Shen et al.

BMC Medical Education (2024) 24:803 BMC Medical Education

[Link]

RESEARCH Open Access

Online digital health and informatics

education for undergraduate nursing students
in China: impacts and recommendations
Hongxia Shen1,2,3*†, Chong Chen1†, Sijing Yan1, Cynthia Hallensleben2,3, Rianne van der Kleij2,3, Minyi Li1,
Huohuo Dai2,3, Niels Chavannes2,3 and Ying Zhou1*

Abstract
Background Digital health plays a vital role in healthcare services. Governments in many countries, including
China, are increasingly advocating for the appropriate use of digital technologies to address significant health
system challenges. It is crucial to incorporate digital health education into the curriculum for future nurses to adapt
to the changes in the digital medical system. This study aimed to evaluate the impact of an online Digital Health
and Informatics Course in China on the knowledge and comprehension of key digital health and informatics topics,
self-assessment of nursing informatics competencies, and satisfaction among undergraduate nursing students. The
findings of this study provide recommendations for the design and implementation of future digital health education.
Methods This study employed a one-group, quasi-experimental mixed-methods design with pre- and post-
assessments. The participants received digital health and informatics education through six three-hour online sessions
in six interactive days, with online self-learning materials in between. An online quiz and focus group discussions
pre- and post the course were designed to evaluate the knowledge and comprehension of key digital health and
informatics topics. Also, a validated Chinese version of the Self-assessment of Nursing Informatics Competencies Scale
was conducted pre- and post-course to assess self-assessment of nursing informatics competencies. Additionally, all
students were invited to participate in an online survey with a performance-focused course evaluation form as well as
focus group discussions to gather their feedback on the learning experience and their evaluations of the course.
Results A total of 24 undergraduate nursing students were enrolled in the course. All students completed all sessions
of this course, resulting in an attendance rate of 100%. Additionally, all students completed both pre- and post-
assessments. In terms of the knowledge and comprehension of key digital health and informatics topics, scores of
the quiz on knowledge assessment improved from the pre-test [mean pretest score: 78.33 (SD 6.005)] to the post-
test [mean post-test score: 83.17 (SD 4.86)] upon completion of the course (P < 0.001). Also, students acknowledged
that the course enhanced their knowledge and comprehension of informatics and digital health, the benefits of

†
Hongxia Shen and Chong Chen contributed equally to this work.
*Correspondence:
Hongxia Shen
[Link]@[Link]
Ying Zhou
zhouying0610@[Link]
Full list of author information is available at the end of the article

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Shen et al. BMC Medical Education (2024) 24:803 Page 2 of 14

(nursing) informatics in clinical practice, and the role of health care professionals in informatics and digital health. In
terms of self-assessment of nursing informatics competencies, scores on nursing informatics attitudes demonstrated
significant improvement (P < 0.001). Furthermore, students reported high satisfaction with various aspects of this
course, including the opportunity to explore broad horizons in informatics for future careers, engaging in group
discussions, and analyzing case studies on the use of informatics and digital health in clinical practice.
Conclusions This Online Digital Health and Informatics education effectively improved undergraduate nursing
students’ knowledge and comprehension of the key digital health and informatics topics, nursing informatics attitudes
in the self-assessment of nursing informatics competency with high levels of satisfaction. In order to ensure that
future education in digital health and informatics for nursing students is in line with the technological advancements
in clinical settings, it is necessary to foster collaboration between medical school training and clinical practice. This
collaboration should involve the use of clinical examples to illustrate advanced digital health applications and the
inclusion of practical exercises on the use of digital health technology in clinical settings.
Keywords Digital health, Informatics, Chinese nursing students, Education, Competency, Knowledge

Background appropriate use of digital technologies and therefore help

Digital health is defined by the World Health Orga- address key health system challenges in general and in
nization (WHO) as the field of knowledge and prac- China in specific, it is important to enhance individuals’
tice associated with the development and use of digital understanding and use of digitally enabled approaches to
technologies to improve health. Developments such as care. This will ultimately lead to improved quality of care,
digitally mediated diagnosis and treatment, cloud com- better health outcomes and reduced medical costs.
puting, machine learning, artificial intelligence, block- Currently, numerous digital health technologies remain
chain, telehealth, and consumer-facing mobile health in the pilot stage and have not yet demonstrated their
applications have enhanced the delivery of care for indi- effectiveness or been successfully implemented on a
viduals across the spectrum of health promotion and larger scale in a real-world setting. The limited knowl-
disease prevention, diagnosis, treatment, and rehabilita- edge and skills of healthcare professionals (HCPs) in uti-
tion [1, 2]. Digital health solutions are also recognized lizing new technologies and concerns regarding privacy,
for their benefits in nursing practice, including integrat- and security quality are significant obstacles to the adop-
ing data records across various databases, providing tion of digital health in clinical practice [13]. The Global
electronic decision support and resources, and develop- Digital Health Strategy 2020–2025 of WHO empha-
ing digital devices that facilitate remote monitoring and sizes the importance of incorporating specific actions
individuals’ positive behavior change [3–5]. Especially to ensure that all health professionals and allied work-
during the coronavirus disease (COVID-19) pandemic, ers, at all levels of formal education and informal train-
digital health applications have been noted as an innova- ing, receive education and training on digital health [14].
tive health solution that improves continued healthcare Developing high levels of digital health informatics com-
accessibility and streamlines public health action to stop petencies among health professional students will facili-
the rapid spread of the crisis [6, 7]. tate their understanding of the essential requirements for
Governments in the United States, India, Tanzania, successful implementation of digital health [15]. There-
Ethiopia, and other countries have developed national fore, there is an urgent need to develop courses on digi-
digital health strategies, which outline a shared vision for tal health in medical schools to educate future HCPs on
addressing health priorities through the coordinated and integrating digital health technological innovations and
strategic use of interoperable digital technologies [8–10]. preparing them to adapt to future changes in the digital
As the largest developing country, policymakers and medical system within their workforce.
healthcare experts in China have launched the national At present, many medical schools and research insti-
health strategy ‘Healthy China 2030’ [11]. This strategy tutions worldwide have incorporated the digital health
recognizes digital health technology as an essential pillar education into their curricula for the next generation of
to enhance disease self-management, as well as improv- HCPs. For instance, digital health education programs
ing the accessibility and cost-effectiveness of care in were designed and implemented as mandatory or elective
(rural) China- where over 558 million people have access courses for bachelor or master health professional stu-
to mobile phones. According to the correspondence from dents at the University of Maryland-Baltimore, Vander-
the National Health Commission of China, as of August bilt University, Duke University, New York University, the
2022, more than 1700 internet hospitals have been University of Pittsburgh [16, 17]. These programs cover
established nationwide [12]. In order to promote the a range of topics, including an introduction to health
Shen et al. BMC Medical Education (2024) 24:803 Page 3 of 14

