events [ 18 ]. Participants were asked how frequently they had talked about unpleasant things that had occurred at work in the past month with their lovers, family members, friends, and coworkers. Responses were recorded on a five-point scale (“0” = never and “4” = often). The Cronbach’s alpha coefficient was 0.86.

• Emotional exhaustion

Emotional exhaustion was measured using the emotional exhaustion component of Maslach et al.‘s (2001) MBI scale [ 64 ], which consisted of nine items. Sample items included “I feel emotionally drained from my work.” Responses were made on a seven-point scale (“1” = never and “7” = every day). The alpha coefficient for this scale was 0.93.

• Work-family conflict

Work-family conflict was measured using the five-item subscale of Netemeyer et al.’s (1996) [ 46 ]. A sample item is “The stress of my job makes it difficult for me to meet my family responsibilities.” Participants indicated their agreement with the items on a 7-point Likert scale (“1” = strongly disagree and “7” = strongly agree). The alpha coefficient for this scale was 0.94.

• Perceived organizational support

We used the eight items developed by Shen and Benson (2016) to measure perceived organizational support [ 65 ]. Sample items included “My organization values my contributions to the organization” and “The organization really cares about my health and welfare.” Responses were recorded on a seven-point Likert scale (“0” = strongly disagree and “6” = strongly agree). The alpha coefficient for the entire scale was 0.90.

Control variables

Following previous studies [ 19 , 20 ], we controlled for nurses’ gender, age, education, working years and position, all of which have been shown to possibly correlate with emotion exhaustion and work-family conflict. In addition, we controlled for marital status and children, two variables that may have an impact on work-family conflict [ 66 , 67 ].

Statistical analysis

We used SPSS 25.0, Amos 23.0 and Mplus 8.5 for data analysis. Descriptive statistics were used to present the demographic characteristics of the sample. Pearson correlation analysis was used to explore the correlations among patient mistreatment, social sharing of negative work events, perceived organizational support, emotional exhaustion, and work-family conflict. Harman’s single factor analysis and the confirmatory factor analysis were used to investigate the common methods variance (CMV). In addition, we tested the hypotheses using hierarchical regression analysis, bootstrapping tests, and conditional process analysis (specifically, moderated mediation in this study).

Characteristics of participants

The demographic characteristics of the participants are presented in Table  1 . A total of 1627 nurses participated in the study, with a mean age of 31.3 years (SD = 6.0). Among them, 94.7% were female and 5.3% were male. The average number of working years was 9.3 (SD = 6.4). Most participants were married (62.6%) and had undergraduate degree (89.7%). 76.8% of participants were primary nurses. More than half of the participants had children (56.5%).

Correlations among variables

Table  2 presents the means, standard deviations, and correlations of all the measured variables. First, the results indicated that patient mistreatment was positively correlated with social sharing of negative work events ( r  = 0.198, p  < 0.01), emotional exhaustion ( r  = 0.361, p  < 0.01) and work-family conflict ( r  = 0.316, p  < 0.01), and negatively correlated with perceived organizational support ( r =-0.319, p  < 0.01). Furthermore, social sharing of negative work events, emotional exhaustion, and work-family conflict were all negatively correlated with perceived organizational support ( r =-0.193, p  < 0.01; r =-0.471, p  < 0.01; r =-0.460, p  < 0.01; respectively).

We used the Harman single-factor test to assess the common method variance (CMV). Factor analysis shows that the first principal component explained 33.20% of total variance, suggesting that the same source bias is not severe in this study. Before testing our hypotheses, we conducted confirmatory factor analyses (CFA) to confirm the factor structure of our measurement model. As shown in Table  3 , the proposed five-factor model fits the data better: χ 2  = 2492.156, df  = 831, Confirmatory Fit Index (CFI) = 0.971, Tucker-Lewis Index (TLI) = 0.970, and root-mean-square error of approximation (RMSEA) = 0.035. Thus, the distinctiveness of key constructs is supported [ 68 ].

Testing for the mediating effect

We used hierarchical regression and bootstrapping technique to test the mediation hypotheses. As shown in Table  4 , patient mistreatment was positively associated with emotional exhaustion in Model 5 ( β  = 0.354, p  < 0.001) and work-family conflict in Model 8 ( β =  0.314, p <  0.001), thus supporting H1. The test for the mediating effect followed the recommended procedures by Baron and Kenny (1986) [ 69 ]. First, Model 2 indicated a positive correlation between patient mistreatment and social sharing of negative work events ( β  = 0.201, p  < 0.001), supporting H2. Second, Model 6 and Model 9 indicated that social sharing of negative work events was positively associated with both emotional exhaustion ( β  = 0.199, p  < 0.001) and work-family conflict ( β =  0.206, p  < 0.001). Finally, although patient mistreatment was still significantly associated with emotional exhaustion in Model 6 ( β  = 0.314, p  < 0.001) and work-family conflict in Model 9 ( β  = 0.272, p  < 0.001) after the introduction of mediation variables, the size of effects was slightly weakened, suggesting that there exists a partial mediation effect.

We also calculated the indirect effects of patient mistreatment on two outcome variables via social sharing of negative work events and its 95% confidence interval, which was repeated 5000 times using bootstrapping technique. Bootstrapping is useful for testing indirect effects because it produces a repeated replacement sampling distribution of indirect effects rather than assuming a normal distribution (Preacher and Hayes, 2008) [ 70 ]. The results are presented in Table  5 . Social sharing of negative work events significantly mediated the relationship between patient mistreatment and emotional exhaustion (estimate = 0.067, 95% CI = [0.043, 0.094]) and work-family conflict (estimate = 0.077, 95% CI = [0.050, 0.108]). Taken together, these results support H3a and H3b.

