E-Health in Rural Healthcare Delivery

Introduction

There is a growing pressure for the health sector to provide cost effective and more efficient health care services. According to Elder & Koehn (2009), the reasons for this pressure include the aging population, decreasing healthcare budgets, and the increasing cost of accessing health care services. Thus, people are becoming more aware of the potentiality of e-health (i.e. information and communication technology-enabled healthcare) to help in delivering long distance health care services, especially in remote or rural areas. Particularly, e-health is more important in countries such as the UK where there are large distances between patients and practitioners settled in urban areas. Equally, there has been an increasing vulnerability of health systems due to the increasing demographic challenges (Grant et al, 2009). As a result, health authorities and governments are beginning to explore the potential benefits of e-health and are integrating it as an alternative to the conventional methods of delivering health services. A major sector that has experienced this integration is the nursing education sector, with most national health authorities getting more determined to introduce technological knowledge as a pre-registration requirement for trainee practitioners. In the UK, most nursing pre-registration programs have largely been focused on the higher education sector since the 1990s. Hence, the Nursing and Midwifery Council’s (NMC) standards for pre-registration nursing programs require that all registered nurses must have up-to-date knowledge and skills for assessing, planning, delivering, and evaluating care (NMC, 2018). Looking for further insights on Technology's Role in Challenger Banking? Click here.

Besides, the nurses must be able to make evidence-based decisions and judgments that are cantered on the patients to ensure they receive quality care. More importantly, according to NMC (2018), the pre-registration programs require that all the students must acquire and administer their technological capabilities and digital literacy before being enrolled in the program. Similarly, there has been a massive technological advancement within the nursing career during the 21st century (Ikolo & Okiy, 2012). Therefore, there is a need for pre-registered student nurses to understand the various elements of these technologies, enabled by systematic and objective training. Kirkkova-Bagdanova et al (2016) highlights the importance of digital literacy among pre-registered nursing students and identifies three major competencies that are important for pre-registered nursing students namely: “information and knowledge management, professional and regulatory accountability, and use of Information computerised technology ICT’s.” Lin (2011) also notes that implementing high-quality skills for critical appraisal of online information is crucial for pre-registered nursing students. This dissertation aims to systematically review and synthesise the best available findings from studies exploring the level of digital literacy (DL) among pre-registration nursing students in the present programme; because technology contributes a significant part of the teaching, learning and assessment of students. the review seeks to answer the following question is “what is the level of digital literacy among pre-registration student nurses?”

Background of the Study and statement of the Problem

The Concept of Digital Literacy (DL)

At the moment, according to Chartered Institute of Library and Information Professionals (CILIP, 2018) there is not a clear definition for digital literacy and competency. Different scholars have different definitions which they develop depending on the context within which they seek use the phrase. However, as will be demonstrated in a while, these definitions generally demonstrate that the term ‘digital literacy’ has been used more frequently in higher-education research than ‘digital competency.’ Nonetheless, existing academic literature give various meanings of digital literacy, for instance, Ministry of Education Republic of Bulgaria (2016) defines digital literacy as the ability to navigate through digital environments characterised by finding, evaluating, accepting or rejecting information for a particular purpose. Similarly, National League for Nursing (n.d) defines DL as integration of cognitive science, computer science, information science and specialty science to communicate information, data wisdom and knowledge in a particular field of practice. Nonetheless, Health Education England (2017, para, 3) defines DL as “capabilities that fit someone for a living, learning, working, participating and thriving in a digital society.” Similarly, definitions by Chartered Institute of Library and Information Professionals (CILIP, 2018) reveal that DL is “knowing when and why you need information, where to find it, and how to evaluate, use and communicate it in an ethical manner.” All in all, these definitions converge at the idea that DL involves various knowledge and skills in digital information and utilising these skills and knowledge to solve problems. The impact of DL on the contemporary education system cannot be underestimated.