informatics, system design, implementation, evaluation, informatics specialists, and a teacher with extensive
and policy and ethics in digital health. experience in designing and conducting medical courses
While there has been an increasing amount of research for nursing students. The team held monthly meetings to
on digital health education within the medical school discuss the development, implementation, and evalua-
curriculum in Western countries, a systematic review has tion planning of the course.
shown that the literature on digital health courses often The course was developed in three stages. Firstly, a
lacks comprehensive evaluation, and more evaluation comprehensive list of digital health and informatics areas
and implementation research is recommended in low was generated based on previous education in this field
and middle-income countries [17]. Also, there is a lack [16, 17]. This list was used to define the most relevant
of literature on this topic in the Chinese context. Health topics for nursing students. Secondly, the team of eight
professional students in China have expressed a need for experts reviewed the objectives, learning activities, and
digital health knowledge and skills in their medical cur- assessment tools for the course. Based on this review, a
riculum [18]. proposed course with five core topics was devised, which
Nurses, as the largest group of HCPs, play a crucial all eight experts agreed upon. Thirdly, the course proce-
role in the digital health transformation. It is important dure was enhanced by incorporating multimedia learn-
to enhance the readiness and education of the nurs- ing materials such as illustrations, photos, animations,
ing workforce in digital health to provide effective, safe, and videos. This was in accordance with the Multimedia
and efficient patient care with the support of existing Learning Theory [19]. Through group meetings and dis-
and emerging digital health technologies. Therefore, cussions, the multidisciplinary team reached a consensus
to prepare future nurses to meaningfully contribute to on the final course module and procedure.
the design, development, implementation, and evalua-
tion of digital health technologies in China, the present Digital health and nursing innovation topics
study aimed to evaluate the impact of an online Digital The course was named as the Digital Health and Infor-
Health and Informatics Course in China on undergradu- matics course and was held at a medical university in
ate nursing students’ knowledge and comprehension of Guangzhou, China, for eleven days in six weeks. Details
key digital health and informatics topics, self-assessment of the overview and content of the course are shown in
of nursing informatics competencies, and satisfaction. additional file 1. The content of this course focused on
Based on the actual experiences of nursing students, our five key topics: digital health informatics, nursing infor-
study will also provide recommendations for medical matics, emerging technologies for eHealth solutions,
educators, medical universities, and health institutions to patient data security and privacy, and eHealth. The time-
improve the design and implementation of digital health table and focus of each topic are shown in Table 1.
education in China and beyond. In the final week of the course, students were assigned
group work-based learning activities to present a critical
Methods reflection on the following three questions:
Study design and participant
This study employed a one-group, quasi-experimental (1) Given the recent emergence and certification of
mixed-methods design with pre- and post-assessments. health informatics professionals, will there continue
The study focused on an online Digital Health and Infor- to be a role for nurses in informatics within the next
matics Course for undergraduate nursing students in decade?
China. All students who enrolled in the course at our (2) Should there be a specific professional designation
university, a medical university located in Guangzhou, for nurses with informatics expertise? What will the
southern China, were invited to participate in the study. role of the Informatics Nurse look like in the future?
To be eligible, students had to agree to participate and (3) In the face of the evolving sophistication of
successfully complete the six-week course. Students who technology, will there still be a need for nurses with
expressed disinterest or were already engaged in other informatics expertise?
digital health learning or programs were excluded from
the study. During the group work, students were encouraged to
read materials such as scientific papers and textbooks
Course details related to digital health and nursing informatics. Fol-
Development of course lowing each group’s presentation, the teachers provided
A multidisciplinary team of experts in digital health, feedback on students’ performance and on the mate-
informatics, and the medical field was established at a rial they were presenting, thus enabling them to review
medical university in Guangzhou, southern China. The their strengths, areas that needed improvement, their
team consisted of three nurses, two doctors, two health
Shen et al. BMC Medical Education (2024) 24:803 Page 4 of 14