Testing for the moderated mediation effect

In our conceptual model, perceived organizational support was proposed to moderate the relationship between patient mistreatment, emotional exhaustion and work-family conflict via social sharing of negative work events. Following Aiken and West (1991), we mean-centered the variables used to form the interaction term [ 71 ]. As shown in the Model 3 of Table  4 , the interaction between patient mistreatment and perceived organizational support was significantly correlated with social sharing of negative work events ( β  = 0.074, p  < 0.01), supporting H4.

We used the Process plug-in to conduct a simple slope analysis [ 70 , 72 ]; the results are shown in Table  6 . The interaction patterns are shown in Fig.  2 . The graph shows that when perceived organizational support was low (-1SD), patient mistreatment was positively correlated with social sharing of negative work events (simple slope = 0.156, p  < 0.001), which was smaller than the coefficient when perceived organizational support was high (+ 1 SD) (simple slope = 0.338, p  < 0.001).

Moderating effect of POS on the relationship between patient mistreatment and social sharing of negative work events. Note PM = Patient Mistreatment; POS = Perceived Organizational Support; SS = Social Sharing of Negative Work Events

Finally, we used Mplus 8.5 to examine the moderated mediating effects. The results in Table  7 show that the indirect effect of patient mistreatment on emotional exhaustion via social sharing of negative work events was positive and statistically significant when perceived organizational support was low (estimate = 0.029, 95% CI = [0.013, 0.047]) and high (estimate = 0.060, 95% CI = [0.035, 0.092]) There was a significant difference in indirect effects between high and low perceived organizational support (estimate = 0.037, 95% CI= [0.005, 0.074]), supporting H5a. Similarly, the indirect effect of patient mistreatment on work-family conflict via social sharing of negative work events was significant when perceived organizational support was low (estimate = 0.033,95% CI = [0.015, 0.055]) and high (estimate = 0.070, 95%CI = [0.039, 0.106]). The difference in indirect effects between high and low perceived organizational support was significant (estimate = 0.037, 95% CI= [0.005, 0.074]), supporting H5b.

In addition, we use the Johnson-Neyman method to depict continuous confidence intervals for indirect effects [ 73 ]. Figure  3 shows that the continuous intervals of indirect effect are greater than zero, and increasing with the perceived organization support. The higher the perceived organizational support, the stronger the effect of patient mistreatment on emotional exhaustion through social sharing of negative work events. Figure  4 shows similar pattern when work-family conflict is the outcome variable.

Conditional indirect effects of patient mistreatment on emotional exhaustion (via social sharing of negative work events) at different levels of perceived organizational support (POS)

Conditional indirect effects of patient mistreatment on work-family conflict (via social sharing of negative work events) at different levels of perceived organizational support (POS)

Leveraging the goal progress theory, this study found that social sharing of negative work events mediated the relationship between patient mistreatment and work-family conflict and emotional exhaustion. The results of the moderated mediation analysis showed that the indirect effects of social sharing of negative events on the two outcomes caused by patient mistreatment were stronger among nurses with high (vs. low) perceived organizational support.

Our study contributes to the literature on the adverse consequences and negative emotions associated with patient mistreatment in several ways. Firstly, the research expands the scopes of literature on the outcomes of patient abuse by innovatively introducing the work-family conflict into the model. Previous research mainly focused on personal aspects directly related to work such as sleep quality, job satisfaction, and career withdrawal [ 27 , 74 , 75 ]. Our findings indicate that the boundary between work and family life is permeable, and negative emotions may flow from the work area into the family domain, causing certain conflicts.

Secondly, based on the goal progress theory [ 31 ], we explored the mediating role of social sharing of negative work events between patient mistreatment and negative outcomes, filling the research gap in this area. The social sharing of negative work events may be a maladaptive coping mechanism in stressful environments. It is a process of social cognitive rumination of service failure that challenges the self-concept of nurses and a typical manifestation of shared ruminative thinking that hinders the positive thinking at individual and/or team levels [ 34 ]. Our findings suggest that patient mistreatment, as a source of stress, produces a sufficiently long duration of negative emotions, which will be further amplified in the process of social sharing [ 40 ], eventually affecting the role conflict between work and family [ 43 ].

Thirdly, we incorporated perceived organizational support as a boundary condition and investigate its moderating role in the effects of patient mistreatment on emotional exhaustion and work-family conflict via social sharing of negative work events. The higher the perceived organizational support, the more likely employees were to experience severe rumination, resulting in further burnout. Perceived organizational support does not always produce positive outcomes [ 58 ] and in some circumstances it enhances the rumination of negative events, leading to greater occupational and psychological stress [ 61 ]. This finding enriches our understanding of the mechanism by which patient abuse affects nurses’ emotions and reactions in the context of the pandemic.

Limitations and future directions

This study has several limitations. First, our research was conducted in the context of the Confucian Chinese culture. Thus, Chinese nurses tend to show greater tolerance for patient mistreatment, since considering the overall interests of the organization is of great priority in a collective society. However, the same result may not hold for individualistic cultures. It is important to consider whether similar conclusions can be drawn in different cultural contexts.

Second, this cross-sectional study required nurses to recall patient mistreatment and negative emotions over previous months. Nurses’ subjective recall may have produced retrospective bias. Future research should use diary studies or experience-sampling techniques to record changes or fluctuations in patient mistreatment and nurses’ emotions over time.

Moreover, our findings supported the negative influences of the patient mistreatment. However, effective alleviations or remedies remained largely unexplored. It is highly recommended to study mindfulness interventions and other mechanisms to deal with patient mistreatment [ 74 ].

