Influence of information anxiety on core competency of registered nurses: mediating effect of digital health literacy

The core competency of registered nurses refers to the professional ability shown in the completion of nursing works, including knowledge, skills, attitudes, values and other comprehensive abilities [10, 11]. NCC is a holistic and dynamically evolving competency, involves the integration of multiple abilities in response to changes in society, healthcare environments, and the nursing profession [12]. Liu et al. [10, 13] developed the Competency Inventory for Registered Nurses (CIRN) in China based on International Council of Nurses (ICN) Framework of Competencies for the Generalist Nurse proposed by the ICN. This framework includes competencies in clinical care, leadership, interpersonal relationship, legal/ethical practice, professional development, teaching-coaching, critical thinking/research aptitude [10, 13]. In this study, NCC signifies the application of knowledge, skills, and attitudes by nurses in clinical practice, enabling individuals to effectively perform a range of tasks and adhere to appropriate standards to adapt to the continuously evolving social, medical environment, and nursing profession [12]. The process of digitization will result in substantial alterations to the roles and duties of the healthcare personnel, hence underscoring the necessity for capacity building and continuous professional development [14]. Digital technologies are increasingly being employed in the healthcare sector, offering new avenues for nurses to care for patients, conduct research and education, track diseases, and monitor public health [3, 9, 15]. When integrated with clinical practices and tailored to fit these practices, ICTs can be effectively utilized, transforming the internet into a convenient digital information resource for busy nursing professionals [16, 17]. This supports the professional development of healthcare personnel [18]. And previous study [19] indicate that proficient users of ICTs exhibit higher nursing abilities compared to those with lower ICTs skills. In essence, ICTs empowers nurses to enhance their core competencies by leveraging technology to improve patient care, streamline operations, foster collaboration, and advance professional development within the rapidly evolving healthcare landscape. The abilities to generate, send, and process information are recognized as practical skills influencing nursing capacity in such a digital healthcare environment [20]. This implies that the ability to gather, process and send information as well as other skills relating to ICT, exert an influence on nursing competency [19]. Therefore, when nurses encounter difficulties and uncertainties while using ICTs, they are prone to negative emotions [21], which may affect their core competencies.

Individuals may experience anxiety when they come to the realization that they lack the ability to comprehend perceived information [22, 23]. Wurman proposed that “Information anxiety is produced by the ever-widening gap between what we understand and what we think we should understand” [24]. The information generated within the healthcare sector, as well as information pertaining to healthcare, has experienced exponential growth with the advent of the World Wide Web (www) and online communication [22]. Registered nurses hold a distinctively crucial role in the provision of medical services, to stay current with professional advancements and navigate the swiftly evolving, multifaceted realm of medical practice, they consistently require access to information to supplement their knowledge and clinical experience [25, 26]. However, accessing and processing a vast amount of information within a limited time frame can prove burdensome and stressful, leading to information overload [27]. The increase in health information technology is supposed to improve nursing quality, efficiency, and safety. However, information overload in electronic health records has been shown to detract from the ease of use of the system, contribute to stress and burnout among healthcare professionals, worsen workloads, and create opportunities for errors [28‐30]. Previous studies [31, 32] pointed out that when faced with a health crisis such as COVID-19, it generated a deluge of information [33, 34], which impeded nurses’ ability to process the information accurately leading to subpar decision-making. The information on the internet is complex, chaotic and of varying quality, while users have a strong psychological reaction to the reliability of information, inaccurate or duplicated information often compels nurses to spend a significant amount of time collecting and utilizing data, leading to they have strong irritability and anxiety. Persistent exposure to anxiety may have adverse effects on their behavior patterns, psychological states and work performance [35‐37]. It has been shown that although a certain level of anxiety can be beneficial for motivating and arousing enthusiasm in an individual, unmanaged anxiety can have long-term consequences on the work performance and job satisfaction of nurses [38, 39]. Earlier study [40] have found that when nurses are uncertain about the relevance, accuracy, or effective application of information, or when they feel overwhelmed by the volume and complexity of research evidence, the information overload or anxiety can impede evidence-based practice (EBP) and clinical decision-making in the context of nursing.

Previous study [41] has shown that digital health literacy (DHL) contributes to alleviating the adverse consequences (e.g., information anxiety) of the infodemic (an infodemic is too much information including false or misleading information, in digital and physical environments during a disease outbreak [42]). DHL, refers to “the ability to search, select, appraise, and apply online health information and health care-related digital applications” [43, 44]. Studies [45‐47] have shown that high DHL contributes to nurses’ ability to effectively navigating the healthcare system web-based for information retrieval and decision-making, enabling them to accurately comprehend and utilize essential data to enhance nursing competency and medical service. DHL has evolved into an essential skill for health professionals, enabling them to find accurate and reliable health information online, improved skill development is probably going originate from valuable medical internet research chances that foster critical thinking [48, 49], ensuring that individuals are optimally making use of available digital health access. Poor digital health literates might suffer more from information overload. Indeed, study has underlined the significance of strengthening DHL level to cope with information overload [50]. Previous study [51] showed DHL can mitigate the heightened psychological distress elicited by the infodemic. Furthermore, Kim et al. [52] found that online misinformation leads to misunderstandings regardless of DHL levels. However, individuals with higher DHL are better equipped to verify and correct these misunderstandings, making them less likely to act on them. This indicates that DHL is crucial for helping individuals navigate environments with information overload.

