Electronic Continuing Professional Development (e-CPD) to Improve Competencies of Indonesian Clinical Nurses: An exploratory action research study protocol

doi:10.21203/rs.3.rs-4619908/v1

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Study protocol

Electronic Continuing Professional Development (e-CPD) to Improve Competencies of Indonesian Clinical Nurses: An exploratory action research study protocol

https://doi.org/10.21203/rs.3.rs-4619908/v1

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Background.

The CPD programs available for nurses in Indonesia need an organized structure to align with individual nurses' specific career trajectories. The distribution of opportunities for CPD is inequitable, posing problems for nurses engaging in CPD activities. These challenges arise from insufficient financial support, a lack of time, and constraints due to work schedules. These programs should be designed in accordance with fundamental principles, advancements in educational technology, cost-effectiveness, ease of access, and the advantages they offer for career advancement and the development of competencies. Study aims to explore and develop the e-CPD model as it is applied on clinical nurses in Indonesia.

Methods.

Research design used Exploratory action research. Data collection will occur in two primary stages: exploration and acting. During the exploration stage, the research team conducted Focus Group Discussions (FGDs) with three distinct groups of participants. Simultaneously, inside the acting stage’s scope, instructional design development, e-CPD platform creation, and user testing will be undertaken.

Discussion.

The e-CPD is a ward-based learning activity that facilitates self-directed learning by providing information resources such as protocols and literature. The inherent nature of this model promotes the distribution of concise segments of essential content presented in platform formats that facilitate engagement among peers and mentors, interactivity, user-friendly digital learning opportunities, and support from peers and mentors. This study offers new light on how an e-CPD might be used as an alternative CPD model for clinical nurses.

Trial Registration.

This trial is registered under ClinicalTrial.gov with identifier number NCT06047652 on September 14, 2023.

exploratory action research

electronic learning

CPD

continuing professional development

nurses/nursing

protocol

The electronic continuing professional development (e-CPD) that will be made in this study is a type of CPD in which educational services are combined using face-to-face and e-learning as an information and communication technology application. This definition encompasses blended, distributed, decentralized, hybrid, and flexible learning (Leidl et al., 2020). E-CPD is identified to be as effective as face-to-face CPD in improving nurses' knowledge, clinical skills, motivation, job satisfaction, self-confidence, and facilitating career (Beckett, 2020; Hakvoort et al., 2022; Sajwani et al., 2020).

This study introduces a blended approach to CPD in nursing as an innovative and necessary strategy to enhance lifelong and continuous learning, specifically in Indonesia, where there is a need for enhanced implementation of formal CPD initiatives. Different learning activities can be facilitated through face-to-face interaction and distance learning, including formal, informal, self-directed, research-based, and community-based approaches. These activities are acknowledged as effective means of conducting CPD initiatives. The activities provided are customized to suit the specific practice area of everyone, hence addressing their unique learning requirements. Clinical mentorship is integral to the ongoing professional development initiative, which endeavours to cultivate proficient healthcare practitioners. The mentorship program can adopt a hybrid approach to cater to the learning needs of mentees, incorporating both face-to-face consultations and virtual consultations (Michel-Schuldt et al., 2018).

Currently, CPD for license renewal for nurses is mandatory in Indonesia. However, there is no definite standard and structure for its implementation, resulting in a lack of coordination and no quality control over the training held. To address this gap, e-CPD was developed to accommodate training needs to stay with the required competencies. This study aims to develop, implement, and evaluate e-CPD for clinical nurses.

Background

A brief definition of CPD

Continuous professional development (CPD) refers to the ongoing educational opportunities that are accessible to professionals after the completion of their first professional training (Nyiringango et al., 2023). CPD is an essential component of continuous learning that enables nurses to maintain their competence in the field (Cusack et al., 2019). CPD contributes to continuous learning and preserves the practicability of nurses (Nursing and Midwifery Board of Australia, 2016). Given its beneficial impact on patients, professionals, and organizations, encouraging the CPD of nurses within a clinical setting is crucial (Vázquez-Calatayud et al., 2021). Conversely, the method of delivering CPD is another crucial factor in attaining the desired objective. In the field of healthcare, there are three primary modalities for offering CPD: primarily face-to-face, purely online, and a hybrid approach combining elements of both. The utilization of face-to-face mode for distribution is commonly employed, yet it is perceived as a costly approach in terms of both temporal and financial resources. Primarily, the augmented expenses are attributable to the transition from the professional setting to a location where individuals can convene with the specialist (Nyiringango et al., 2023).