Table 1 Topics of Digital Health and Informatics course

Week Time Learning objectives Details Procedure
duration
Week 1 3 h • Able to determine what is health Lecture 1: Digital Health Informatics • The teacher introduced the topics related to
informatics • Definition of Health Informatics basic information about information manage-
• Able to formulate a type of Health • Health Information Systems ment, digital health, health informatics, and
Informatics • Standardization and Interoperability forces driving information technology (e.g.,
• Knows the elements that health • Tutorial 1 patient safety, nursing shortage, genomics,
informatics should consist of demands for cost-efficient, quality care)
• Knows the formalities of digital • Course structure
health informatics ­ Lectures
­A written tutorial formulated by 15 multiple-
choice questions
Week 2 3 h • Able to explain the definition and Lecture 2: Nursing Informatics • The teacher introduced the topics of Nursing
importance of nursing informatics • Definition of Nursing Informatics Informatics definition, scope of systems used
• Able to explain the difference • Emerging eHealth Agenda in Nursing, specialty area for practice, and its
between nursing informatics and • Nursing Early Role in Medical application.
other fields Informatics • Course structure
• Able to describe the role of nurses • Nursing Informatics: Progression of a ­ Lectures
in digital health management Specialty ­A written tutorial covering three discussion
• Impact of Nursing Informatics on questions and 10 multiple-choice questions
Nursing
• Nursing Informatics Competencies
• Tutorial 2
Week 3 3 h • Able to elaborate on the use of Lecture 3: Emerging Technologies for • The teacher introduced the topics on
emerging eHealth technologies in eHealth Solutions a range of technologies used in clinical
clinical practice and give examples • Service Oriented Architecture (SOA) practice.
• Able to explain the difference and Web Services • Course structure
between complex and complicated • Cloud Computing - Lectures
systems. • Wireless Technologies and the Mobile - Workshops
• Able to describe the strategies Internet
used in eHealth technologies for • Health Informatics Standards
simple, complex, or complicated
interventions.
• Able to describe the eHealth solu-
tion used on different levels
Week 4 3 h • Able to describe the principles of Lecture 4: Patient Data Security and • The teacher introduced the importance of
the use of digital health technolo- Privacy patient privacy and security
gies that need to be adhered to in • Why patient privacy matters • Course structure
the clinical practice • Definitions - Lectures
• Able to explain, recognize, and give• What constitutes personal health - The workshops were highly interactive and
examples of privacy principles in information? unstructured, with an emphasis on hands-
clinical practice • What determines the sensitivity of on practice time and group discussion on
• Able to explain the state of the personal health information? formulation of patient privacy and security
art and the gaps in knowledge and • Privacy Principles questions, critically appraising the literature,
practice of patient data security and • Information Security Principles and applications to patient scenarios.
privacy • The Role of Nurses in Maintaining the
Privacy and Security of Personal Health
Information
Week 5 3 h • Able to understand how eHealth Lecture 5: eHealth: The application • The teacher introduced the definition of
can support self-management in of Technology and Data in Modern eHealth its importance, and key factors for
daily life Health and Social Care Services the successful implementation of the eHealth
• Able to critically appraise eHealth • Electronic Medical Records system.
applications in terms of content, im- • Telehealth • Course structure
pact, implementation, advantages/ • mHealth ­ Lectures
disadvantages, and evidence • Cloud Computing ­Small group tutorials
• Tutorial 3 ­ Task-based assignments
­Internet-based instruction
­Tutorials covering description of nursing in-
formatics nurses’ work and sharing experience
Shen et al. BMC Medical Education (2024) 24:803 Page 5 of 14

Table 1 (continued)
Week Time Learning objectives Details Procedure
duration
Week 6 3 h • Able to gain insight into the role • Team Project • Students present the reflection on the role
of HCPs in informatics, a specific • Presentation of HCPs in informatics, a specific professional
professional designation for HCPs • Concluding designation for HCPs with informatics exper-
with informatics expertise, and the • Remarks tise, and the specific role of informatics nurses
specific role of informatics nurses • Closing Session in small groups. The integration of knowledge
and skills was encouraged in formative evalu-
ations spaced throughout the class.
• Course structure
-Presentation

Table 2 Field methods, outcomes and measurements used in the mixed-method study
Outcome Outcome measurement Methods Pre- Post-
Sur- Focus Course Course
vey group
or discussion
quiz
Knowledge and comprehen- • An online quiz pre-and post the course with a total score of 100 pointsX X X X
sion of the key digital health and • Focus group discussions regarding comprehension of informatics and
informatics topics digital health topics
Self-assessment of nursing infor- • A validated Chinese version of the Self-assessment of Nursing Informat- X X X
matics competencies ics Competencies Scale
Students’ satisfaction with the • An online survey with a performance-focused course evaluation form X X X
Digital Health and Informatics • Focus group discussions regarding evaluations and suggestions of the
course course