According to Niyomkar (2012), fundamental understanding and capabilities are especially important in a pre-registration learning process particularly with the increasing pressure on health systems to adopt e-health as an alternative to conventional health delivery system. Moreover, information and communication technology (ICT) has impacted on both health and medical fields with growing consensus among scholars and practitioners that ICT has led to an improvement in the efficiency and quality of health care services delivered in hospitals (Ranasinghe et al, 2012). As a result, several studies have been conducted to evaluate the need for ICT training among nursing professionals. For instance, Safabakhsh et al (2016) quote a qualitative study by UK’s National Health Service which revealed that only a few health care professionals participating in the study had effective knowledge in ICT, and thus were able to apply these skills in the delivery of healthcare services. A possible implication of these results is that more health practitioners in the study were not sure of their ICT skills and therefore could not effectively apply these skills in delivering care. In 1990’s, the emergence of the internet and the need to deploy more computerised equipment in healthcare facilities triggered many practitioners to learn how these technologies could be applied in their daily practice (Spencer, 2012). As a result, according to Topkaya & Kaya (2014), more health training institutions begun to include ICT as a core training area in their curricula, incorporating ICT skills training programs as part of core studies that nursing students must undertake. In fact, Zarei et al (2012) assert that in some cases, national strategies were developed by health authorities to incorporate IT into nursing education. According to Deltsidou et al (2010), these changes were mainly aimed at giving nurses the necessary skills and competencies in ICT – based on the assumption that acquiring these skills would enable nurses to effectively and efficiently manage IT-based duties such as healthcare documentation and records keeping, clinical problem solving and healthcare planning. Moreover, according to Jamshidia et al (2012), it was hypothesized that ICT would facilitate effective research to promote evidence-based practice.

Pre-Registration Nursing Education

According to NMC (2018), the phrase ‘pre-registration nursing education’ refers to a program undertaken by nursing students in the UK to acquire several competencies before they are officially registered by the NMC. These standards are well defined and documented so that students are clearly aware of what it takes to be a registered nurse in the UK. The pre-registration nursing education is established within the context of various requirements to ensure that the public’s health and well-being are protected as required by the NHS policies and regulations (Edirippulige et al, 2007). Therefore, the pre-registration program is meant to achieve a multiplicity of objectives within the UK’s health care sector including ensuring that future midwives and nurses in the UK have up-to-date skills and knowledge, and uphold the professional code of conduct. The idea behind pre-registration nursing education was motivated by the need for nursing education in the UK to respond to changing developments, needs expectations and priorities within the UK’s health care sector (Ogur et al, 2004). It is believed that by acquiring the skills, knowledge, and behaviours that meet the pre-registration standard, nurses would be able to address the current and future challenges that are inherent in the healthcare system while promoting health and well-being and improving the quality standards of healthcare (Hobbs, 2002). In short, pre-registration nursing education is based on the role of nurses to provide high-quality essential care, as well a standardized complex care based on technology and available evidence as appropriate.

As a result, a significant section of the standards for Pre-registration nursing education gives priority to technology and as a critical enabler for the delivery of quality care. For instance, the standards for nursing practice and decision-making, the NMC Standards for Pre-registration Nursing Education (2010 p. 17) asserts that: “...Decision-making must be shared with service users, caregivers and families and informed by critical analysis of a full range of possible interventions, including the use of up-to-date technology…” A possible implication of this standard requirement is that without digital literacy, nurses are not able to deliver effective and high-quality health care services using the most recent technology, thereby justifying the inclusion of DL and technological skills as a prerequisite for NMC registration. Another reference to technology within the NMC Standards for Pre-registration Nursing Education is made that: “People can trust a newly registered graduate nurse to keep and maintain accurate records using information technology, where appropriate, within a multi-disciplinary framework as a leader and as part of a team and in a variety of care settings including at home” (NMC Standards for Pre-registration Nursing Education 2010 p. 140). Again, this statement alludes to the importance of digital literacy in the nursing profession and why the NMC purposed to include it as part of pre-registration nursing education standards of requirement. Nonetheless, a grey area within the research is whether pre-registered nurses manage to acquire the right level of DL to execute such roles (Park et al, 2014).