Practical implications

Previous research has indicated that patient mistreatment decreases frontline nurses’ job enthusiasm, thereby damaging job satisfaction and triggering withdrawal behaviors and dysfunction in the work-family domain [ 27 , 44 , 75 ]. This study shows that Chinese nurses suffer from emotional exhaustion and work-family conflict caused by patient mistreatment. Managers can employ certain techniques during recruitment to select individuals who are better equipped to handle patients’ incivility during frontline work [ 76 , 77 ].

Moreover, managers can provide frontline staff with training and guidance, simulate scenarios of patient mistreatment, and improve their ability to address patient incivility [ 78 ]. At the meantime, managers should be careful with the polices regarding the social sharing within the organization. Too much exposure and immersion into the rumination of negative work events may deteriorate morale and cause personal and family problems. Additionally, medical professionals should be encouraged to have a positive mindset and demonstrate empathy and compassion towards patients while providing medical services to minimize unnecessary conflicts [ 22 , 79 , 80 , 81 ].

Furthermore, hospital managers can establish eye-catching signs and indicators to guide patients to behave correctly and maintain a civilized manner throughout the treatment process. Society should collaborate with hospitals to create an appropriate medical environment for all patients by encouraging them and their families to take respectful and responsible actions, which will help nurses improve their work efficiency [ 82 ].

This study provides empirical evidence that patient mistreatment causes nurses’ emotional exhaustion and work-family conflict through the social sharing of negative work events. The findings of this study enrich the understanding of the mediating mechanism of patient mistreatment affecting nurses’ emotions and work-family conflict. We also reveal how perceived organizational support, as a moderating variable, enhances the positive relationship between patient mistreatment and the social sharing of negative work events and highlight that organizational support could result in greater psychological stress and family-related conflicts induced by patient mistreatment and mediated by social sharing of negative work events. Therefore, to effectively deal with patient mistreatment, hospital managers should provide training and other resources to nurses, help them regulate their negative emotions, and achieve a balance between work and family. Finally, patients should be educated to receive medical services in a civilized manner.

Data availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. We affirm that the methods used in the data analyses are suitably applied to our data within our study design and context, and the statistical findings have been implemented and interpreted correctly.

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Acknowledgements

We would like to thank all nurse participants and Zhang Yong, Li Hua, Ma Li, and Wee Chow Hou for their helpful comments as well as the seminar participants at Chongqing University, Peking University, and Nanyang Technological University.

This study was supported by the National Social Science Foundation of China (Grant number: 19BJY052, 22BGL141), National Natural Science Foundation of China (Grant number: 72110107002, 71974021), Natural Science Foundation of Chongqing (Grant number: cstc2021jcyj-msxmX0689), Fundamental Research Funds for the Central Universities (Grant number: 2022CDJSKJC14), and Chongqing Social Science Planning Project (Grant number: 2018PY76).

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Wei Yan and Zeqing Cheng designed the study and prepared the first draft of this manuscript. Di Xiao and Xin Du participated in the data analysis. Huan Wang contributed to writing and revising the manuscript. Li Li and Caiping Song contributed to data collection and analysis. All the authors have read and approved the final version of the manuscript.

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Ethical approval was obtained from the Ethics Committee of the School of Economics and Business Administration of Chongqing University (IRB No. SEBA201906). Authors explained research objectives and procedures to all participants who were assured that their participation in this study was voluntary and anonymous. All procedures performed in this study were in accordance with the ethical standards of the National Research Council and Helsinki Declaration of 2013. Informed consent was obtained from all subjects and/or their legal guardian(s).

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Yan, W., Cheng, Z., Xiao, D. et al. Patient mistreatment, emotional exhaustion and work-family conflict among nurses: a moderated mediation model of social sharing of negative work events and perceived organizational support. BMC Med Educ 24 , 1041 (2024). https://doi.org/10.1186/s12909-024-06022-9

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The implementation of telemedicine in wound care: a qualitative study of nurses’ and patients’ experiences

• Kjersti Marie Blytt 1 ,
• Beate-Christin Hope Kolltveit 1 ,
• Marit Graue 1 ,
• Mari Robberstad 2 ,
• Thomas Ternowitz 3 ,
• Siri Carlsen 2 &
• Marjolein Memelink Iversen 1 , 2  

BMC Health Services Research volume  24 , Article number:  1146 ( 2024 ) Cite this article

Metrics details

The increasing use of telemedicine (TM) represents a major shift for health workers and patients alike. Thus, there is a need for more knowledge on how these interventions work and are implemented. We conducted a qualitative process-evaluation alongside a larger randomized controlled trial designed to evaluate a telemedicine follow-up intervention for patients with a leg- or foot-ulcer, who either have or do not have diabetes. Accordingly, the aim of this study was to explore how both health care professionals and patients experienced the implementation of TM follow-up in primary care.

The intervention comprised an interactive TM platform facilitating guidance and counselling regarding wound care between nurses in primary care and nurses in specialist health care in Norway. Nurses and patients from seven clusters in the intervention arm were included in the study. We conducted 26 individual interviews (14 patients and 12 nurses) in primary care between December 2021 and March 2022. Thematic analyses were conducted.

The analyses revealed the following themes: (1) enhancing professional self-efficacy for wound care, (2) a need to redesign the approach to implementing TM technology and (3) challenging to facilitate behavioral changes in relation to preventive care. As to patients’ experiences with taking part in the intervention, we found the following three themes: (1) experience with TM promotes a feeling of security over time, (2) patients’ preferences and individual needs on user participation in TM are not met, and (3) experiencing limited focus on prevention of re-ulceration.

