Educational gaps, training challenges and learning needs among early-career rheumatology nurses in resource-limited county hospitals: a multicenter qualitative study

Abstract

Background

Rheumatology and immunology nursing involves complex, long-term patient care. However, the effectiveness of current training in supporting early-career nurses remains unclear. Therefore, this study aimed to explore stakeholders’ perspectives on training experiences and perceived learning needs, and to identify key implications for competency-based continuing professional development, with a focus on enhancing sustained patient safety.

Methods

This descriptive qualitative study employed semistructured interviews with 26 participants (15 trainees and 11 trainers) from six county-level hospitals in Ningxia, China. Data were analyzed using Braun and Clarke’s reflexive thematic analysis, and reporting followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

Results

Three main themes emerged: (1) Trainees reported misalignment between training content and daily clinical demands, insufficient support for safe routine practice, and limited opportunities for supervised skill development; (2) Trainers highlighted gaps in preparation and educational resources, resulting in primarily didactic approaches and variable training quality, which may hinder the development of patient safety-related competencies; (3) Trainers emphasized the need for a structured, progressive training framework integrated with clinical practice. Shared priorities included clearly defined competency progression, contextually relevant content, experiential learning strategies such as case discussions and supervised practice, and the integration of psychological support, humanistic care, and lifelong learning awareness and methods. Faculty development and standardized teaching materials were considered essential to ensure consistent and safe practice standards.

Conclusion

Strengthening specialist nursing capacity in resource-limited county hospitals requires not only structured, practice-integrated training curricula but also sustainable continuing professional development pathways that support progressive competency development. Embedding competency-based learning within routine clinical practice, alongside investment in trainer capability and standardized educational resources, may help reinforce patient safety competencies and promote sustained professional growth across the early stages of nursing careers.

Background

Rheumatic and autoimmune diseases are chronic and clinically heterogeneous conditions that require long-term management and sustained patient support [1]. They impose substantial physical and psychological burdens on patients and contribute to considerable healthcare utilization and economic costs for families and health systems [2]. Advances in diagnostics and treatment, alongside population ageing and the increasing prevalence of chronic disease, have collectively contributed to growing demand for rheumatology and immunology services. This demand is partly driven by an increasing number of patients who are diagnosed, treated, and living longer with chronic conditions, thereby intensifying workforce pressures and raising concerns regarding the sustainability and safety of care delivery [3, 4]. In such complex clinical environments, characterized by heterogeneous disease presentations, multi-morbidity, and the need for long-term management, maintaining patient safety requires healthcare professionals who are not only appropriately trained at baseline but also continuously supported through structured and ongoing professional development to sustain and update their knowledge and skills.

Within this context, specialist rheumatology and immunology nurses are increasingly recognized as essential members of multidisciplinary care teams [5, 6]. International recommendations, including those from the European Alliance of Associations for Rheumatology (EULAR), emphasize nurses’ roles in patient education, treatment monitoring, and long-term care coordination [5, 7]. However, evidence from international surveys and mixed-methods studies indicates that the implementation of these recommendations remains challenging, with reported barriers including limited awareness, insufficient educational preparation, and contextual constraints across healthcare systems [8, 10].

Evidence suggests that appropriately trained nurses can enhance service efficiency without compromising clinical outcomes [11, 12]. Notably, a multicenter randomized controlled trial demonstrated that nurse-led care in rheumatoid arthritis is both clinically effective and cost-effective, further supporting the value and expanding role of specialist nursing practice in rheumatology care [13]. However, training pathways and competency development for rheumatology nursing roles remain inconsistent across regions, and structured continuing professional development (CPD) opportunities are often limited in resource-constrained settings, a challenge that has also been documented in other low-resource contexts [14]. This gap persists despite the availability of established competency frameworks, such as those developed by the Royal College of Nursing [15] and European Alliance of Associations for Rheumatology EULAR [16]. The absence of accessible training structures may hinder the sustained development of specialist competencies necessary for safe and effective chronic disease management.

Rheumatic and autoimmune diseases represent a significant global health challenge. In China, the disease burden is substantial, particularly outside major urban centers where specialist services are unevenly distributed [17, 19]. National initiatives have prioritized expanding physician training and establishing rheumatology departments; however, comparatively little attention has been directed toward specialist nurse preparation and CPD [20]. Workforce shortages and geographic disparities are likely to persist, especially in county-level hospitals serving rural and underserved populations [21, 22]. Limited data on the rheumatology nursing workforce further complicate efforts to design structured educational pathways that support long-term competence and patient safety.

County-level hospitals play a crucial role in delivering accessible healthcare but often face constraints in specialist staffing, mentorship, and educational resources [23]. In regions such as Ningxia, rheumatology services are concentrated in tertiary hospitals, leaving county-level facilities with limited access to specialist training and continuing education. These structural barriers may restrict opportunities for early-career nurses to engage in sustained learning and competency development, potentially affecting their preparedness to manage complex chronic conditions and emerging patient safety risks.

Competency-based training has been proposed as an approach to bridge the gap between theoretical knowledge and clinical application, supporting clinical judgment and decision-making in chronic disease management [24]. However, empirical research examining how early-career rheumatology nurses in county-level hospitals experience specialist training and CPD remains scarce. Existing studies largely focus on tertiary institutions or single stakeholder perspectives, providing limited insight into how training programs are structured, accessed, and experienced in resource-limited clinical environments. A greater understanding of these experiences is needed to inform educational strategies that strengthen sustained competence and support patient safety across the early stages of professional practice.