CPD can be carried out to maintain and ensure competent nurses who can improve professional nursing practices. CPD aims to improve nurses' competence, safety, and professionalism (Hariyati & Safril, 2018). Continuing development is defined as the entirety of educational opportunities provided in practical settings, and it holds significant importance in the enhancement of nurses' competencies (Azimirad et al., 2023). CPD is thus essential for nurses to attain, retain, and improve the expertise and abilities required to provide person-centred, safe, and effective care (Embree & Little, 2021). This CPD activity has also become a requirement for health workers, particularly nurses, in order to improve professional development, retain staff, and be trained (World Health Assembly, 2021).

CPD in nursing should be implemented in accordance with the professional needs of their work. Each nurse's CPD needs should be planned in accordance with the competencies that must be possessed. This planning is based on training assessment and clinical assessment of nurses (Gallagher et al., 2012). Nurse working in a paediatric ward, for example, should have all her CPD activities related to her competence and clinical authority. Alternatively, the nurse on duty in the emergency department should participate in CPD related to emergency knowledge and skills. The better the competencies, the more advanced the expertise and career path.

According to Benner (1982), the concept of CPD is that every professional development activity carried out will help nurses progress from novice to expert. This means that nurses' continuing education is closely related to the career path they will take. CPD should be implemented on a continuous basis and in accordance with the nursing career map (Herawati et al., 2017). The implementation of this career path must include not only the mapping and clinical authority that each nurse has, but also the relevant CPD program (Nelson et al., 2008).

CPD, regardless of method, including e-CPD, is a learning process. When designing an e-CPD program, not only technology but also other learning tools such as curriculum, which must be prepared with learning plans, assessment instruments, and learning media, are prepared (Davies et al., 2017). All learning activities must be in sync with the compiled curriculum in order for the learning method to be effective and efficient (Friese & Ailey, 2015). It should also be noted that CPD provided by nurses can help to improve nurse competence.

The implementation of CPD varies across countries. For example, in the UK nurses must clearly show that they have completed a minimum number of hours of CPD over a three-year period to attain their licence (Nursing & Midwifery Council, 2019). In India, nurses must renew their registration every five years and complete 30 credit hours per year by attending continuing education activities (Delhi Nursing Council, 2016). There is no CPD requirement for nurses to re-register in the Netherlands. Nurses can simply voluntarily register their CPD activities in the National Quality Register (Cutcliffe & Forster, 2010).

Barriers to CPD implementation, according to Alshahrani (2020), include finances, a nursing shortage, and a lack of sufficient time due to improper scheduling. CPD is usually offered by nursing academic institutions, for which nurses must reimburse, or it is occasionally provided by the hospital where the nurse works. Many employees compete for a limited amount of money. When educational institutions discontinue providing this activity, its implementation can be hampered (House of Common Health Select Committee, 2018). The hospital management's allocation of funds for CPD appears to be a minimal cost in order to encourage and foster nurse competence; it should be supported and recognized, as competent nurses are a valuable asset (Scammell, 2018). CPD in Indonesia has not been based on development needs or competency requirements due to lack availability to undertake CPD (Herawati et al., 2017). To overcome the barriers, e-CPD is a potential effective method.

Indonesia study context

In Indonesia, the Clinical Nurse Professional Career Path begins with Level I Clinical Nurses and progresses to Level V Clinical Nurses. Further, CPD is a component of the prerequisites for nurses to re-register. Registration is done every five years by showing a minimum of 25 credit units in CPD, professional practice activities, community service, and scientific program. Thus far, the CPD that has been implemented does not align with the level of expertise possessed by nurses. Nurses has the autonomy to engage in CPD pertaining to any subject matter. The likelihood of nurses obtaining CPD is inconsistent. The challenges arise due to several limitations, including time constraints, availability of nurses, financial considerations, and the need for clearance from supervisors. Finally, the implementation of CPD has not been carried out in accordance with the specified competency evaluation requirements (Hariyati et al., 2017). The discovery of competency gaps from credential results or the advancement of science and technology in the context of the career path, which requires certain competencies, are two reasons for the need for CPD. This policy also specifies all CPD activities that clinical nurses could perhaps pursue based on their competencies at each career level (Ministry of Health of The Republic of Indonesia, 2017).