Conclusions

TM presents both opportunities and challenges. Future implementation should focus on providing nurses with improved technological equipment and work on how to facilitate the use of TM in regular practice in order to fully capitalize on this new technology. Future TM interventions need to tailor the level of information and integrate a more systematic approach for working with preventive strategies.

Clinical trial registration

NCT01710774. Registration Date 2012-10-17.

Peer Review reports

Telemedicine (TM) has been introduced as a decision support system for delivering follow-up care to patients with foot ulcers [ 1 , 2 , 3 , 4 ]. TM refers to the use of telecommunication technologies to provide clinical services to patients in a manner that improves the quality and continuity of individual treatments [ 4 ]. TM gives the opportunity for interactions at a distance between healthcare professionals in primary and specialized care [ 5 ]. The concept of TM has been developed alongside the development of different digital technologies (e.g. smartphones, wearable devices, clinical and remote sensors), which has given the opportunity to provide remote clinical services [ 2 ]. Prior studies indicate beneficial outcomes after digital health interventions in relation to smoking termination [ 6 ], increased physical activity [ 7 ], reduced blood pressure [ 8 ] and weight loss [ 9 ]. These studies are indicative of applying TM approach in this context. More recently, TM has become a more common practice in healthcare, especially in developed countries [ 2 ]. TM follow-up has the potential to improve the quality and continuity of care, reduce the need for the patient to visit the hospital and it may be more cost-effective than standard treatments [ 10 ].

Previous research has provided knowledge on the efficacy of TM treatment relative to standard outpatient care on outcomes such as ulcer healing time, amputation [ 1 , 11 ], health, well-being and quality of life [ 3 ]. Furthermore, TM has been found to provide community healthcare professionals with more knowledge, improved wound assessment capabilities and more confidence [ 12 ]. However, TM applications were easier to implement at hospital outpatient clinics compared to home-based care settings [ 13 ]. Central to this understanding was that outpatient clinics at the hospital provided a work setting that eased TM, whereas the environment and work setting in home-based care was found to challenge the implementation of TM. By extension, home-based care required more individual effort from each nurse to act in a way that produced the intended high quality of care [ 13 ]. Time and adequate equipment have been suggested as central factors to take advantage of TM and to accommodate these challenges [ 13 ].

A systematic review by Hazenberg et al. [ 10 ] aimed to explore the different available TM applications that may be valuable in assessment/monitoring, prevention and/or treatment in diabetic wound care. Although several of these applications were found to be valuable, there is still need for more investigation into their effectiveness and/or feasibility [ 10 ]. Furthermore, the results from a systematic review of qualitative studies on patients, carers and healthcare professionals’ perceptions of barriers and facilitators and the use of digital technology in the management of diabetic foot ulcers, shed light on different factors that might be central to the implementation of TM [ 2 ]. The review highlights that patients’ preferences, attitudes and circumstances, healthcare professionals’ training and the support given by the organization, are all important factors to increase the probability for successful adaptation of TM. Examples of concrete barriers to the use of TM in wound care include lack of wound care competency among home care nurses [ 14 ] and unsystematic wound care training [ 11 ]. In addition, lack of interest in using digital technologies [ 14 ] and ambivalent attitudes towards the usefulness of daily wound image taking in diabetic foot care [ 15 ] are central barriers. Although several studies have investigated various aspects related to implementation, TM is still in its early stages [ 10 ]. No prior studies have investigated the wider implementation process of TM from the view of both nurses and patients in light of assessment/monitoring, prevention and/or ulcer treatment. Thus, the aim of this study was to identify how nurses and patients experienced the implementation of telemedicine in wound care.

This study was conducted as part of a broader noninferiority parallel-cluster clinical trial among diabetes foot ulcer patients in 2013–2016 and among patients with foot or leg ulcers who either have or do not have diabetes in 2019–2021 (Clinical trial reg. no. NCT01710774). We performed embedded qualitative interviews in both trial waves to gain insights about patients’ and nurses’ perceptions and experiences of implementing the TM intervention in wound care. The results from the qualitative studies in the first wave have been published elsewhere [ 5 , 12 , 13 , 14 ].

Intervention

The content of the intervention has previously been reported more in-depth by Smith-Strøm et al. [ 1 ]. The TM intervention consisted of a smartphone and a web-based ulcer record. The system was developed to optimize the interaction between community nurses in primary care and specialized health personnel working at the hospital outpatient clinic. The same equipment was used by both groups. During the intervention period, the healthcare professionals documented in both an internal system and in the web-based ulcer record. The system was accessed online from both smartphones and computers. Through these applications, images and written reports and different measurements of the foot ulcer to support the imaging of the foot ulcer were accessible for all the healthcare professionals included in the intervention. The current TM intervention is somewhat different from the usual TM that most often link patients (as actual users of the technology) together with healthcare professionals. The current intervention may rather be viewed as a telemedicine platform to facilitate communication between healthcare professionals working at the hospital and community care nurses managing wound care among patients at home. Every six weeks, the patient visited the outpatient clinic for consultation. The procedure of TM follow-up care was given until an end point (healing of the ulcer (intact skin) or amputation) occurred. All the nurses in the intervention received training regarding wound treatment, follow-up and how to use the TM equipment. Physicians were involved in making the wound care procedure and they were also contacted if it was considered necessary. For each patient, there was an individual plan and if any changes occurred or if there was a deterioration of the wound, the nurses were instructed to act. The study team did however not include a care quality improvement team, implementation framework or health technologies experts, which could have been beneficial for the implementation process. However, the training that the community nurses received was a combination of standardized training and individual teaching at the specialist clinic to ensure comparable and competent handling of patients. Organizational flexibility in the municipalities was somewhat limited because of the complex nature of the intervention.