Pedagogical Approach to Use Technology for Learning

Technological development and the emergence of the internet as an information tool has revolutionized the way people learn. The nursing education sector is no exception to the changing ways in which teaching and learning are conducted within the nursing education sector. As a result, according to Romanov & Nevgi (2007), the knowledge delivery within the nursing education sector has rapidly changed. Ideally, this change has been characterised by a review of various teaching qualifications (e.g. the preparation in Teaching in the Lifelong Learning Sector, PTLLS) with an aim of ensuring that teachers acquire the best skills and knowledge to offer modern forms of education and training within the context of ‘digital pedagogy.’ A fundamental concept upon which the pedagogical approach to using technology for learning is based is digital literacies. According to Elder & Koehn (2009), pedagogies have experienced a major change characterised by increased knowledge and skills required of learners for effective engagement in civic society and employment. This has led to a new wave of academic research on digital literacies, defining the meaning of digital literacy and what a digitally literate individual can do. Nonetheless, according to Rajalahti et al (2014), the role of digital literacy in supporting effective pedagogies is evident in the work of Gillen & Barton (2010: p5) who highlights the conceptualization of The New London Group about pedagogies.

The group assert that pedagogy is: “Situated Practice, which draws on the experience of meaning-making in everyday life, the public realm and workplaces” Attwell & Hughes (2010) also argue from the perspectives of various scholars to highlight the importance of e-learning by stating that: “we are now learning in technology-rich societies and need to remodel education as lifelong learning”. Attwell & Hughes (2010) further highlights the role of digital literacy in pedagogies by evaluating a European i-curriculum project whose main focus was on pedagogical approaches to learning and teaching. According to Attwell & Hughes (2010), the project held that a ‘digitally literate’ learner has more knowledge required to effectively exploit practices, symbol systems, and tools availed by digital technology; compared to the traditional forms of literacy which were predominantly print-based. To put things into perspective, Attwell & Hughes (2010) give several examples of activities that a digitally literate individual can engage in, for instance, a digitally literate person can engage in knowledge management, which involves combining different levels of knowledge to acquire new sets of knowledge through different information structures. Equally, a digitally literate learner can engage in electronic communication, which not only involves sending emails but also the different activities of communicating between each other within a community to promote the learning process (Grant et al, 2009). The scope of technology usually includes the use of technical devices to facilitate instruction. Educational technology might also entail digital media, audio-visual, models, digital media and video (Ikolo & Okiy, 2012). However, Niyomkar (2012) acknowledges that some authors confine it to computers peripherals, computers and learning or teaching software. Yet, a major shortcoming of defining educational technology within the confines of computers and computer peripherals is that it does not capture the use of technology in pedagogical processes that technology is supposed to support. For instance, according to Lin (2011), assuming educational technology to be an embodiment of computers does not account for the role of technology in facilitating learning objectives, the pace of learning, evaluation and assessment techniques and learning style of students. Contrariwise, technological education should capture the technological ability and skill to use knowledge in pedagogy as the basis of integrating technology into learning and teaching (Choi & Martinis, 2013). This means that teachers have the responsibility of motivating students to keep them focused during the instructional process and to understand that students’ preferences for learning styles differ and that they learn at a different pace (Grant et al, 2009).

All in all, according to Elder & Koehn (2009), the integration of technology into education involves the use of existing tools, materials and equipment such an electronic media to enhance teaching and learning. It also involves coordinating and managing instructional resources and aids in a manner that facilitates learning (Choi & Martinis, 2013). Similarly, Lin (2011) and Niyomkar (2012) opine that the identification of the most appropriate technology that considers the student’s learning needs and capabilities to ensure that the selected technology fits the underlying learning objectives. Thus, in nursing pre-registration programs, the use of educational technology would have to consider several factors. First, students should be able to use the available technological tools and aids to facilitate their learning. Secondly, instructors should select the right technological tools that not only considers the student’s technological capabilities (DL) but also facilitates the achievement of the learning objectives. This analogy informs the interest of this study, which is to evaluate the DL capabilities of pre-registration nursing students.