McKenna et al., (2022) conducted a study among 1355 Indonesia nurses and found that Indonesian nurses perceived direct care tasks are more important than performance, and training need., while supporting tasks were rated lower on performance and training need. Nurses with less than a year of experience said they needed more training. Another study conducted in Indonesia is the participation rate of nurses in a regional hospital, where 69.2% is classified as a low participation rate. Some nurses in this survey are reported to be able to quickly achieve structural and clinical positions of nurses through skills, approaches, and recommendations of managers rather than achieving competencies that are in accordance with the improvement of the clinical career path (Muhadi & Titin Wahyuni, 2023). This provides strong evidence for the necessity of implementing structured CPD programs that adhere to established regulations and standards. These programs should be designed in accordance with fundamental principles, advancements in educational technology, cost-effectiveness, ease of access, and the advantages they offer for career advancement and the development of competencies.

Since the Covid-19 pandemic, virtual education and training has become a new trend globally including in Indonesia. INNA hosted an online webinar series as a form of e-CPD with a variety of topics covered in each session. Participants in each activity can reach a total of 20,000 people. Academic institutions, in addition to INNA, offer free nursing webinar series (Elysia, 2020; Indonesian National Nurses Association, 2020). According to the findings of interviews with webinar organizers and trainings from INNA's association of nurse’s seminar, there are several things that require attention and consideration when organizing e-CPD activities such as those organized by INNA.

To begin with, the number of participants is always in the tens of thousands. This large number of participants is advantageous on one hand because it is hoped that many nurses will gain knowledge and understanding. However, it is debatable whether the following CPD topic is relevant to the professional development of nurses in the workplace. This issue should undoubtedly be given special consideration. Second, at the start and end of the webinar session, load the application system. For example, when a webinar begins, tens of thousands of participants log in at the same time, resulting in numerous complaints from participants if they are unable to join, and it is not uncommon for the system to hang. Why did the same thing happen at the end of the session? Due to this tendency, participants will join fully only at the beginning and end of the webinar session, and many participants will leave the online meeting room during the session. Third, participants' active participation. Despite the large number of participants, the activity is not proportional to the number of participants who join. Participants who asked questions or responded to the source's questions made up less than 1% of those who joined. Fourth, both speakers and participants must maintain network stability. In Indonesia, this is still very common. Furthermore, participants came from various geographic areas with varying network connection quality. Lastly, there is no formal evaluation of participants; only attendance and/or pre- and post-test scores for knowledge and/or attitude are recorded (Arisandi et al., 2023; Bakar et al., 2023; Main et al., 2019; Yo et al., 2021). The aforementioned phenomena present an opportunity for nurses in Indonesia to utilize online learning technology. This is expected to mitigate any difficulties in the future regarding the development of e-CPD.

The CPD programs available for nurses in Indonesia lack an organized structure and struggle to align with the specific career trajectories of individual nurses. The distribution of opportunities for CPD is not equitable, posing problems for nurses in engaging in CPD activities. These challenges arise from insufficient financial support, a lack of time, and constraints due to work schedules. Therefore, developing a pertinent e-CPD framework for clinical nurses is of utmost importance, as it can potentially promote professional nursing practice and cater to diverse career trajectories. The incorporation of information and communication technologies is important to overcome current obstacles. The e-CPD holds significant importance in Indonesia because to its flexibility in regard to time and location. It allows professionals to engage in continuous learning during a designated period. Moreover, e-CPD enables mentors to provide aid without interrupting their regular work commitments.

Additionally, this approach integrates existing activities with service-oriented initiatives, obviously, through the modification of the requisite level of proficiency for each tier of professional advancement. Nurses are anticipated to expeditiously meet their skills and embark upon a vocation as proficient healthcare practitioner. The intention is that this e-CPD platform will serve as an umbrella for implementing CPD utilizing the blended learning approach within the context of Indonesia.

Aim

This study is to explore and develop the e-CPD model as it is applied within the clinical nursing setting, with a specific focus on Level II clinical nurses. The intention is to enhance these models to contribute to the professional development of clinical nurses in Indonesia. The precise study objectives are to:

Exploring the necessity of e-CPD among clinical nurses.