development and learning, and to reconsider their learn- in digital health course planning and education admin-
ing processes. istration. As a result, they are capable of delivering
engaging online lessons, promoting interactive student
Teaching members online participation, and maintaining open discussions
For the Digital Health and Informatics course, teachers between students and teachers.
were eligible if they had extensive experience in digital
health and informatics, software engineering, informa- Course procedure
tion management, and knowledge management. They The course commenced on July 23, 2022. The students
were also eligible if they had previous teaching experi- who enrolled in the course were sent a link via email. In
ence in software engineering and enterprise systems order to take part in the study, they were required to pro-
development, or if they had conducted wide-ranging vide informed consent and complete the electronic base-
research in the areas of information sharing, healthcare line questionnaires. Following each lesson, students were
informatics, artificial intelligence, machine learning, and granted access to the course through various modalities,
digital health. including offline and online access to downloadable les-
In this course, all lectures were delivered by two son videos for offline viewing on their electronic devices.
teachers, all of whom hold a Doctoral degree and have Participants had the flexibility to watch the modules in
a proven academic or professional background in the their preferred order. The course structure for each topic
fields of software engineering, artificial intelligence, is outlined in Table 1.
and information systems, or digital health research,
nursing, public health, and implementation science. Evaluation
Additionally, both teachers have obtained Teacher The assessment of the impacts of the course was con-
Qualification Certificates, which demonstrate that they ducted using a mixed methods approach to evaluate (1)
possess the basic teaching skills necessary to perform knowledge and comprehension of the key digital health
educational and teaching activities in higher education. and informatics topics, (2) the self-assessment of nurs-
Furthermore, both teachers have in-depth knowledge ing informatics competencies, and (3) the students’ sat-
of the course content, aligning with the course’s subject isfaction with the Digital Health and Informatics course.
expertise. Moreover, they have more than three years Table 2 summarizes the below-described outcome and
of teaching experience and were extensively involved outcome measurements.
Shen et al. BMC Medical Education (2024) 24:803 Page 6 of 14

Research materials but also the knowledge and attitudes needed by nurses
The demographic questionnaire to complete specific informatics tasks. The online survey
The questionnaire was used to collect students’ demo- consisted of two parts (See additional file 4).
graphic data, including age, gender, year of bachelor • Part one provided instructions for completing the
study, and experience with nursing informatics use. survey.
• Part two included a validated Chinese version of the
Knowledge and comprehension of key digital health and Self-assessment of Nursing Informatics Competencies
informatics topics Scale (SANICS) [21] developed by Yoon [22]. The scale
To evaluate the knowledge and comprehension of key consisted of a total of 28 items, covering three domains:
digital health and informatics topics, an online quiz with computer technology, information technology, and infor-
a total score of 100 points and focus group discussions mation knowledge. The Cronbach’s alpha of the Chinese
pre-and post the course were designed. version of SANICS was 0.931 [21]. Five-point Likert-type
The quiz consisted of a total of 25 choice questions that criteria was applied (1 = not competent; 2 = somewhat
were developed by the multidisciplinary team of experts. competent; 3 = competent; 4 = proficient; 5 = expert), with a
These questions were considered important learning top- higher total score indicating a higher level of nursing infor-
ics and were based on relevant lecture materials. Before matics competency. The Chinese version of SANICS items
finalizing the quiz, a pilot version was tested by ten were categorized into 5 sub-scales: role of clinical infor-
nurses who had graduated from the same medical uni- matics (Factor 1; items 1–5), basic computer knowledge
versity within one year and had experience with digital and skills (Factor 2; 6–16), applied computer skills (Fac-
health learning. The pilot test aimed to improve the con- tor 3; 17–20), wireless device skills (Factor 4; 21–24), and
tent, length, and understandability of the quiz. The final nursing informatics attitudes (Factor 5; 25–28). The five
version of the quiz focused on eliciting students’ knowl- domains and examples of items are presented in Table 3.
edge and comprehension of digital health, health infor-
matics, and nursing informatics including definitions, Satisfaction with the Digital Health and Informatics course
nursing’s early role, and nursing informatics competen- Following the implementation of the course, all students
cies (see additional file 2). were invited to join an online survey using a perfor-
In addition to the quiz, all students were invited to par- mance-focused course evaluation form (See additional
ticipate in focus group discussions pre- and post-course. file 5). The survey aimed to gather feedback on stu-
The focus group topic lists were developed based on dents’ learning experience and obtain specific comments
examples from similar studies and research team dis- regarding the course. Also, students were invited to take
cussions. The focus group discussion questions aimed part in focus group discussions on the course evaluation.
to assess participants’ knowledge and comprehension The focus group discussion questions were as follows:
on informatics and digital health such as definitions and
emerging technologies. The discussion also explored •  “What do you like about the course?”
the importance of informatics and digital health as well •  “What do you dislike about the course?”
as the role of nurses in nursing informatics and digital •  “Do you have any suggestions on the future
health implementation (See additional file 3). improvement of the course?”

Self-assessment of nursing informatics competencies

All students were invited to participate in an online nurs- Data collection
ing informatics competency survey pre- and post-course. Quiz and survey
According to previous literature [20], nursing informatics Prior to the study, participants were provided with infor-
competencies include not only computer-related skills, mation regarding the purpose of the study. They were

Table 3 Domains in the self-assessment of nursing Informatics competencies Scale

Domain Explanation Examples of scale items
Role of clinical informatics The practice that nurses implemented in the clinical Promote the integrity of and access to information to
informatics include but not limited to confidentiality, legal, ethical, and
security issues
Basic computer knowledge Techniques and tools in systems analysis and project Use database management program to develop a simple
and skills management database and/or table
Applied computer skills Use of computer hardware and software Perform basic trouble-shooting in applications
Wireless device skills Wireless device to locate resources and enter data Use wireless device (PDA or cellular telephone) to enter data
Nursing informatics attitudes Evaluations on nursing informatics Recognize that internet + plus will become more comment
Shen et al. BMC Medical Education (2024) 24:803 Page 7 of 14