This study explores the educational experiences, training challenges and learning needs of early-career rheumatology nurses in resource-limited county hospitals. By identifying gaps in existing training and CPD pathways, the study aims to inform the development of contextually appropriate, competency-based educational strategies that promote lifelong learning and reinforce patient safety in specialist nursing practice. Through a qualitative exploration of stakeholder perspectives, the study seeks to generate practical insights to guide the design of sustainable professional development frameworks.

Methods

Design

A descriptive qualitative design was employed to explore perceived training challenges and educational needs among early-career rheumatology and immunology nurses in county-level hospitals, drawing on the perspectives of both trainees and trainers. This approach was intended to generate practical insights to inform the development of sustainable professional development frameworks. Needs Assessment Theory informed both the development of the interview guide and the interpretation of the findings, enabling a systematic identification of gaps between existing training and desired competencies [25]. The study was conducted and reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines [26] and the data were analyzed using Braun and Clarke’s reflexive thematic analysis framework [27].

Setting

This study was conducted in county-level hospitals in Ningxia, China, which serve as primary healthcare providers for large rural and underserved populations. These hospitals offer rheumatology and immunology nursing services but operate with limited specialist staffing, training opportunities, and access to specialized resources.

Participants and recruitment

Purposive sampling was used to recruit two key stakeholder groups: (1) trainees, defined as nurses with ≤ 5 years of experience in rheumatology or immunology nursing, and (2) trainers, including head nurses and nurse educators working within the same departments as the trainees, with relevant experience in supervising or delivering rheumatology and immunology nursing training. To capture a range of perspectives, maximum variation sampling was applied to ensure representation across six county-level hospitals, varying levels of clinical experience, and professional roles.

Participants were identified through department heads or nursing education offices and were provided with written information about the study prior to participation. Participation was entirely voluntary, and it was clearly communicated that declining participation would have no impact on participants’ professional roles or evaluations. Informed consent was obtained directly from all participants. Recruitment continued until data saturation was achieved, defined as the point at which successive interviews generated no new codes or insights relevant to the study aims [28]. No eligible participants declined participation, and none withdrew after providing informed consent.

Theoretical framework

This study draws on Needs Assessment Theory to examine the training challenges and educational needs of early-career rheumatology and immunology nurses in resource-limited county hospitals. The theory views training development as a process of identifying gaps between existing competencies and those required for effective practice [25]. By focusing on these discrepancies, it provides a structured basis for prioritizing context-specific educational needs and informing competency-based training design. In nursing education, needs assessment aligns training with clinical realities, ensuring it addresses gaps in knowledge, skills, and organizational support structures, thereby supporting sustained competence and patient safety in resource-constrained settings [29, 30].

Interview guide

Semistructured interview guides were developed based on a review of relevant literature and discussions within the research team [31, 32]. Informed by Needs Assessment Theory, the guides were designed to explore training needs, current skill gaps, and requirements for effective practice. They were pilot-tested with three trainees and three trainers to refine question wording, sequencing, and relevance. The guides were further reviewed by two nursing education experts to enhance clarity and content validity [33]. Core interview questions and probing prompts are summarized in Table 1.

Table 1.

Semistructured interview guide for trainees and trainers

Participant Group	Questions / Prompts
Trainee Interview Questions	1. Can you describe your experience with the rheumatology and immunology training? 2. What aspects of the training were beneficial? 3. How have you changed since completing the training (e.g., knowledge, skills, confidence)? 4. What improvements would you suggest for future programs?
Trainer Interview Questions	1. Can you describe your experience providing rheumatology and immunology training? 2. How do you evaluate training effectiveness? 3. How have nurses changed since completing the training? 4. What recommendations do you have for improving training?
Probing Questions (both groups)	• Could you elaborate on that? • Can you provide a specific example? • What factors contributed to this situation or challenge? • Where do you think these training difficulties mainly originate? • What training approaches would be feasible in your hospital setting?

Data collection

Semistructured interviews were conducted between April and May 2022 by LJX (female, MSc, RN), a head nurse with formal training in qualitative research methods. Participants were informed that the interviewer was a nurse researcher conducting the study as part of an academic project aimed at understanding training challenges and educational needs in rheumatology and immunology nursing. The interviewer had no prior relationship with the participants. Interviews were conducted in a quiet, private space within the hospital or via secure online conferencing, depending on participant preference and feasibility. Each interview lasted approximately 35–40 min, was audio-recorded with participants’ consent, and was transcribed verbatim. Field notes were systematically recorded during and immediately after the interviews to document contextual information and, where feasible, nonverbal cues. While both face-to-face and online interviews were conducted, potential differences in nonverbal communication were carefully considered. Online interviews may have limited the observation of certain nonverbal cues; however, methodological consistency was ensured by using the same interview guide and interviewer, and by focusing on verbal responses and employing probing strategies for clarification where needed. No substantial differences in the depth or quality of responses were observed between the two interview modes. No repeat interviews were conducted.

Data analysis

Data were analyzed using reflexive thematic analysis, following Braun and Clarke’s framework, which emphasizes the active role of researchers in constructing and interpreting meaning from qualitative data [27]. Data collection and analysis occurred concurrently, allowing for the iterative refinement of coding and interpretation.