Attributes of Digital Literacy

Digital technology has evolved and matured as more people continue to participate in the creation of digital content. As a result, people have taken different approaches to digital literacy as these literacies develop alongside the application technology (Grant et al, 2009). Interestingly, the same dynamism has been experienced in people’s conceptualization of the term ‘digital literacy’ and its attributes. In short, different scholars construe digital literacy and its attributes differently. For instance, Beetham et al (2009: p. 9) define DL in contrast to terms such as skill and competency. First, they claim that digital literacy is “a foundational knowledge or capability, such as reading, writing or numeracy, on which more specific skills depend on cultural entitlement – a practice without which a learner is impoverished in relation to culturally valued knowledge communication – expressing how an individual relates to culturally significant communications in a variety of media. Nonetheless, digital literacy seems to always be dynamic especially considering that technology evolves faster, and that human use of technology changes with changes in technology. To paraphrase Gillen & Barton (2010: p. 9), the dynamic nature of technology and digital literacy can be used to define digital literacy as “the constantly changing practices through which people make traceable meanings using digital technologies.” Gillen & Barton (2010) continue to analyse the attributes of DL by saying that digital literacy is different from traditional forms of literacy (i.e. reading and writing) which are based on a new form of media that not only enables people to understand new modes of communication but also to understand the gap created by former forms of literacy.

Thus, if DL is not embraced, there would be a gap in the application and disposition of knowledge within various fields of practice. From a pedagogical perspective, the dynamic nature of DL can also be evaluated by considering the changing demands of learners resulting from the use of technology. In this regard, Hargittai et al (2010: p. 468-494) asserts that: "Thinking differently about information is going to be crucial as web 2.0 takes off, for both teachers and learners. To tell a story orally demands a certain set of skills, but to write a good report, the information must be deployed in a different way. A television journalist, weaving pictures and sound together to tell the story, needs a whole different set of skills, manipulating the information in a new way; which academics have called “secondary orality”. In the era of networking and emergent information systems, a whole new range of skills is necessary for our academic culture; the skills required for creating online frameworks for collaborative, learner-led work." Nonetheless, from a more general perspective, digital literacy entails the understanding of basic concepts and ideas involved in using computers and computer peripherals to acquire any necessary information useful in achieving a particular objective (Ikolo & Okiy, 2012). Still, different scholars have a different conceptualization of the meaning of digital literacy, and the characteristics or attributes of digital literacy. For instance, Elder & Koehn (2009) argue that a digitally literate person must be able to access and operate digital devices such as computers, mobile phones, and tablets. In a learning context, digitally literate learners should have the space to carry and operate their devices freely and comfortably, so that the learning process is technology based and different from the traditional forms of learning of paper and pen. However, Lin (2011) opines that digital literacy not only entails having the knowledge and digital skills but also applying them in real life situations. Also, Niyomkar (2012) and Zarei et al (2012) argue that digital literacy entails being aware of the principles and underlying concepts of various computer-based activities such as the use of internet of handling data. In this regard, Niyomkar (2012), argues that a digitally literate person must not only be able to use the internet but also understand the meaning of cybersecurity and online safety. Similarly, a digitally literate person should not only be able to create digital content (e.g. word processing) but also store, retrieve or share that content. For example, a digitally literate pre-registered nursing student should not only be able to store patient information into the electronic health records system but also to retrieve and share them when needed. Indeed, the traits of DL and its complex relationship with pedagogy calls for a deeper inquiry in the context of nursing pre-registration programs, shedding more light on the attitudes and reception of DL among these students. There is a need to deeply evaluate whether pre-registered nurses understand these complexities and respond to them in a manner that promotes their learning objectives and ultimately enhances their practice.