asked to complete web-based questionnaires in the form digital health technologies was extracted from pre- and
of an online quiz, SANICS surveys, and course evalu- post-course focus group discussions. We will compare
ation forms. The surveys were conducted between June the differences in relevant quotations, such as whether
and July 2022. A link containing a password to access the students mentioned more types of technology after the
private survey questionnaires was sent to each student’s course.
individual email inbox. Participants were informed that Additionally, based on the focus group discussion data
their participation in the study was voluntary and that and responses to two open-ended questions in the course
choosing not to participate would not affect their learn- evaluation form provided by students, we analyzed their
ing or assessments. They were assured that they could evaluations and suggestions regarding the course. Data
withdraw from the study at any time without any nega- saturation was achieved as being the point at which no
tive consequences or impact on their academic grades. new or relevant information could be identified through
Furthermore, their privacy and confidentiality would be the iterative, preliminary analysis of the data [23]. After
protected, and all participants provided written consent the first two focus group discussions, a preliminary anal-
to participate. Participation in the online poll was also ysis using the proposed codes was performed, and a data
voluntary and anonymous. saturation grid [23] was developed to determine if satura-
tion was reached. The data saturation grid consists of a
Focus group discussions report of the occurrence of themes and codes (displayed
A total of five pre- and post-course focus group discus- in rows) during each focus group (displayed in columns)
sions were conducted with all students to explore their in a tabular format. In the grid, saturation is considered
knowledge and comprehension of key topics in digital reached when the grid column for the current focus
health and informatics, as well as their satisfaction with group indicates no new information emerged for that
the course. The face-to-face focus group discussions were particular theme or code. We found that in the fifth focus
conducted by one researcher (HS, PhD, female). The group discussion, data saturation on all themes and codes
interviewer had received training and possessed exten- was achieved (data saturation table included as additional
sive experience in qualitative research. Each focus group file 6).
discussion lasted approximately 50–60 min and was
recorded with the participants’ consent. The recordings Ethics and consent
were later transcribed and used as textual data. This study was assessed and approved by The Univer-
sity Ethics Committee of Guangzhou Medical University
Data analysis (Reference Code: L202303012). All methods were carried
For the quantitative data, survey data were exported from out per relevant guidelines and regulations. Informed
SPSS version 23 (IBM, Armonk, NY, USA) for analysis. consent was obtained from all participants.
After data cleaning, frequency descriptive statistics were
utilized for categorical variables. Descriptive statistics Results
such as the mean, standard deviation, median, and range Demographic characteristics of students
of linear variables were calculated, along with frequencies A total of 24 undergraduate nursing students were
and percentages of categorical variables. We compared enrolled in the course. All students completed all sessions
the difference of the SANICS scores pre- and post-course of this course (attendance rate 100%) and pre- and post-
using paired t-test analysis. P-values < 0.05 was consid- assessments. Most participants (83.33%; n = 20) were in
ered statistically significant. the 19 to 20-year age category. Also, 22 students (91.7%)
For the focus group discussion data, transcripts were were in the first or second year of their bachelor study.
imported into [Link] for Windows version 7.5.18 Additionally, students’ experience with nursing informat-
(Scientific Software development, Berlin). Qualitative ics was limited before launching the digital health and
content analysis was performed inductively using the nursing informatics course, with only 41.7% of students
following steps: (1) open coding, (2) categorization, and having prior experience with nursing informatics system
(3) theming. Rigor was enhanced by repeatedly read- use.
ing the transcripts, keeping a record of the analytic
decision trail, and through crystallization with mul- Impact of the Digital Health and Informatics course
tiple researchers engaging in discussions of evolving Knowledge and comprehension of key digital health and
categories and emergent themes. In terms of students’ informatics topics
knowledge and comprehension of key digital health and Scores of the quiz on knowledge assessment improved
informatics topics, related quotations were compared to from the pre-test [mean pretest score: 78.33 (SD 6.005)
identify the changes in the same themes extracted pre- to the post-test [mean post-test score: 83.17 (SD 4.86)]
and post-course. For instance, the theme of emerging upon completion of the course (P < 0.001).
Shen et al. BMC Medical Education (2024) 24:803 Page 8 of 14