Two researchers (LJX and SJC), both with experience in qualitative research and data analysis, independently familiarized themselves with the transcripts through repeated reading and independently coded the data, generating initial codes using an inductive, reflexive approach [34]. Codes were reviewed and compared to identify patterns and similarities, and related codes were grouped into subcategories, which were subsequently refined into overarching themes. Theme development attended to both semantic content and underlying patterns across the dataset, following the six-phase approach outlined by Braun and Clarke [35].

Ongoing analytic discussions among the research team supported reflexivity and enhanced the robustness of the analysis, with differences in coding and theme development resolved through consensus. Two researchers cross-checked the transcripts for accuracy and completeness [36], and key analytic decisions, including code definitions and theme boundaries, were documented to maintain an audit trail. Selected quotations were translated into English and back-translated to ensure accuracy and fidelity to the original meaning. Themes were interpreted in relation to the study aims and existing literature to ensure analytic coherence. A summary of the preliminary findings was shared with participants for member checking to confirm the credibility and relevance of the interpretations [37]. Any discrepancies were resolved through further dialogue, and ambiguous responses were clarified through follow-up contact via phone or email for clarification purposes only, rather than as additional interviews.

Initial codes were organized into subcategories and subsequently into overarching themes, forming a hierarchical coding structure that reflected relationships across the data. Data were managed and coded manually without the use of qualitative data analysis software.

Rigor and trustworthiness

Rigor was ensured through interviewer training, pilot testing of the interview guide, and regular team meetings to support reflexive discussion and ensure consistency in data collection and analysis [36].

Credibility

To strengthen credibility, member checking was conducted by sharing a summary of preliminary themes with participants and inviting their feedback to ensure the interpretations accurately reflected their experiences. This process enabled verification of alignment between the findings and participants’ intended meanings. Any discrepancies were resolved through further dialogue, and ambiguous cases were clarified through follow-up contact via phone or email to ensure the validity of the interpretations.

Dependability

Dependability was ensured by cross-checking the interview transcripts for accuracy and completeness by two researchers [38]. This collaborative approach ensured consistency of data management and analysis. Additionally, an external expert in qualitative research, with specific experience in nursing research and qualitative data analysis, reviewed a subset of the interview transcripts to further enhance the reliability and rigor of the coding process.

Reflexivity

Reflexivity was supported through ongoing team discussions, during which researchers critically reflected on their assumptions, professional backgrounds, and potential influences on data interpretation. The interviewer’s professional background as a head nurse informed her interest in nursing education and training development. This influence was explicitly acknowledged and reflected upon during the analytic process to ensure transparency in the research approach.

Confirmability

Collaborative coding and consensus-based theme development were employed to minimize the influence of individual researcher perspectives, thereby enhancing confirmability.

Social desirability bias

To reduce social desirability bias, participants were assured of confidentiality and anonymity throughout the study. Interviews were conducted in a supportive, nonjudgmental environment, encouraging open and honest responses, and helping participants feel comfortable sharing their experiences.

Transferability

To ensure transferability, maximum variation sampling was employed to include a diverse range of participants, providing a comprehensive view of the topic and enhancing the potential for findings to be applied to other contexts.

Ethical considerations

Ethical approval was obtained from the Ethics Committee of the General Hospital of Ningxia Medical University (approval number: KYLL-2022-1155). All participants provided written informed consent for participation, audio-recording, and the use of de-identified quotations in publications. Participants were informed of the voluntary nature of participation and of their right to withdraw at any time without consequence.

Confidentiality was ensured through the anonymization of transcripts and secure storage of all study materials. To minimize the risk of identifiability within a small professional community, personal and indirect identifiers were removed or generalized during data analysis and reporting.

Results

A total of 26 participants were interviewed, including 15 trainees and 11 trainers. Three themes were generated from the analysis. Theme 1 reflects trainees’ perspectives and captures a perceived misalignment between existing training provision and the practical demands of work in resource-limited county hospitals. Themes 2 and 3 reflect trainers’ perspectives, with Theme 2 focusing on constraints related to trainer preparedness and educational resources, and Theme 3 outlining recommendations for training reform emphasizing competency-oriented and practice-integrated approaches. A cross-stakeholder synthesis is presented at the end of this section.

All participants were women. Trainees were aged 21–31 years (mean 25.33 ± 2.35 years), while trainers were aged 33–56 years (mean 43.72 ± 7.27 years). Trainees had a mean of 2.40 ± 1.44 years of experience in rheumatology and immunology departments (range < 1–5 years), whereas trainers had a mean of 13.09 ± 3.14 years of departmental experience (range 9–19 years). Participant characteristics are summarized in Table 2.

Table 2.