Participants

To conduct embedded qualitative interviews in the second wave, we invited a purposive sample of 16 patients from seven of the 11 clusters. We included patients with different age, sex and functional level in order to maximize diversity. Likewise, we included nurses of different sex, age and work experience in order to reflect the group’s different characteristics that may influence their experiences. The clusters were of varying size and geographical location. Patients were eligible for participation if they were currently receiving or had recently finished the TM intervention. Nurses were eligible if they were involved or had recently been involved in the TM intervention. The term saturation is mentioned as a criterion for sample size in some qualitative studies and a central element in grounded theory. To develop new knowledge, we kept in mind the aim of the study. Thus, at the point when we considered our collected data not to give us more information regarding the aim, we discontinued our data collection. The power in the information we had gathered after these interviews indicated that we could provide new insights to respond to the research question [ 16 ]. Twelve nurses (graduated between 1993 and 2021) were invited to partake in the interviews, and all consented to participate. Eight of the nurses had additional education in wound care. Thus, a total of 26 individual interviews were conducted among patients and nurses between December 2021 and March 2022.

Data collection

Data was collected in individual telephone interviews. The interviews had a duration of approximately 30–60 min. We have no information whether the caregivers or any others were present in the same room when the telephone interview was conducted. The interviews with the nurses included questions related to how they experienced the changes that came with TM from a nursing and organizational perspective, their perceptions of how nurses experienced their communication with the patients during the TM intervention, how they involved the patients in the treatment, and how they experienced that TM gave an opportunity to apply preventive care. The interview guide for the patients included questions regarding communication with the nurses, their own involvement during the intervention, the organization of the service, and the overall experience with the treatment process. All interviews were conducted by the second author (BCHK) and audio-recorded with the permission of the participants.

The recordings were transcribed verbatim. Transcripts were analyzed using Braun and Clarke’s [ 17 , 18 ] thematic analysis, which provides a systematic procedure for analyzing qualitative data [ 19 ]. Thematic analysis can be used to reflect reality and themes can be identified in one of two primary ways – in a theoretical-deductive manner or using an inductive approach [ 17 ]. In the present study, we used an inductive approach, which implies that the identified themes are clearly linked to the data.

We applied a step-by-step guide in the analysis process, which involved six phases: (1) familiarizing with the data, (2) generating initial codes, (3) searching for patterns, (4) proposing and reviewing themes, (5) defining and naming themes, and (6) producing the report [ 17 ]. In phase 1, the material was collected by one of the authors. In the following process, authors KMB, BKHK, MGR and MIV read the material several times. We all aimed to read the data in an active way, which implies searching for meaning, patterns in the data and so on. As recommended by Braun and Clarke [ 17 ], we all read through the entire dataset before we started coding. In phase 2, the first author generated a list of possible codes and by doing so categorized the data into meaningful groups. The codes were discussed in the group, and further elaborated into meaningful patterns in line with our understanding. In phase 3, the first author read all the codes, went back to the original material and sorted the different codes into potential themes using mind-maps. In phase 4, we read the collected extract for each theme and discussed if they were coherent with the theme. In this process, we found that some of the data extracts did not fit together, and that we therefore needed to rework the theme. In phase 5, we defined, discussed and considered and named the themes. Phase 6 entailed the writing of this manuscript. The interviews were conducted in Norwegian, while our analyses were conducted such that we also proposed English translations of themes that were proposed and reviewed.

We have attempted to achieve trustworthiness throughout the study in terms of credibility, dependability, confirmability and transferability [ 20 ]. Three researchers with knowledge of both thematic analysis and diabetes have been involved throughout the study (BKHK, MG, MIV). BKHK is a diabetes specialist nurse and has been involved in all stages of the research project. Her experience represents a factor that might threaten reflexivity. On the other hand, substantial knowledge from the field can be a valuable source of relevant and specific research [ 21 ]. BKHK clinical experience can be seen as an advantage in the process of formulating relevant questions for the interview guide. MG is a professor in nursing with extensive methodological knowledge of thematic analyses, and MIV, MR, SC and TT have been involved in the TM intervention. Awareness of the potential influence of previous experiences has been considered in the interpretation of the data. We have sought clarity in the description of the data and the descriptions have been discussed in depth within the research team to strengthen the credibility of the study (KMB, MIV, BKHK, MR). The interviews were all performed by BKHK, which increased the likelihood that the interview guide was used in the same way in all the interviews. To strengthen dependability and to facilitate confirmability, the systematic procedure (as described in the Method section) is clearly presented in the Result section with main themes as headings followed by quotations (KMB).

Ethical considerations

The study was approved by the Norwegian Agency for Shared Services in Education and Research (Ref. 837886) and the main project was approved by Regional Committee for Medical Research (REK-VEST 2011/1609). Informed written consent was obtained from all participants. The written information specified that participants’ contribution was voluntary and that they could withdraw from the study at any point without consequences.

To explore how nurses and patients experienced the implementation of TM in wound care, we organize the Results  section in two parts. First, we present themes related to the community nurses’ experiences of implementing TM in primary care and using the TM communication platform. Second, we present themes related to patients’ experiences from taking part in the intervention.

The analysis revealed the following themes related to the community nurses’ experiences: 1) enhancing professional self-efficacy for wound care , 2 ) a need to redesign the approach to implementing TM technology , and 3) challenging to facilitate behavioral changes in relation to preventive care. We treat each of them in turn.