Creating e-CPD instructing designs for clinical nurses.

Tailoring a design for an e-CPD program specifically for clinical nurses.

Conducting e-CPD tests for clinical nurses.

Design

The design of this study will be exploratory action research (EAR). The design is chosen because the purpose of the research is to develop an e-CPD model for hospital nurses by exploring the needs of all stakeholders in the expectation of improving the situation then proceeded with the action based on the findings of the investigation. The principle is made up of exploration and action research, specifically when exploration research is followed by action research. According to Smith & Rebolledo (2016), the EAR stage consists of the exploration stage and the action stage. EAR also allows for the use of non-traditional data collection methods such as sharing stories, in-depth interviews, workshops, and focus group discussions (FGDs). This research will be divided into two stages (Fig. 1), as follows:

Exploration Stage

This stage has three steps: plan to explore – explore – analyse and reflect. At plan to explore step, the researcher selects the area or situation that will be the focus of the research, organizes the questions that must be answered, and plans how to collect information to answer the questions that have been prepared using the FGD guidelines. Proceed to the explore step, The researcher collects data through focus groups involving hospital management, nurse professional organizations, and nurses to clarify the identified situation. The main thing is to collect data on a regular basis so that researchers can effectively analyse and interpret it. The final step is to analyse and reflect, in which the researcher analyses the entire process and reflects on what is happening by conducting analysis FGD and determining a follow-up plan.

Action Stage

The action stage is divided into four steps: plan - act - observe - reflect. The researcher begins by deciding what to change and planning how to collect additional data to see what happens when making instructional and e-CPD design. In the act step, researchers put planned changes or interventions into action by piloting e-CPD. Followed by observe step, researchers collect data during implementing the e-CPD, which is then analysed. Finally, reflect step, the researcher interprets what has happened, focusing on the evaluation of e-CPD and considering any additional actions that are deemed necessary. Researchers will almost certainly decide that this research should be expanded or that additional action research should be conducted.

Setting

The study will be undertaken at a regional private hospital in Indonesia, with the understanding that a private hospital has the freedom to develop its own system because it is not heavily regulated by the government.

Sample

The sample in this study changes at each stage to meet the needs of the research. Samples for the explore stage include: 1) Nurses with criteria are those who provide direct nursing care to patients and have at least a level II clinical nurse. This activity requires the participation of ten nurses. Purposive sampling criteria are used; 2) Hospital management with serving criteria holds a managerial position in the hospital and is involved in the implementation of nurse CPD. The number of participants ranged from 9 to 12. Criteria for sampling using criterion sampling; 3) Representatives of the professional nursing association with members of the criteria regional committee who are directly involved in overseeing CPD policies for nurses. The number of participants ranged from 9 to 12. Criteria for sampling using criterion sampling.

Participants in the action stage include: 1) Nurses with the ability to prepare nurse modules and nurses who have received nurse competency assessor training both internally and externally. This activity requires 8–10 nurses to participate using purposive sampling techniques; 2). Secondary participants as experts are nurses who have been designated as an expert partner in the hospital's nursing credentialing process; 3) IT professionals with expertise and experience in developing e-learning systems for education and healthcare; 4) Level I clinical nurses who need CPD in accordance with the competences that have been prepared, have and can use gadgets, and are willing to participate in all e-CPD activities. Purposive sampling techniques were used to select 8 participants. This number was chosen in reference to Johanson & Brook (2010) who stated that the amount was the minimum acceptable number of samples for a device feasibility clinical trial.

Data collection

Data collection usually breaks down into two main stages. The flowchart study is illustrated in Fig. 1 and can be described as follows:

Stage I: Exploration

The explorations stage focuses on exploring the current situation (Smith & Rebolledo, 2016). This stage's objective is to gathering data on current CPD implementation, experiences, and policies in nursing. The following activities were carried out: 1) FGD with nurses to discover experiences and hope; 2) FGD with hospital management to continue exploring experiences, support, and internal regulation; and 3) FGD with professional nursing association to explore how to control and regulate it. Each focus group session will last approximately 90 minutes. The FGD results will be analysed to identify strategic issues for consideration in the next stage.

Stage II: Acting

Three research activities will be carried out at this stage.