Participant characteristics

Characteristic	Trainees (n = 15)	Trainers (n = 11)
Sex, n (%)	Female 15 (100.0)	Female 11 (100.0)
Age (years), mean ± SD	25.33 ± 2.35	43.72 ± 7.27
Age range (years)	21–31	33–56
Education level, n (%)	Vocational secondary education 0 (0)	Vocational secondary education 2 (18.2)
	College degree 12 (80.0)	College degree 7 (63.6)
	Bachelor’s degree 3 (20.0)	Bachelor’s degree 2 (18.2)
Years of experience in the rheumatology/immunology department, mean ± SD	2.40 ± 1.44	13.09 ± 3.14
Range of years of experience	< 1–5	9–19

Trainees’ perspectives

Theme 1: misalignment between training provision and practice needs in county hospitals

Trainees reported entering rheumatology and immunology nursing with limited prior exposure and minimal opportunities for structured learning. This lack of foundation often led to uncertainty regarding core knowledge and clinical priorities, which trainees felt hindered their ability to perform effectively in practice. Limited exposure to specialty cases, particularly in smaller hospitals with mixed wards, constrained experiential learning opportunities. Overall, trainees emphasized the need for structured, contextually relevant training approaches that prioritize practical competencies for routine care in county-level hospitals.

Subtheme 1.1: need for a structured and progressive training pathway

Trainees highlighted the absence of a clearly defined, progressive training pathway spanning pre-service education, clinical rotations, and in-service training. Trainees described training as fragmented, with limited continuity and few explicit milestones, which often caused confusion about learning priorities. Foundational concepts were not consistently introduced before more complex material, which hindered understanding. For example, one trainee noted, “Complex concepts were introduced before simpler ones, which made learning difficult to understand” (Trainee 14). This reflects how sequencing gaps can impede comprehension and confidence in applying knowledge. Another trainee added, “Theoretical knowledge is simply poured into us. It is difficult for us to understand without ground knowledge” (Trainee 7). This emphasizes the need for a stepwise, scaffolded approach to training that builds from basic to complex concepts.

Subtheme 1.2: need for nursing-relevant and context-appropriate content

Trainees perceived current training as insufficiently tailored to nursing roles and the realities of county-level hospitals. They reported that physician-oriented and overly technical content limited the practical relevance for daily nursing tasks, such as clinical observation, risk identification, and patient education. One trainee explained, “Sometimes, training is provided only when a specific patient case occurs, at which a physician is invited to give a lecture” (Trainee 3). This illustrates that training opportunities were often reactive rather than proactive, reducing systematic learning. Another stated, “The current training content is unsuitable for nurses… too complex and hard to understand” (Trainee 1). Such perceptions highlight the importance of designing content that aligns with nurses’ roles and the specific needs of county-level hospitals.

Subtheme 1.3: need for engaging, application-focused teaching methods

Most trainees described sessions as largely lecture-led and information-dense, making it difficult to follow and apply knowledge in practice. They emphasized that limited interaction and few opportunities for practical application reduced learning effectiveness. One trainee described current sessions as “one-dimensional… lacking interactive elements” (Trainee 3). This suggests that passive learning formats are insufficient for building clinical competence. Another added, “Our training lacks practical, applicable knowledge. For instance, with too much detailed explanation of pathogenesis and immune responses” (Trainee 8). This indicates a mismatch between theoretical content and practical needs, underscoring the demand for interactive, case-based, and scenario-focused learning methods.

Subtheme 1.4: safety-related competency priorities

Trainees highlighted specific competency areas critical for safe and effective practice in county-level hospitals. They emphasized that mastering these competencies is essential for patient safety and care quality, particularly given the complexity of common cases. These areas included: (a) interpreting commonly ordered laboratory tests and understanding associated precautions; (b) managing complex medication regimens, including monitoring side effects, interactions, and adherence; (c) recognizing complications and multimorbidity; and (d) supporting long-term disease management and continuity of care.

Several trainees described uncertainty and challenges in these areas. For instance, one trainee reported difficulty understanding laboratory testing, “the purpose of common laboratory tests… and the associated precautions involved” (Trainee 2). This reflects gaps in foundational knowledge that may impact safe clinical decision-making. Another trainee emphasized the complexity of medication management: “Before working in this department, I didn’t realize that a patient might be prescribed so many medications… including antibiotics, anti-inflammatory and analgesic medications, immunosuppressants, corticosteroids, biologics, and antihypertensives” (Trainee 6). This quotation underscores the need for training that equips nurses to handle polypharmacy safely and effectively.

Trainees also highlighted challenges in managing patients with multiple comorbidities. Trainee 8 described how complexity in patient profiles can strain nursing capacity, “A patient might also have interstitial pneumonia, hypertension, coronary artery disease, diabetes, and depression. Managing these different complications can be quite challenging for nurses.” This illustrates the practical difficulties nurses face and the importance of structured guidance in comorbidity management. Additionally, Trainee 2 stressed the importance of chronic disease management, stating, “Training on how to systematically manage patients with chronic conditions should definitely be included.” Her insight emphasizes the need for longitudinal and integrated care competencies in training programs.

Collectively, these accounts highlight that trainees require structured, context-appropriate training that balances theoretical knowledge with practical, safety-critical skills. Incorporating participants’ perspectives into curriculum design could directly enhance learning outcomes and patient care quality in county-level hospitals.

Trainee-derived priorities for competency-based training design are summarized in Table 3.

Table 3.