A cross-sectional survey was conducted in Fujian Province, China. From July to October 2023, eligible nurses from the 3 selected tertiary hospitals located in Western Fujian (Longyan), Central Fujian (Fuzhou), and Southern Fujian (Quanzhou) were included using convenience sampling. Inclusion criteria were: (a) being a registered nurse and being employed at the hospital; and (b) volunteering to participate in the study. The exclusion criteria were as follows: (a) work less than 6 months; (b) absence due to illness, maternity, or other personal reasons for more than 6 months. The relationship between information anxiety, DHL, and NCC was analyzed using a structural equation model (SEM), requiring a minimum of 200 samples to run the model, as suggested by Shah and Goldstein [54]. And the suggested empirical power tables based on study by Fritz and Mackinnon [55], a sample size of 558 or greater is required for 0.8 power when using the percentile bootstrap to test the mediating effect [56]. A total of 656 nurses completed and returned the surveys. However, 48 questionnaires were disqualified due to irregular responses and were excluded from the overall analysis. As a result, 608 nurses participated in the study, with a response rate of 92.68%.

Four tools were used to collect data and analyze the variables of this study:

Socio-demographic information collected included age, gender, educational background, years of nursing experience, professional title, working position (general nurse, clinical nursing teachers, nursing team leader, head nurse), average monthly earnings (CNY), form of employment (contract nurses or official nurses), official nurses are hired for a job position to work stably and continuously, covered by the social insurance system of health care institutions, with good benefits than contract nurses in China [57].

The DHLI [44] was used to assess DHL. The DHLI was developed by van der Vaart and Drossaert [44] and translated into Chinese version (CR-DHLI) by Zhao et al [58]. CR-DHLI is comprised of 7 subscales: (1) operational skills; (2) navigation skills; (3) information searching; (4) determining relevance; (5) evaluating reliability; (6) adding self-generated context; (7) protecting privacy and 7 performance-based items [44, 58]. Each self-reported item was scored on a Likert 5-point scale with scores ranging from 0 (very difficult) to 4 (very easy) and 0 (never) to 4 (often), each performance-based item has 4–5 answer options, of which 1 is correct, correct answer receives 1 point, accumulating a maximum of 7 points in total. The mean of subscales was used to calculate DHL total score, the higher the score, the greater the DHL. The validity and reliability of the CR-DHLI was approved, the Cronbach’s alpha coefficient was calculated to be 0.929 in the study of Zhao et al [58]. In this study, the Cronbach’s alpha was 0.947.

To access information anxiety, the IAS was used [59], It consists of 30 items. Each item response is rate on Likert 5-point scale with scores ranging from 1 (strongly disagree) to 5 (strongly agree). It has 6 subscales: (1) information quality anxiety; (2) information quantity anxiety; (3) information retrieval tool anxiety; (4) information literacy anxiety; (5) information acquisition anxiety; and (6) information processing anxiety. An increased score signifies a more severe degree of information anxiety. Cronbach’s alpha coefficient of IAS in the original study was calculated to be 0.972 [59]. In the present study, the Cronbach’s alpha value was 0.984.

Nurse’s core competency was accessed by the CIRN [10]. It consists of 55 items. Each item response is rate on Likert 5-point scale with scores ranging from 0 (not competent at all) to 4 (very competent). It has 7 subscales: (1) clinical care; (2) leadership; (3) interpersonal relationship; (4) legal/ethical practice; (5) professional development; (6) teaching-coaching; (7) critical thinking/research aptitude [10]. A higher score corresponds to a greater NCC. The Cronbach’s alpha coefficient for this scale has been in the range of 0.90 to 0.97 in current studies [10, 60, 61], and it has been psychometrically evaluated and implemented in different countries. The Cronbach’s alpha value was 0.988.

The data for the study were gathered via an online questionnaire survey platform (accessible at www.​wjx.​cn), utilizing an innominate, self-reported questionnaire. Initially, we contacted three hospital administrators in Fujian province via WeChat, requesting their assistance in distributing the web-based survey link to their nurse staff who met the criteria. With the cooperation of nursing managers, the questionnaires were successfully distributed to the nurses. Participants were acquainted about the purpose, significance, and precautions of the survey process. Those who voluntarily chose to take part in the study completed the questionnaire by either clicking on the provided link on WeChat or scanning the QR code. To ensure the completeness and validity of the questionnaire, we adhered to unified guidelines, designated all questions as mandatory, restricted each IP address to one submission only, and established a minimum cumulative answer time of 200 s. One week before the survey, the primary researcher provided training to other worker. These trained researchers were responsible for collecting the online questionnaires and monitoring the quality of responses throughout the process. In the event of any issues, researchers communicated with the nursing managers of each hospital for resolution.

Data were analyzed using IBM SPSS Statistics 29.0 software and Mplus version 8.0. Normally distributed continuous variables were expressed as the mean and standard deviations (SD), nonnormally distributed continuous variables were presented as the median and interquartile range (IQR). The relationship among information anxiety, DHL, and NCC was verified using the Pearson correlation test. The mediating effect of DHL in the relationship between information anxiety and NCC was estimated using the structural equation modeling method implemented in Mplus 8.0. The covariance matrix of relevant variables was evaluated by maximum likelihood (ML) estimation. We applied 5,000 samples for bootstrap resampling and a 95% confidence interval (CI) to examine the direct and indirect effects between information anxiety, DHL, and NCC. To assess the model fit, the following criteria were used: χ²/df < 3, comparative fit index (CFI) > 0.9, Tucker–Lewis index (TLI) > 0.90, standardized root mean square residual (SRMR) < 0.08, and root mean square error of approximation (RMSEA) < 0.08 [62]. The statistical significance was set at P < 0.05, with two-tailed testing.