First, we will develop instructional design. A workshop on drafting instructional designs with clinical nurse assessors will be held 2 times. The workshop resulted in the creation of a draft of the e-CPD module. The research team will revise the layout on the draft created from the workshop results. The draft module will then be sent to the expert for a conformity check. Following the expert review results, a workshop will be held to make improvements based on the expert review. The research team will finalize module, which will then become a suitable e-CPD module that will serve as a model for future e-CPD development.

Second, the development of the e-CPD design, with the goal of creating an e-learning system that is tailored to the prepared modules. Activities at this stage include: communicating with IT professionals for the purpose of developing an e-CPD system; develop applications made by IT professionals; compiling teaching media in accordance with the modules and design of the e-learning system; discussions and coordination between researchers and IT professionals during the system development process; coordinate with hospital management and educational institutions providing e-learning if the system development process encounters problems. Because hospitals have no experience managing learning management systems, educational institutions are involved in order to increase the success of implementing e-CPD.

Third, the evaluation of an e-CPD design. The final stage is carried out with the goal of evaluating the e-CPD design that was developed in the previous stage. Among the activities carried out are: socialization about how to use of e-CPD to hospital management, structural nursing, and nurses; conducting trials using e-CPD in accordance with the prepared modules; communicate with and assist nurses during the trial; coordinate and communicate with IT professionals if obstacles arise during the trial process; conduct a feasibility test by distributing the System Usability Scale questionnaire (Sharfina & Santoso, 2016) to nurses; hold discussions with the research team to evaluate the process and results of e-CPD development; and develop a follow-up plan.

Data analysis

The analysis will be conducted utilizing both quantitative and qualitative methodologies.

Qualitative analysis

This analysis is used for data analysis during qualitative data gathered during the exploration and the end of action stage to evaluate e-CPD development and develop a follow-up program. Qualitative data analysis involves three interconnected stages: data reduction, data presentation, and drawing conclusions or verification (Matthew B. Miles et al., 2014). The instrument is considered valid in qualitative research if there is no difference between what the research study investigated and what probably occurred to the object being studied. According to research design, data reality is diverse and dependent on human concept, constructed in a person as a result of each individual's mental processes with different backgrounds. Qualitative analysis software such as NVIVO will be used to facilitate in the analysis.

Quantitative analysis

The design evaluation includes data analysis for quantitative data. The analysis of the study's results will carry out using univariate analysis. This analysis, in general, only produces the distribution and percentage of each variable. Age, gender, gender, education level, length of service, and SUS scores. To analyse statistical results, the Statistical Package for the Social Sciences will be used (SPSS Version 25).

Ethical considerations

At each stage, all samples will be given an explanation of the study's purpose and informed that their participation is confidential and voluntary. Participants will be required to sign an informed consent form in writing. Digital audio files from interviews and focus groups will be saved in a pin code file accessible only to members of the research team. The Medical and Health Research Ethics Committee (MHREC) Universitas Gadjah Mada – DR. Sardjito General Hospital granted permission to conduct this study (Ref. No.: KE/FK/0963/EC/2022). This trial is registered under ClinicalTrial.gov with identifier number NCT06047652 (Registration date 09/14/2023).

Validity and reliability/rigour

The following will be addressed regarding rigor in the qualitative components of the research. Data triangulation from focus groups and different groups of participants will be used as needed to check for consistency and divergence across the data set. Data analysis will involve all of the research group. An initial analysis conducted by one researcher will be checked by a second researcher to ensure consistency in coding and to protect against data selectivity. Throughout, a reflexive approach will be used in which researchers will examine their role in the research process as well as the assumptions that influence their interpretation of data. A detailed audit trail will be kept, detailing the steps involved in gathering and analysing data.

The study's validity and reliability will be improved by using validated questionnaires to assess the feasibility of e-CPD designs for nurses. Sharfina & Santoso (2016) worked on the translation of the instrument (2016). The instrument is made up of ten statement items with a Cronbach's alpha of 0.841. Accepted if the score is greater than 70; slightly acceptable if the score is between 50 and 70; and not accepted if the score is greater than 50.