Trainee-derived priorities for competency-based training design

Subtheme	Summary of trainees’ accounts
1.1 Structured and progressive training pathway	Trainees described fragmented training across pre-service education, rotations, and in-service learning, with unclear progression and milestones.
1.2 Nursing-relevant, context-appropriate content	Trainees perceived the content as physician-oriented and overly technical, with limited relevance to routine nursing work in county hospitals.
1.3 Engaging, application-focused teaching methods	Trainees described sessions as largely lecture-led and information-dense, making it difficult for them to sustain interest and active participation and offering few opportunities to apply learning.
1.4 Safety-related competency priorities	Trainees prioritized high-frequency, safety-critical competencies, including common laboratory tests and precautions, medication safety and adherence support, managing complications/multimorbidity, and continuity of chronic care.

Trainers’ perspectives

Theme 2: constraints on trainer preparedness and educational resources in county hospitals

Trainers broadly echoed trainees’ concerns about limited specialty preparation, while also highlighting systemic and infrastructural constraints that shape what training can realistically achieve in resource-limited county hospitals. Although both groups expressed similar views on the characteristics of effective training, trainers emphasized a key dependency: the implementation of a structured, competency-based framework was described as contingent upon sufficient investment in trainer preparation, both in specialty content and pedagogical skills, and on improved access to standardized, nursing-oriented educational resources. Trainers indicated that without addressing these system-level conditions, efforts to enhance training consistency and clinical preparedness across county-level hospitals would be limited.

Subtheme 2.1: limited trainer preparation in specialty content and pedagogy

Trainers reported limited formal preparation in rheumatology and immunology nursing and described uncertainty in structuring and delivering systematic training. For example, one trainer stated, “We haven’t received systematic training… [so] I feel unsure about how to deliver systematic and effective training” (Trainer 1). This highlights how gaps in foundational preparation can undermine trainers’ confidence and the quality of instruction. Rapid advances in medications and treatment concepts were described as difficult to keep pace with, particularly in the absence of structured continuing education opportunities. Trainers also noted that training often relied on informal apprenticeship models rather than clearly defined objectives and teaching strategies, which contributed to variability in learning experiences (Trainer 8).

Subtheme 2.2: limited access to nursing-relevant, high-quality training resources

Trainers described difficulties in identifying or adapting nursing-oriented teaching materials that were relevant to county-level hospital contexts. One trainer explained, “I wanted to update our training content, but the available resources were either unsuitable or of poor quality” (Trainer 3). Limited access to appropriate materials was reported as a key barrier to consistent and effective training, often forcing trainers to develop resources themselves. Another trainer noted, “It’s challenging to find relevant videos and materials for this field” (Trainer 5). Similarly, Trainer 9 observed, “I searched databases to improve our program but found very few useful resources to reference.” These accounts underscore the need for structured, accessible, and context-appropriate educational resources to support trainers and ensure training quality in county-level hospitals.

Theme 3: from fragmented instruction to structured, practice-integrated training

Trainers highlighted the need to move beyond simply requesting “more training” toward establishing structured, competency-based pathways integrated into everyday nursing responsibilities. They emphasized that training must connect theoretical knowledge with hands-on application to improve competence in county-level hospital settings. Lifelong learning and CPD were described as essential for maintaining up-to-date skills. Trainers also stressed the importance of incorporating psychological and humanistic care into clinical training to ensure holistic, patient-centered care for patients with chronic conditions.

Subtheme 3.1: from reactive training to proactive training with defined milestones

Trainers characterized current training as reactive and case-triggered rather than planned and systematically progressive. They advocated for structured programs with clearly defined goals, timelines, and progression markers to ensure comprehensive skill development. Milestones were described as including comprehensive patient assessment, understanding disease management principles, and identifying potential complications. As one trainer noted, “To comprehensively improve training outcomes, a systematic plan is essential” (Trainer 1). Another emphasized the reactive nature of current approaches, “Currently, training is reactive, occurring only when new cases arise. A proactive approach is crucial” (Trainer 5). These insights underscore the importance of planning and clear progression markers in training programs.

Subtheme 3.2: progressive learning and case-based approaches to support clinical reasoning

Given the clinical complexity of rheumatology and immunology care, trainers emphasized the importance of a staged approach that progresses from foundational knowledge to advanced clinical decision-making. This allows nurses to build confidence and competence in managing the heterogeneous cases commonly encountered in county hospitals. One trainer explained, “Training should start with basic concepts, progressively adding depth. This layered approach helps nurses develop a solid and expanding knowledge structure” (Trainer 7). Case-based learning was highlighted as an effective method to integrate theoretical knowledge with practical decision-making. Trainers noted that structured case discussions enable trainees to work through realistic scenarios, identify risks, and determine appropriate responses. Medication management, frequently encountered in routine care, was particularly emphasized within these case-based discussions (Trainer 6).

Subtheme 3.3: ensuring practice integration through supervised application

Trainers identified a persistent gap between knowledge delivery and clinical application, emphasizing supervised practice as critical to bridging this divide. They reported that practical sessions allow trainees to apply theoretical concepts safely and gain confidence in routine care. As one trainer stated, “Training often focuses on delivering knowledge without ensuring trainees understand how to apply it. Practical sessions are essential” (Trainer 1). Trainers described workplace-based learning strategies such as supervised practice, coaching, and structured feedback as central to competency development and patient safety. These approaches provide nurses with hands-on experience, directly connecting learning to clinical practice.