Enhancing professional self-efficacy for wound care

The health care professionals experienced that access to the TM platform gave them a feeling of security and thereby enhanced their ability to perform better follow-up care for people with foot and/or leg ulcers. The interactive web-based ulcer record changed the nurses’ everyday work life as the platform made it possible to seek help regarding ulcer treatment from more experienced healthcare professionals in specialist healthcare. The platform also made it possible for the community nurses to receive guidance and confirmation regarding their own thoughts on the follow-up care. As a result of this, quick and easy access within healthcare services made it possible for the community nurses to act fast, correct and with greater confidence than without TM. The nurses expressed that the opportunities related to the TM technology and the support thereof was important to them. Furthermore, they believed that this interaction made the patients feel more secure. The nurses experienced that the platform made them feel as though they were working as part of a team, although they were on their own in the field. One nurse said: “[This is a] great tool when I am insecure about how to proceed. I also get quick answers”. Similar statements were expressed by nurses working in both rural and urban areas. However, nurses who worked in more rural districts expressed even more appreciation. One nurse said: “I think that telemedicine has been very good and supportive for those of us who are working in the districts”. Taken together, the nurses clearly valued the opportunity and support that TM provided. Noticeably, this was also expressed by their wish that TM would proceed as a tool in practice going forward, and that it should be available for all the nurses in their community. As stated by one of the nurses; “[But] I hope that TM will be available again”.

A need to redesign the approach to implementing TM technology

The nurses claimed that TM was not well-integrated in relation to other work tasks. Therefore, they expressed a need for better organization and integration of the service. In the words of one nurse: “It is not organized well enough. This might be my own fault. It takes a lot of time. We are doing this on top of everything else”. Also, technical issues are mentioned as a barrier and a possible explanation for the lack of integration that the nurses experienced in the implementation process. As stated by one nurse: “We have experienced problems with the connection to the telecommunication network because of the phone that is part of the nursing service. Several of the nurses find it difficult to follow up using telemedicine because of this issue”. Other technical challenges were also expressed. One nurse stated: «I found it unfavorable that I did not have my own phone with camera. I had to use a phone that I shared with my colleagues. And this led to interruption in action. I had to answer the phone and other practical tasks”. Hence, the results indicate that there is room for further organizational and technical improvements in implementation and delivery of TM. Consequently, the role of health service managers is key. This was also expressed by the nurses as they highlighted that they did not get enough time to really get familiar with TM and consequently felt that it was not fully internalized.

Challenging to facilitate behavioral changes in relation to preventive care

As part of the implementation of TM, the nurses were also asked how they were working with preventive care strategies in order to prevent recurrent ulcers. The data revealed that some nurses found it difficult to involve patients in preventive aspects and to produce lasting behavioral changes. A nurse explained it as follows: “Some of the patients are interested in preventive strategies and some do not care. They don’t want to take responsibility for their own health. Some of these patients are very set in the way they are living their lives and they want us to stop nagging” . Similar statements were expressed from other nurses. For instance, one nurse stated: “My experience is that they are interested in doing preventive measures , but they find it hard to pull through”. Some of the nurses also expressed that patients seemed interested in taking action and doing preventive measures. Furthermore, they believed that patients were interested and involved when they received information about it. Moreover, nurses expressed that they gave plentiful advice to the patients regarding different preventive measures. However, they experienced that the patients often did not follow up the plan afterwards. Thus, the nurses found it challenging to implement preventive care strategies and produce lasting behavioral changes.

As to patients’ experiences related to taking part in the intervention, we found the following three themes: (1) experience with TM promotes a feeling of security over time , (2) patients’ preferences and individual needs on user participation in TM are not met and, (3) experiencing limited focus on prevention of re-ulceration.

Experience with TM promotes a feeling of security over time

The interaction between healthcare professionals at different levels in the health care system provided the patients with a positive experience and made them feel more secure. Hence, we found that through interaction, communication and follow up, the patients experienced a feeling of security regarding TM and its functions. As stated by one patient: “ When the wound was quite big and painful , I felt more insecure if it was the nurses with less competence who came to assist me. But it worked very well. Sometimes they contacted help via the phone. They have contact and receive help from the hospital and I find this reassuring. The nurses at the hospital decide which treatment and follow up should be carried out by the community nurses.” In addition, the patients expressed that they wished that TM treatment would be continued, and they stated that it was beneficial and essential for good treatment. Taken together, the results indicate an initial worry and a sense of insecurity when less competent nurses were responsible for wound care. However, TM overcame this issue, and the patients developed a feeling of security and expressed that they hoped that TM would proceed.

Patients’ preferences and individual needs on user participation in TM are not met

Patient preferences differed from patient to patient. This relates to how much they wished to be involved in the treatment and how much detail they would like regarding the communication that is exchanged via the TM platform. The results indicate that each patient’s different needs were not fully met in the implementation of TM. Some of the patients said they would like to be little involved and received little information. One patient said: “I felt safe , I think I knew too little about this and the nurses would do what they knew were correct and best for me”. On the other hand, some patients would like to be more involved and to receive as much information as possible. One patient stated: “What I think seems a bit odd is that I did not get clear feedback about whether the information that was handed to the hospital on my behalf had any implications for the treatment. I never received any feedback about whether the information I provided was received or not at the hospital.” Also, the patients pointed out the need for individual adaption in TM follow-up care. In the words of one patient: “I am a person with quite good communication skills , but that is not the case for everyone in this patient group. I think they need to take it very slowly and carefully with other patients. This is something that is very new for the elderly in this patient group.”