Furthermore, when analyzing the data from focus among future HCPs. This study analyzed the impacts
group discussions, three key themes emerged regard- of an online digital health and informatics course for
ing nursing students’ knowledge and comprehension of nursing students in China. Students reported improved
key digital health and informatics topics before and after knowledge and comprehension of key digital health and
the course. Overall, the students acknowledged that the informatics topics, nursing informatics attitudes in the
course improved their understanding of informatics and measure of self-assessment of nursing informatics com-
digital health, the benefits of (nursing) informatics in petencies, and high satisfaction with the course. Also,
clinical practice, and the role of HCPs in informatics and qualitative results showed notable advantages of the
digital health. For instance, after the course, the theme course, including the provision of a broader understand-
of ‘Understanding of informatics and digital health’ was ing of informatics for future careers, opportunities for
formulated based on constructs that emphasized the engaging in group discussion, and case analysis on the
application of information management and analytical use of informatics and digital health in clinical practice.
abilities, more guiding principles of nursing informatics The findings of this study provide recommendations for
and digital health use, and more emerging technologies the design and implementation of incorporating digi-
of digital health compared with pre-course. Also, after tal health and informatics education into the course for
the course, students highlighted detailed technologies for health professional students.
improving clinical practice. In addition, students noted
the different types of informatics roles held by HCPs What content of digital health and informatics education
working in the field of informatics and the critical roles should be provided?
they play after the course. The main constructs frequently Previous research has shown that an individual’s per-
mentioned by students were summarized from the inter- formance expectancy has an impact on their acceptance
view transcripts before and after the course, which were and use of information technologies in the workplace
translated into English from colloquial Chinese, support- [24]. Our study highlights that improving education on
ing these findings (Table 4). the role of HCPs in health information systems, raising
awareness of the impact of informatics, and introduc-
Self-assessment of nursing informatics competencies ing emerging digital health technologies in clinical care
Scores of students’ nursing informatics attitudes can potentially enhance the adoption of digital health
improved significantly after the course. There were no technologies. This finding is consistent with previous
statistically significant changes observed in the scores of research [25].
students’ competency including the role of clinical infor- To ensure that students develop a comprehensive
matics, basic computer knowledge and skills, applied understanding of digital-enabled healthcare, we have
computer skills, and wireless device skills (Table 5). designed this course to provide a broad and founda-
tional education in digital health and informatics for
Students’ satisfaction with Digital Health and Informatics undergraduate students. However, we did not observe
course significant improvements in students’ self-assessment of
All 24 Students responded to six questions regarding nursing informatics competencies in the areas of basic
the effects of the digital health and informatics course computer knowledge and skills, applied computer skills,
(Table 6). A total of 50% of the students indicated that “I and wireless device skills. This may be explained by that
am now somewhat familiar with the concept of (nursing) these domains are more practical aspects of competence
informatics.” and 41.7% of the students indicated that“I in digital health and informatics. Online lectures may
am now really familiar with the concept of (nursing) not be the most effective approach for developing practi-
informatics.” Also, a total of 83.3% of the students indi- cal competency, and real-life practice with digital inno-
cated that,“The learning made me more sensitive to issues vation is necessary. Also, nursing students in our study
related to (nursing) informatics”. expressed a need for more practice lessons on digital
Furthermore, based on the focus group discussions and health use. Therefore, we suggest that nursing students
responses to two open-ended questions in the course should be exposed to specialized digital health innova-
evaluation form, three themes were generated including tion use to enhance their digital literacy in clinical deci-
the pros and cons of the course, and suggestions for the sion support and quality improvement in future course
course. Details are presented in Table 7. development. This could include trainings on handling
medical data and applying data in patient care. Also,
Discussion case analysis should be incorporated to help students
Digital health and informatics education is an unmet understand how technology and data are used in modern
need to address the global shortage of health workers by health and social care services, such as electronic medical
promoting the adoption of digital health technologies records, telehealth, and mHealth.
Shen et al. BMC Medical Education (2024) 24:803 Page 9 of 14

Table 4 An overview of the main constructs of themes and subthemes mentioned by students pre-and post-course
Themes and Pre-course Post-course
subthemes Main constructs mentioned Main constructs mentioned
Theme 1 Understanding of digital health and informatics
Definition of digital - A discipline that includes nursing practice as- - A science with multiple information management and analytical abilities in
health and (nurs- sessment based on nursing information data.” addition to information technologies
ing) informatics - The processing of collecting nursing or patient - A cross-discipline to improve nursing and requires a change in thinking and
data and information competence
- The application of information technology to - The application in nursing research, nursing science, nursing research, nurs-
assist nursing care ing education and nursing management.
- An interdisciplinary practice of nursing and - The urgent need to use technology in medical settings to ensure patient
informatics safety
- Provides needed standardized nursing language
Guiding principles - Patient privacy - Patient privacy and safety
of informatics - Patients’ willingness to use digital health - Efficient, timely, and accurate data collection and entry
practice and use of - Accurate data entry - Data security
digital health - Protecting confidentiality of personal information
- Confidentiality
- Ease of use of digital health
Emerging - Electronic health records - Wireless technologies
technologies of - Personal digital assistant - Telemedicine
digital health and - Tablet for patient data collection - Electronic health records
informatics - Internet-based outpatient clinic reservation - Personal digital assistant
- Mobile phone-based patient discharge follow- - Tablet for patient data collection
up and health education - Internet-based outpatient clinic reservation
- Mobile phone-based patient discharge follow-up and health education
Theme 2 Benefits - Improving the efficiency of care with online - Monitoring devices that record vital signs and other measurements directly
of digital health documentation into the client record
and informat- - Facilitate information integration, access, and - Automatic reminder with nursing documentation
ics in nursing retention with monitoring devices recording - Reminders and prompts that appear during documentation to ensure
practice patient measurements comprehensive charting.
- Ensure the accuracy of patient information and - Quick access to computer-archived patient data from previous encounters
care with automatic reminder in documentation - Automated staff scheduling for nursing administration
and wearable devices for data collection - The ability to find trends in aggregate data, which is data derived from large
- Self-monitoring by patients helped health population groups.
care professionals to provide accurate medical - Use of the Internet for obtaining data collection tools and conducting
advice, based on the changes in parameters or research.
symptoms tracked - Communication with healthcare providers via e-mail and instant messaging.
- Remote monitoring and other telehealth services.
Theme 3 The role - Provide feedback on care information needs to - The different roles of the Beginning Nurse, the Experienced Nurse, and The
of health care technicians Informatics Nurse, and The Informatics Nurse Specialist
professionals in - Participate in the selection, design, implemen- - Implementer:
informatics tation, and evaluation of information systems • Use relevant information and knowledge to support the delivery of
- Act as a leader and be able to integrate innova- evidence-informed patient care.
tive and informatics concepts into their area of • Use information and communications technology in accordance with
expertise professional and regulatory standards and workplace policies (e.g., protection
- Generalize or promote knowledge or applica- of health information, privacy, and security)
tion of skills in information systems to others - Informatics systems development
- Informatics systems use and evaluation
- Act as educators to deliver informatics knowledge to other learners