Subtheme 3.4: incorporating psychological and humanistic care into clinical training

Trainers emphasized that psychological support and empathetic communication are integral to caring for patients with chronic rheumatic conditions. They highlighted that addressing emotional and psychosocial needs should be embedded within training programs. Trainers observed that patients often experience anxiety or depression due to the long-term nature of their illnesses. As Trainers 2 and 3 noted, including strategies for psychosocial assessment and emotional support is essential. Additionally, enhancing communication skills and empathy was described as crucial for reducing misunderstandings and improving patient care (Trainers 9 and 10). These insights point to the need for competency-based training that prepares nurses to address both physical and emotional aspects of patient care.

Subtheme 3.5: lifelong and self-directed learning as a foundation for sustained competence

Trainers stressed that initial training cannot encompass the full scope of required knowledge, making lifelong learning and CPD essential for sustained competence. They emphasized cultivating self-directed learning skills so nurses can adapt to the evolving demands of the specialty. One trainer stated, “Due to the rapid advancements in this discipline in recent years, we need to instill the concept and methods of lifelong learning in our trainees” (Trainer 3). Another added, “We cannot cover all the knowledge in training, so we must teach our trainees how to acquire knowledge independently” (Trainer 10). Trainers recommended strategies such as reflective practice, case discussions, and access to current evidence-based resources to support ongoing learning and adaptability.

Collectively, these accounts highlight the importance of structured, practice-integrated training, reinforced by proactive planning, hands-on application, psychosocial competence, and lifelong learning strategies. Implementing these approaches can help ensure nurses in county-level hospitals develop sustained competence and deliver holistic patient care.

Trainer-derived priorities for competency-based training design are summarized in Table 4.

Table 4.

Trainer-derived priorities for competency-based training design

Subthemes	Summary of trainers’ accounts
2.1 Limited trainer preparation (specialty and pedagogy)	Trainers reported limited preparation in specialty-specific knowledge and teaching methods, and described uncertainty in structuring and facilitating training activities.
2.2 Limited access to nursing-relevant, high-quality resources	Trainers described challenges in accessing nursing-specific and high-quality educational resources, resulting in inconsistent or self-developed training materials.
3.1 From reactive teaching to a structured program	Trainers described current training as largely reactive and case-triggered, lacking an overarching structure, defined timelines, or explicit milestones.
3.2 Progressive learning and case-based approaches	Trainers described the importance of staged learning from foundational knowledge to advanced practice, supported by case-based approaches to develop clinical reasoning and prioritization.
3.3 Transfer to practice through supervised application	Trainers reported that knowledge delivery alone was insufficient and emphasized supervised clinical application and skills-focused learning to support competence development.
3.4 Psychological support and humanistic care	Trainers highlighted communication, empathy, and psychological support as important components of care in long-term disease management.
3.5 Lifelong and self-directed learning for sustained competence	Trainers emphasized the importance of integrating lifelong and self-directed learning into training and equipping nurses with strategies to support ongoing professional development.

Cross-stakeholder synthesis

Across both trainee and trainer accounts, three shared priorities emerged regarding training reform: (1) a structured, progressive pathway with clear progression markers; (2) content specifically adapted to the constraints and realities of county-level hospital nursing practice; and (3) interactive, case-based learning reinforced through supervised workplace application. These priorities highlight the need for a competency-based approach that integrates patient safety principles and practical decision-making skills into the training framework.

Notably, this synthesis identifies a critical dependency within our findings: although both trainees and trainers aligned on what constitutes effective training, trainers emphasized that the successful implementation of these shared priorities is contingent upon strategic investment in trainer preparation (including both specialty-specific knowledge and pedagogical expertise) and improved access to standardized, nursing-oriented educational resources. This finding underscores the importance of contextual and institutional support for effective implementation. Furthermore, the trainers pointed out that without these foundational resources and training, it would be difficult to achieve the consistent, high-quality learning outcomes necessary to ensure patient safety and competence in daily nursing practice.

The synthesis reinforces that reforming training requires a comprehensive approach, one that not only addresses the structural aspects of education but also integrates lifelong and self-directed learning to keep pace with advances in medical knowledge and evolving patient care needs. Ensuring that nurses receive appropriate, context-specific training, integrated into their routine practice, is essential for improving care quality and mitigating risks associated with insufficient preparation.

Discussion

This study highlights significant gaps in rheumatology and immunology nursing training in resource-limited county-level hospitals. Importantly, the findings suggest that these gaps extend beyond isolated training deficiencies to reflect a broader absence of structured, continuous professional development pathways that support sustained competence over time. In complex chronic disease management, patient safety depends not only on initial preparation but also on nurses’ capacity to engage in ongoing, contextually grounded learning throughout their professional trajectories.

Existing competency frameworks, such as those developed by the Royal College of Nursing [15], may offer a valuable reference point for addressing the identified gaps by providing structured approaches to rheumatology nursing training. However, their direct application in resource-limited settings may be constrained by differences in healthcare systems, workforce capacity, and access to educational resources. Therefore, rather than direct adoption, the findings of this study underscore the need for context-sensitive adaptation of such frameworks to ensure alignment with the realities of county-level hospitals. In this regard, translating competency frameworks into practice requires not only contextual tailoring but also the use of effective learning strategies that support their implementation in routine clinical practice.