Experiencing limited focus on prevention of re-ulceration

A central theme in the interviews with patients revolved around their thoughts about different preventive measures. This included perceptions of how patients themselves take preventive measures as well as how the healthcare professionals communicated the importance of this to the patients. The patients in the present study mainly reported that there was little or no focus on prevention. In the words of one patient: “No , I cannot remember that any of them has talked about prevention” . Similar statements were provided from several participants, for instance as follows: “No , they have not talked about it. The only thing they have mentioned is that I should be careful not to knock my foot into a table or something like that.” It is unclear if this is indeed the case or if the patients did not have enough knowledge to determine what constitutes preventive measures. If so, they would not be aware that nurses provide them with important easy-to-use advice that is crucial for daily management and prevention of new ulcers. However, this sheds light on an area in which there is room for further improvement regarding how such information is provided to this patient group.

We found that implementation of TM gave nurses an increased ability to act although there are still minor, but essential barriers to full integration. The patients expressed an increased feeling of security after having had positive experiences with TM. In addition, the patients reported that they had different preferences and needs regarding how much information they would like on what is communicated on the TM platform and how involved they wanted to be. Furthermore, the results indicate that although TM provides the community nurses with a tool to be more proactive in preventive care, the nurses found it challenging to facilitate behavioral changes in relation to such care. This is a complex issue as some of the patients report that they experience receiving limited information on strategies to prevent-re-ulceration.

The first theme describes an “enhancing professional self-efficacy for wound care”, which also implies that the knowledge and guidance provided to the community nurses are facilitating their actions. This is in line with previous research that has shown that TM increased health care professionals’ skills and knowledge on wound assessment [ 11 , 12 , 22 , 23 ]. Increased knowledge, and consequently an enhanced ability to act, are important elements when evaluating the use of TM. Through these factors, the nurses may experience improved confidence and a feeling of security. This can in turn empower them to act and give high quality care.

These results are also reflected in the patients’ feedback, as they reported having developed more security through their experiences with TM. Furthermore, different factors such as self-esteem, positive emotions, and organizational and personal commitment have been found to mediate job satisfaction [ 24 ]. Considering this, it would be interesting to investigate how TM may affect or mediate job satisfaction, as it provides the nurses with an increased ability to act. This is important, not merely because of the positive aspect of job satisfaction in itself, but also because job satisfaction is a determinant of turnover intention. For instance, Perry et al. [ 25 ] found that turnover intention (i.e., employees’ intent to find a new job with another employer) is more present among employees that are less satisfied with their jobs. Hence, the results from the present study may have other important implications beyond the scope of this paper.

The results indicate that there are areas with room for further improvement. Although the nurses in the present study reported that they felt more secure and that TM provided them with an increased ability to act, they also recognized that TM has the potential to function even better. The nurses described different challenges with the technology that could be improved. These issues include difficulties with the basic services as the telecommunication system. Moreover, it also relates to more comprehensive issues. One such issue relates to a feeling that the application is not fully integrated in work life. Another relates to the experience of TM as a time-consuming process and consequently increasing workload, contrary to the intention of the use of TM.

The nurses expressed that the service managers should provide them with more time and resources to really get familiar with TM and thus be able to fully integrate it in practice. These results are in line with a scoping review that pointed out that the technology itself is a hindrance due to a shortage of resources and time, training, and finances [ 26 ]. This is also reflected in previous results from an earlier stage in this project showing that documentation is seen as overly time-consuming [ 12 ]. Moreover, adequate equipment and time is essential to benefit from this new technology [ 13 ]. In order to address these challenges, the responsibilities of health service managers in primary care need to be addressed more. These responsibilities also need to be specified to facilitate the adoption of new technologies and work to integrate them in practice. Consequently, the use of TM technology can be a relevant alternative and supplement to usual care [ 1 ].

The main difference between the current study and the qualitative study conducted in the first wave of the TM project [ 12 ] is that the current study provides knowledge regarding the experiences of both health care professionals and patients. Furthermore, Kolltveit et al. [ 12 ] found that introducing TM in primary and specialist health care implied a change in wound assessment knowledge and skills. The authors further emphasized that the health care professionals developed a better and increased understanding of what they saw when they evaluated the ulcers and performed wound care. The results from the present study indicate a change in relation to the nurses’ everyday work life, as the online web ulcer platform made it possible to seek help regarding the ulcer treatment from more experienced healthcare professionals.

The results further highlight that the differences in patient preferences and needs are central to consider in the implementation of TM. Some of the patients express that they would like to be more involved, while others express that they do not want further information or involvement. The latter group would therefore like the nurses to take full control over their situation. Two central concepts in the health science literature are person-centered-care or patient-centered care, respectively [ 27 ]. Both concepts imply that patients should be more involved as partners in their care and treatment. Thus, they highlight that the patient should be the most central stakeholder in the decision-making process [ 28 ]. A recent systematic review investigating the use of person-centered care in chronic wound care found improved outcomes regarding pressure ulcer prevention, patient satisfaction, patients’ knowledge and quality of life [ 29 ]. Considering the findings from Gethin et al. [ 29 ] and the results from the present study, we argue that patients’ needs, beliefs, strengths and personality should be carefully considered in the implementation process. This is also highlighted and pointed out by Foong et al. [ 2 ], who argued that patients’ preferences, attitudes and circumstances are important factors for successful adoption of digital technology in diabetic foot ulcer treatment.