Table 5 Self-assessment of nursing informatics competencies pre- and post-course

Factor Pre- Post- t P
course course
Mean SD Mean SD
Role of clinical informatics 13.08 5.11 13.00 3.32 0.062 0.951
Basic computer knowledge and skills 33.75 7.66 33.54 7.26 0.107 0.916
Applied computer skills 8.38 3.68 9.67 3.29 -1.210 0.239
Wireless device skills 10.46 4.18 11.75 3.03 -1.325 0.198
Nursing informatics attitudes 16.88 2.54 18.46 1.96 2.486 0.021
Shen et al. BMC Medical Education (2024) 24:803 Page 10 of 14

Table 6 Evaluation of Digital Health and Informatics Course

Survey question Item Fre-
quency
(%)
After attending the course, to what extent are you now
familiar with the concept of nursing informatics? Choose
one answer.
A I am still at least a little confused about the concept of nursing 0
informatics.
B I am now somewhat familiar with the concept of nursing informatics. 12(50)
C I am now really familiar with the concept of nursing informatics. 10(41.67)
D I am now ready to use nursing informatics related knowledge in my 2(8.3)
future work.
E I feel expert now to start using nursing informatics related knowledge 0
in my future work.
What impact, if any, will the course have on your ability to
use nursing informatics? Choose as many answers as are
true for you.
A The learning reinforced my previous thoughts on nursing informatics 16 (66.6)
B The learning made me more sensitive to issues related to nursing 20(83.3)
informatics
C The learning will likely change how I use nursing Informatics at my 16(66.6)
future clinical practice
D The learning did not do enough to prepare me to deal with work situ- 4(16.6)
ations related to nursing informatics
After attending the course, to what extent are you now
familiar with the concept of eHealth? Choose one answer.
A I am still at least a little confused about the concept of eHealth. 2(8.3)
B I am now somewhat familiar with the concept of eHealth. 14(58.3)
C I am now really familiar with the concept of eHealth. 3(12.5)
D I am now ready to use eHealth in my future work. 5(20.8)
E I feel expert now to start using eHealth in my future work. 0
How motivated are you to learn nursing informatics?
Choose one answer.
A I do not need nursing informatics in my future work.
B It is not a priority for me to use nursing informatics in my job. 1(4.2)
C I plan to learn nursing informatics in my study, but it is not a high 5(20.8)
priority.
D It has medium priority for me to start learning nursing informatics. 8(33.3)
E It has high priority for me to start learning nursing informatics. 8(33.3)
F It has very high priority for me to (start) learn nursing informatics. 2(8.3)
To what extent are you now able to use nursing informatics
yourself in future clinical practice? Choose one answer that
best describes the extent to which you consider yourself
capable of doing so.
A I do not need to use nursing informatics in future clinical practice. 0
B I still don’t know what to do, and/or why I need to do it. 0
C I need a little more guidance before I know how to use nursing 4(16.6)
informatics myself.
D I need more experience to be able to use nursing informatics 19(79.2)
properly.
E I can now use nursing informatics myself (without guidance or further 0
experience).
F I feel like an expert now and can use nursing informatics with ease. 0
Which learning activity did you spend the most time on
during the course? Please select up to three options.
A Viewing information presented on a screen (example: via PowerPoint). 20(83.3)
B Reflecting on how I might use nursing informatics. 11(45.8)
Shen et al. BMC Medical Education (2024) 24:803 Page 11 of 14

Table 6 (continued)
Survey question Item Fre-
quency
(%)
C Discussing how nursing informatics should be used. 16(66.7)
D Answering quiz-like questions about the nursing informatics. 9(37.5)
E Previewing courses related to nursing informatics. 6(25)

Table 7 Students’ evaluations and suggestions on the course

Themes Coding of students’ answers Frequency*
Pros
- Broad horizons in informatics for future nursing career choice 12
- Group discussion to practice teamwork skills 12
- Case analysis on the use of informatics and digital health in the clinical practice 7
- Timely problem-solving and technical support by teachers 6
- Clear and informative presentation slides 6
- A team Project and presentation to review all previous knowledge 5
- Online resource sharing in the course online platform 5
Cons
- Many teaching activities focus on basic computer and internet use rather than on specific nursing informat- 7
ics profession
- A lack of videos of nursing informatics nurses’ work 5
- The long duration of teaching activities with three hours per class 4
- Few group discussions 4
- Old reference of nursing informatics 4
Suggestions
- Increase detailed information and examples on the roles and functions of nursing informatics nurse 20
- Increase practice lessons on digital health use 15
- Increase videos or individual interviews on the real examples of nursing informatics and digital health use in 15
clinical practice
- Increase group discussions and more knowledge on nursing informatics profession 12
- Upload some test questions to facilitate testing of learning content 5
- Increase interactive sessions in the course 5
- Adjust the duration of teaching activities 4
*The numbers indicate the frequency of key words mentioned by 24 students in the course evaluation form and focus group discussions