Interactive workplace learning emerged as a critical strategy for facilitating the transfer of competencies to practice. Participants consistently emphasized the value of experiential, case-based engagement, reinforcing the importance of lifelong and self-directed learning in maintaining adaptability within evolving clinical environments. However, the sustainability of such approaches depends on systemic conditions beyond curriculum design, including trainer development in both specialty expertise and pedagogy, as well as access to standardized, nursing-specific educational resources. Together, these findings suggest that strengthening nursing capacity in resource-limited settings requires not episodic training initiatives, but integrated CPD systems that enable continuous learning and reinforce patient safety over time.

Understanding the training–practice gap in county hospitals

Beyond identifying key content and teaching methods, the findings reveal a structural misalignment between how training is organized and the competency requirements of county-level hospital practice. Participants described fragmented and poorly progressive learning experiences, often oriented toward physician-centered biomedical knowledge that was difficult to translate into nursing-specific decision-making.

Drawing on Situated Learning Theory [39], this misalignment reflects a failure of contextual authenticity. Learning is not only the acquisition of abstract knowledge, but also participation in a community of practice. When training content is decontextualized, detached from workflow realities, available resources, and common patient presentations, its contribution to safe practice becomes limited. Nurses in county-level hospitals require actionable knowledge that supports surveillance, triage, medication safety, and patient education under resource constraints. Without such contextual integration, training cannot effectively support the development of safety-oriented competence.

From a lifelong learning perspective, this gap also indicates a weakness in the design of developmental learning pathways. Early-career nurses require sequenced opportunities to progressively assume responsibility within their clinical context. When learning is episodic and disconnected from workplace realities, the transition from novice to confident practitioner may be hindered, and the cultivation of safety habits may be compromised.

Defining nursing-relevant, context-feasible competencies

Across both trainee and trainer accounts, a consistent theme emerged: existing training content lacked contextual fidelity. Participants prioritized competencies directly linked to safe rheumatology care in county-level hospitals, including medication safety and adherence support, laboratory result interpretation, recognition of deterioration, escalation decision-making, and long-term follow-up management.

These findings align with broader concerns that rheumatology medication education is often insufficiently practice-oriented [40] and with evidence that nurses rely on pragmatic, accessible resources to translate evidence into routine care [41]. A range of structured learning resources and training programs have been developed to support rheumatology education, including initiatives such as the Arthritis Training, Learning and Up-Skilling for Health Professionals (ATLAS), European Alliance of Associations for Rheumatology online learning modules, and programs offered by professional organizations such as the American College of Rheumatology. While these resources offer valuable opportunities for knowledge development and skills enhancement, their accessibility may be constrained in resource-limited settings due to factors such as cost, language barriers, and limited institutional support. This further underscores the need for contextually appropriate, accessible, and sustainable training strategies that can be effectively integrated into local clinical environments.

Importantly, our study specifies the concrete forms of situated judgment that early-career nurses find challenging: what to observe, when to escalate, and how to communicate risk, highlighting that patient safety in chronic disease management is closely tied to everyday micro-decisions. In resource-limited contexts, such competencies function as forms of “compensatory competence,” bridging gaps in specialist availability. Ensuring that these competencies are continuously reinforced through structured CPD is essential for maintaining safety standards across the early stages of professional development.

Supporting transfer to practice: embedding lifelong learning into everyday work

Participants’ preference for case-based and skills-oriented formats underscores a transfer-to-practice gap: acquiring information does not necessarily translate into its safe application in heterogeneous, time-pressured environments. Lecture-dominant approaches may be insufficient to develop clinical reasoning and situated judgment.

Educational scholarship supports competency-oriented and active learning strategies [24, 42], including structured case discussions, scenario-based learning, and supervised workplace practice [43]. Within rheumatology, interactive case-based teaching has been recommended to connect abstract concepts to clinical reasoning [44]. Regional initiatives in the Asia-Pacific region have reported positive learner experiences using case-based and discussion-oriented approaches in rheumatology nurse education [45].

However, in resource-limited county-level hospitals, the challenge extends beyond pedagogical format. Sustainable improvement requires embedding lifelong learning mechanisms into daily routines. Pragmatic strategies may include brief case huddles during shifts, low-cost simulations reflecting common local scenarios, structured observation-and-escalation prompts, and coached workplace feedback cycles. When integrated into routine clinical workflows, these approaches transform isolated teaching events into continuous developmental processes that strengthen patient safety competencies.

Moreover, fostering habits of reflection and self-directed inquiry is essential. Microlearning modules, accessible digital resources, decision aids, and shared case repositories can provide a scalable CPD infrastructure, particularly where specialist mentorship is limited. Such strategies align with the principle that maintaining patient safety in complex care environments requires ongoing competence renewal rather than one-time certification.

Implementation requirements: sustaining CPD capacity in resource-limited systems

Trainers identified additional systemic constraints, including limited opportunities for specialty updating, insufficient pedagogical preparation, and restricted access to nursing-focused teaching materials. These constraints underscore that curriculum reform alone cannot ensure sustainable lifelong learning.

For CPD systems to function effectively, enabling conditions must be established. Train-the-trainer initiatives, shared case libraries, and standardized microlearning resources may reduce dependence on individual expertise and promote consistency across sites. Emerging evidence suggests that remote and blended modalities can extend educational reach in resource-constrained environments [46, 47], offering potential avenues for scalable and sustainable CPD infrastructure [48].

Future research should evaluate not only educational outcomes but also implementation feasibility and long-term sustainability, recognizing that lifelong learning systems require sustained organizational commitment, resource alignment, and supportive policy frameworks.