The results showed that nurses found it challenging to facilitate behavioral changes in relation to preventive care. This is also somewhat reflected in the answers from patients, as they express that the nurses have limited focus on different strategies to prevent re-ulceration. However, the difficulty of overcoming patient inertia for facilitating change in behavior may not be directly linked to TM use. Instead, it may reflect that the nurses are not truly integrating technology into the process of care. This would require more careful planning and resourcing of the technology implementation process. Meanwhile, the nurses report working with preventive care – communicating central and easy-to-use advice – but experiencing that the patients do not make use of this information. To understand the discrepancies in how these experiences from nurses and patients are intertwined goes beyond the scope of the present study. However, it points out central aspects for future studies to examine. Moreover, we found that different patients had different needs and preferences – an aspect that could also be further improved through patient-centered care. For instance, Li et al. [ 30 ] found that an individualized, educational 12-week program (including one-on-one training during bedside visits, brochures, telephone follow-ups and home visits) significantly improved foot self-care behavior. However, there was no change regarding the incidence of the foot problems. Considering this study and the results from the present study, we argue that future implementation of TM should consider even more systematic and individual-level work with preventive care strategies. TM provides nurses with a tool to be more proactive in preventive care, but it seems difficult to overcome these challenges by only implementing TM without a complimentary behavioral strategy.

Treatment of foot ulcers among people with and without diabetes challenges the health care system in terms of resource distribution and management strategy [ 31 ]. By extension it has been important to investigate the effectiveness of TM, as it may represent an approach that can meet these challenges. The quantitative results that the current study derives from was reported in Smith-Strøm et al. [ 1 ] and Iversen et al. [ 3 ]. Smith-Strøm et al. [ 1 ] found that TM follow-up to patients was noninferior for ulcer healing time when compared with standard outpatient care. Furthermore, when comparing risk from death and amputation was considered, no significant differences in healing time was found. In secondary analyses of data from this study, Iversen et al. [ 3 ] aimed to compare changes in self-reported health, well-being and quality of life. The findings showed no significant differences between the intervention and control group in changes in scores for the patients’ reported outcomes. The current study found some room for further development in how we integrate TM in regular practice and need for better technological equipment. However, we do not know how patients experiences standard care and potential challenges that arise in such care compared to those in the TM setting. The current study does still provide essential insight that enriches our understanding of TM as an appropriate and effective method for wound care management and treatment.

Study limitations

The insights from this study provide knowledge on how nurses and patients experience the implementation of TM in primary care. A potential limitation is that the answers from patients might have been influenced by the interactions and established relationships with the nurses. This may have led them to give more positive answers to show gratitude for the treatment and their involvement. In addition, the nurses may have cultivated a specific culture within the clusters that may have affected their answers. This could lead to responses not necessarily representing their own actual views and experiences. The interviews were conducted over the telephone, which may have led to loss of nonverbal data that could have provided contextual information that could in turn have informed the analyses. As this is a technology-based intervention, one can argue that it would have been beneficial if the interview guide included specific questions regarding technical issues with and barriers to operating the TM technology. This might have provided us with clearer and more detailed information regarding the possible barriers when using this method. In addition it would have been beneficial if this further implementation study also included interviews with the healthcare professionals working at the hospital as this may have provided us with knowledge regarding their experience with the TM intervention. Both of these issues would be a fruitful topic for further research on similar TM approaches.

The results from the present study provide new and valuable knowledge on how the implementation of TM is experienced both from nurses’ and patients’ perspectives. Future implementation of TM should provide nurses with better technological equipment, mapping each patient’s specific needs for information about the communication that is exchanged on the TM platform and provide nurses with tools that facilitate a systematic approach in order to produce behavioral changes in relation to preventive care.

Availability of data and materials

The datasets generated during and analyzed during the current study are not publicly available in order to ensure the participants ‘anonymity but are available from the corresponding author on reasonable request.

Abbreviations

• Telemedicine

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Acknowledgements

We thank the patients and the community nurses for their willingness and motivation to contribute, which made this work possible.

KMB received funding from the Norwegian Nurses Organization.

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Department of Health and Caring Sciences, Western Norway University of Applied Sciences, P.O. Box 7030, Bergen, 5020, Norway

Kjersti Marie Blytt, Beate-Christin Hope Kolltveit, Marit Graue & Marjolein Memelink Iversen

Department of Medicine, Section of Endocrinology, Stavanger University Hospital, Stavanger, Norway

Mari Robberstad, Siri Carlsen & Marjolein Memelink Iversen

Department for Dermatology, Stavanger University Hospital, Stavanger, Norway

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Contributions

BKHK, MG, MMI designed the study. MMI, MR, TT, SC contributed to collecting data in the trial. KMB conducted the initial analyses and wrote the first draft. BKHK, MG, MMI contributed to the analyses process. All authors contributed to writing, revising, and approved the final manuscript. MMI applied for funding. MMI is the guarantor of this work and, assuch, had full access to all the data in the study and takes responsibility for the integrity of thedata and the accuracy of the data analysis.

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Correspondence to Kjersti Marie Blytt .

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The study was approved by the Norwegian Agency for Shared Services in Education and Research (Ref. 837886) and the main project was approved by Regional Committee for Medical Research (REK-VEST 2011/1609). Informed written consent was obtained from all participants. The written information specified that participants were informed that their contribution was voluntary and that they could withdraw from the study at any point without consequences. To ensure the participants’ anonymity, we used numbers instead of names in the transcribed material. All methods were carried out in accordance with relevant guidelines and regulations.

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Blytt, K.M., Kolltveit, BC.H., Graue, M. et al. The implementation of telemedicine in wound care: a qualitative study of nurses’ and patients’ experiences. BMC Health Serv Res 24 , 1146 (2024). https://doi.org/10.1186/s12913-024-11620-w

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Received : 17 April 2023

Accepted : 20 September 2024

Published : 29 September 2024

DOI : https://doi.org/10.1186/s12913-024-11620-w

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