What teaching methods and components should be initially. However, through continuous group coopera-
provided in digital health and informatics education? tion, they were able to develop skills and make progress
Through a review and reflection of this online education, in the learning and building process. Third, given the dis-
we have identified useful components of the course that tance-learning nature of our course, emphasis is placed
can be applied to other educational programs. Firstly, our on online collaboration tools; both formal and informal
course utilized information communication technologies synchronous and asynchronous communication tools
to enhance the quality, accessibility, and sustainability of were used to facilitate communications between instruc-
education. Consistent with previous research [26, 27], tors, students, and members of student groups (e.g., chat
the online course offers significant benefits in terms of rooms, video-conferencing software). Since each course
self-paced, self-directed, and personalized learning. Also, was conducted online, an interactive class management
due to the adaptability of an online platform, this course system can provide students with access to course infor-
can be easily and flexibly implemented in various set- mation, reading assignments, and electronic resources
tings within medical schools with minimal adjustments. for their final presentation.
Secondly, students reported that a valuable feature of
the course is the group work. In our program, students How to improve the quality the digital health and
with different levels of ability and readiness in groups informatics education?
worked together in groups to critically reflect on the Most students are in the first or second year of their
role of HCPs in informatics and digital health, promot- bachelor’s studies and have limited experience in the use
ing interactive group work. Students may lack confidence of computers and wireless devices in clinical practice.
Shen et al. BMC Medical Education (2024) 24:803 Page 12 of 14

Therefore, we recommend that digital health and infor- implementation. Therefore, future course evaluations
matics should be longitudinally integrated into a compul- should consider using a two-arm or Solomon four-group
sory course throughout nursing education, with specific design. Secondly, this was a small study with a sample
learning objectives and content for each year of nursing size of 24 students and may not be generalizable to all
student education. Previous studies have shown that at health professional students in China or a larger popu-
the undergraduate level, students should be equipped lation. Also, study results report the nursing students’
with the necessary digital skills to practice medicine subjectively experienced changes in nursing informat-
in a digital-enabled healthcare environment while also ics competence, and no objective measures in this area
assuring the mastery of compassionate care and improv- were conducted. Therefore, self-reported data may be
ing outcomes for patients [28, 29]. Some studies have subject to bias, and may not accurately reflect the actual
reported that digital health education should be pro- improved competency of the students. Additionally, the
vided earlier in the medical university curriculum such as measurement of knowledge and comprehension of key
in the first year, and that digital health-specific practice digital health and informatics topics must be interpreted
or clinical innovation use should be trained in the final with caution since the quiz has not been validated. Fur-
year of health professional education [30, 31]. Addition- thermore, the duration of the course was only six weeks.
ally, prior studies show that specialized digital skills, The relatively short duration of the course may limit the
such as using digital health for specific clinical tasks in depth of knowledge and competencies that students can
an interdisciplinary environment, should be taught in the acquire. A longer course with follow-up assessments
advanced years of medical training when HCPs enter res- could provide a more comprehensive understanding of
idency and train to become specialists [32]. Therefore, we the long-term impacts.
suggest that future research should use the digital health
competency framework, such as the International Medi- Conclusions
cal Informatics Association Recommendations on Medi- Digital health and informatics education for future
cal Informatics Education, to design and tailor education healthcare professionals is an urgent need to equip them
for the undergraduate health professional students. to adapt to future digital medical system changes in their
Furthermore, we highlighted the value and significance workforce. This Online Digital Health and Informatics
of collaboration efforts between medical school train- education showed promising results for undergraduate
ing and clinical practice [33]; using clinical examples to nursing students in their knowledge and comprehension
explain more novel digital health applications, such as the of the key digital health and informatics topics, nursing
application of artificial intelligence or big data in patient- informatics attitudes in the self-assessment of nursing
centered care. To ensure that this course is aligned with informatics competency, and satisfaction. To optimize
the technological advances in clinical settings, train- the digital health course effect, future course develop-
ing to improve digital competencies in students’ clinical ers should improve students’ basic knowledge and com-
practice is necessary. One way to achieve this is by incor- prehension of digital health and informatics. Also, to
porating a practical exercise on the use of digital health enable the standard design and scale-up of effective
technology in the clinical setting, while also considering digital health and informatics education for nursing stu-
the need for patient privacy and liability concerns [34]. dents, collaboration between medical school training and
clinical practice is needed to enhance students’ practical
Limitations exercise on the application of digital health technologies
Nevertheless, several limitations need to be considered. in the clinical setting. We suggest that the content and
Firstly, the main limitation of the study was that it was teaching methods of this course may form a mandatory
a single-arm study. This raises questions about whether part of digital health education for health professional
the observed improvements in outcomes, such as knowl- students and could be expanded to students in other con-
edge, were solely due to the course or if other factors may texts and countries.
have influenced the results. For example, students’ previ-
Abbreviations
ous use of digital health and eHealth literacy levels could WHO World Health Organization
have potentially influenced their experience and evalua- COVID-19 Coronavirus disease
tion of the course. This could have resulted in a bias in HCPs healthcare professionals
SANICS Self-assessment of Nursing Informatics Competencies Scale
their responses towards course evaluation. Additionally,
improvements in students’ learning outcomes could be
attributed to the test itself, as factors such as partici- Supplementary Information
pants remembering questions or the questions raising The online version contains supplementary material available at [Link]
org/10.1186/s12909-024-05785-5.
awareness and triggering learning after the pre-test may
have influenced the results, independent of our course
Shen et al. BMC Medical Education (2024) 24:803 Page 13 of 14

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