Implications for curriculum development, assessment and evaluation

The findings highlight the need for a structured, progressive CPD framework in county-level hospitals. Effective models should include: (1) a sequenced progression from onboarding to advanced responsibilities, (2) a clear focus on high-frequency, safety-critical tasks, (3) active pedagogical strategies that foster situated reasoning, (4) systematic faculty development, (5) standardized, accessible educational materials, and (6) the integration of psychological support, humanistic care, and lifelong learning awareness and methods.

Assessment strategies must evolve beyond simple knowledge recall to evaluate applied competence and safe clinical reasoning within clinical context. Pilot programs should assess not only learner satisfaction but also the transfer of knowledge into practice and measurable improvements in safety-related behaviors.

By embedding early-career development within a broader lifelong learning framework, healthcare systems can enhance specialist nursing capacity and reinforce patient safety throughout the trajectory of professional growth, particularly in underserved and resource-limited environments.

Strengths and limitations

A key strength of this study lies in its dual-perspective design, recruiting both trainees and trainers from six county-level hospitals. This enabled the triangulation of perspectives, ensuring that the identified educational needs were interpreted in relation to contextual realities and feasibility constraints.

However, several limitations should be acknowledged. First, as participants were recruited from a single region in China, the findings may reflect specific local policies and resource conditions, potentially limiting their transferability to other provinces or differing health systems. Second, this study functioned as a diagnostic needs assessment rather than an interventional study. Although this study did not directly evaluate the outcomes of a newly implemented curriculum, the findings may provide empirically grounded insights to inform the design of future competency-based programs, supporting the development of approaches that are grounded in practice-based evidence rather than assumption.

Implications for health professions education

In light of the study’s findings, competency-based training programs for early-career nurses in rheumatology and immunology could be further developed into more structured and progressive pathways with clearly defined milestones, supporting a staged progression from initial onboarding to independent clinical practice. This framework should prioritize high-frequency, safety-critical tasks, such as laboratory monitoring, medication safety, and complication management, while integrating these technical competencies with humanistic care to promote a holistic, person-centered approach to clinical practice.

To bridge the gap between theory and practice, educational delivery must move beyond passive instruction. Active learning strategies, such as structured case discussions and supervised workplace experiences, should be incorporated to facilitate real-world knowledge transfer and enhance patient safety. However, curriculum reform alone cannot ensure the sustainability of lifelong learning systems. Trainers highlighted systemic constraints, including limited opportunities for specialty updates, insufficient pedagogical preparation, and lack of access to nursing-focused teaching materials, which must be addressed for CPD systems to function effectively and consistently across settings.

For sustainable CPD, enabling conditions are crucial. Train-the-trainer initiatives, shared case libraries, and standardized microlearning resources can reduce dependence on individual expertise and promote consistency across sites. Emerging evidence suggests that remote and blended learning modalities may extend educational reach in resource-limited environments, offering a scalable CPD infrastructure. Future research should assess not only educational outcomes but also implementation feasibility and long-term sustainability, emphasizing the need for sustained organizational commitment, resource alignment, and supportive policy frameworks to ensure enduring, effective lifelong learning systems.

Conclusions

Early-career rheumatology and immunology nursing training in county-level hospitals was perceived as fragmented and insufficiently aligned with routine clinical practice. Strengthening specialist nursing capacity in resource-limited settings therefore requires structured, competency-based CPD pathways that support progressive skill acquisition and sustained clinical competence over time.

Programs should prioritize nursing-relevant, safety-critical competencies and adopt pedagogical approaches that facilitate transfer to practice, including case-based discussion and supervised workplace learning. Sustainable implementation will depend not only on curriculum design but also on strategic investment in trainer development, accessible educational resources, and system-level support mechanisms that enable lifelong learning and reinforce patient safety across early career trajectory.

Abbreviations

CPD

Continuing Professional Development

COREQ

Consolidated Criteria for Reporting Qualitative Research

Authors’ contributions

Lijuan Xia: Writing – original draft, Methodology, Investigation, Funding acquisition, Formal analysis, Data curation, Conceptualization. Sujuan Chen and Yuan Ma: Investigation, Formal analysis, Data curation, Validation. Bin Yan, Zhifang Ma, and Fang Feng: Investigation, Formal analysis, Data curation. Jijuan Yang and Shuhong Chi: Investigation, Funding acquisition, Resources, Formal analysis, Data curation, Conceptualization. Naoko Hayashi: Writing – review & editing, Validation, Investigation.

Funding

This research was supported by the Key Research and Development Program of Ningxia, China (grant number: 2023BEG03006). The funding body had no role in the design of the study; in the collection, analysis, or interpretation of data; or in writing the manuscript.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. The data are not publicly available due to privacy or ethical restrictions.

Declarations

Ethics approval and consent to participate

Ethical approval was obtained from the Ethics Committee of the General Hospital of Ningxia Medical University (approval number: KYLL-2022-1155). The study was conducted in accordance with the Declaration of Helsinki and relevant institutional guidelines and regulations. Written informed consent was obtained from all individual participants included in the study. Participants were informed about the research objectives and procedures. Their anonymity was guaranteed and the confidentiality of their data was strictly protected. Participation was voluntary and participants were free to withdraw at any time without consequences.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.