The study's findings will show how to develop e-CPD in Indonesia starting from exploring need, compiling instructional design by adjusting competencies, designing e-CPD by adjusting learning needs and hospital management capabilities, and evaluating so that improvements can be made to future research by adjusting competencies and incorporating how to utilize information and communication technology.The objective of this research is to provide an alternative CPD model for clinical nurses in Indonesia in order to improve the quality of their nursing care and to foster a learning culture wherever and whenever possible. We believe that this process will be difficult, but with the collaboration of various stakeholders, e-CPD can be a model alternative for internal hospital nurse self-development.

This model hopes that, as daily practice is an abundant resource for learning, its educational potential will be recognized and systematically utilized. The structure is intended to encourage a conducive learning atmosphere. It can promote learning by monitoring and providing feedback to nurses (Pool et al., 2015). The e-CPD is a ward-based learning activity that facilitates self-directed learning through the provision of information resources such as protocols and literature. This study is to enhance the awareness of nurses as lifelong learners.

Previous research has indicated that the online style of blended learning has been widely accepted. Additionally, it has been found that nurses who engage in blended learning can enhance their support abilities, knowledge, and confidence levels (Bos – van den Hoek et al., 2023). The blended learning approach offers an alternative educational setting integrating several instructional systems and technological tools. The ongoing progress in information technology and information systems has significantly facilitated the utilization of new methods, hence enhancing the learning environment for nurses (Tsai et al., 2018).

The e-CPD employs mentorship as a pedagogical approach. The enhancement of social support and reduction of feelings of isolation were observed as a result of increased peer-to-peer and mentor interaction. The inherent nature of this model promotes the distribution of concise segments of essential content presented in platform formats that facilitate engagement among peers and mentors, interactivity, user-friendly digital learning opportunities, and support from peers and mentors. The ultimate goal is to enhance the quality of health services (Guillaume et al., 2022).

Limitation

This study has some limitations, as does the current study protocol. The findings, in specific, cannot be generalized outside of the research context; however, they do tend to provide knowledge of the same context, particularly the development of electronic learning for CPD.

This study will provide new information about how this e-CPD can be used as an alternative CPD model for clinical nurses. It is desired that this model will overcome the various challenges that have arisen in the implementation of CPD for nurses in the past, particularly in Indonesia. In the future, improvements, and studies on the effectiveness of this CPD model to increase nurse competency may be required.

Supplementary Information

Not Applicable

Acknowledgements

The researcher would like to thank Universitas Muhammadiyah Yogyakarta for funding the research study and Prof. Erna Rochmawati, Ph.D., for her helpful insights and comments on the article.

Funding

This study was partially funded by a grant from Research and Innovation Center Universitas Muhammadiyah Yogyakarta's (Number: 517118101).

Author’ Contributions

Criteria	Author initials
Made substantial contributions to the conception and design	NKS, TSP, LL
Involved in drafting the manuscript or revising it critically for important intellectual content;	NKS, TSP, LL
Given final approval of the version to be published.	NKS, TSP, LL
Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.	NKS, TSP, LL

Note:

NKS : Novita Kurnia Sari

TSP : Titi Savitri Prihatiningsih

LL : Lely Lusmilasari

Availability of data and materials

Not applicable.

Ethics approval and consent to participate

This study has been approved by The Medical and Health Research Ethics Committee (MHREC) Universitas Gadjah Mada – DR. Sardjito General Hospital (Ref. No.: KE/FK/0963/EC/2022) and registered under ClinicalTrial.gov with identifier number NCT06047652. All study participants will provide their written informed consent prior to participating in any data collection activities.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author details

Novita Kurnia Sari^1,2, Titi Savitri Prihatiningsih³, Lely Lusmilasari⁴

Corresponding author: Novita Kurnia Sari

¹Student of Doctoral Program, Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University, Sleman, Yogyakarta, Indonesia; ²Department of Fundamental and Nursing Management, Nursing School, Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, Bantul, Yogyakarta, Indonesia, Email: [email protected]; ³Department of Medical Education Unit, Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University, Sleman, Yogyakarta, Indonesia;, Email: [email protected], ^4*Department of Pediatric Nursing, Faculty of Medicine, Public Health, and Nursing, Gadjah Mada University, Sleman, Yogyakarta, Indonesia, Email: [email protected].

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No competing interests reported.

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Electronic Continuing Professional Development (e-CPD) to Improve Competencies of Indonesian Clinical Nurses: An exploratory action research study protocol

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