Digital Literacy and Nursing Education

In the UK, the inclusion of DL in nursing education was informed by a series of academic and policy inquiries during the late 1990s. Upon the publication of Information for health by the NHS executive (1998), various documents were released and they were majorly of two categories namely: documents revealing policy initiatives taken by the government towards the health sector (e.g. DOH 2001 & DOH 2002), and those that supported these policies by providing a guidance on how they would be implemented (e.g. NHSIA 1999, NHS Executive 1999 and the NHSIA 2002a) (Elder & Koehn, 2009). Ideally, according to Zarei et al (2012), a major similarity a between all these documents was their call for a culture within NHS that develops and improves the use of information skills that support effective and quality delivery of healthcare services. For instance, page 3 of the NHSIA (2002b) stated that: “Information searching techniques, critical appraisal of knowledge, and research will be commonplace activities for healthcare professionals...Therefore it is clear that all staff involved in delivering modern NHS services require knowledge and competency in health informatics.” Thus, policy developers at that time considered that competency was not only needed in supporting the nursing practice but also the delivery of quality healthcare that endeavours to inform and empower patients. To put matters into perspective, the implementation documents placed importance on the need to support staff in developing the skills they need to work within the culture of developing information skills (Grant et al, 2009).

However, whereas the specific skills were described differently by different documents, an underlying similarity is that the skills comprised of information handling skills, basic computer skills, and effective knowledge to handle the software that are related to them all (Ikolo & Okiy, 2012) According to Niyomkar (2012), these skills, together with the knowledge required for effective application information in practice defined the foundation of nursing informatics. Thereafter, an exploration of the study was launched by the NHS Executive (1998) to identify the necessary steps for implementing information for Health. The study found that it was opportunistic to include nursing informatics in pre-registration programs, and this opportunity heavily depended on the platform where the students gained their clinical experience. Years later, according to Niyomkar (2012), this opportunity still existed as identified by the NHSIA (2002a) in a study they conducted to explore various elements of nursing informatics. Specifically, the study found variability in the nature and amount of informatics-related knowledge acquired by pre-registered nursing students in education programs (NHSIA, 2002a). Specifically, according to NHSIA (2002a), a major issue identified by the study was that whereas various education programs included health informatics knowledge and skills, a few elements of these knowledge skills and knowledge could be assessed. These research evidences, together with others that may not be of use to mention herein, triggered both the UK higher education quality assurance agency (QAA) and the NMC to make a joint resolution that supported the inclusion of various IT skills and knowledge as part of the pre-registration programs for general health care practitioners and nurses in particular (Ikolo & Okiy, 2012). However, to date, little is known about the uptake of these skills and knowledge (generally referred to as digital literacy), and whether pre-registered nursing students in the UK embrace these skills. Therefore, there is a need to conduct a deeper inquiry into the nature and level of DL among pre-registered nursing students.

Digital Literacy among Pre-Registration Nursing Students

Existing research evidence reveals that pre-registration nursing students have demonstrated their level of digital literacy by using the internet as a digital platform. According to Elder & Koehn (2009), students use the internet as a source of information during their studies and later to inform their practice by accessing information about health-related issues. Thus, digital information among pre-registration nursing students is demonstrated by the extent to which the students are knowledgeable about online resources that give access to health information, as well as their ability to apply the relevant information retrieved online in practical learning situations (Park et al, 2014). Because online health information is increasingly used by patients (especially those with chronic illness) to improve their health conditions (Gilmour et al 2011), pre-registered nursing students have the responsibility to learn the elements of online sources of health information in order to assist patients retrieve and access this information (Grant et al, 2009). To put this point into perspective, the study by Gilmour et al (2011) delivered interesting insights about online health information and why it is important for patients to get assistance from knowledgeable nurse practitioners. The descriptive cross-sectional survey, which included 540 nurses and received a response rate of 58% found that whereas 52% of the respondents were aware that they could improve their health conditions by use of online health information, nearly half of the 52% knew that patients had misconceptions about their illnesses a result of misinterpreting online health information (Gilmour et al 2011). Similarly, the study found a correlation between patient misinterpretations and poor assessment of patient online information needs (Gilmour et al 2011). Indeed, the findings of this study reveal that whereas online health information is a great opportunity for patients to improve their health status, nurses may not be able to adequately assess the patients’ health information needs. Hence, there is a need to make a deeper inquiry onto the pre-registered nurses’ capabilities and levels of knowledge on the internet as well as other online platforms that patients use as a source of health knowledge so that this level of knowledge can be compared with the established standards before acquiring full registration.

The Future of Nursing Education

The future of nursing education, especially in the UK, has predominantly been shaped by the systematic changes introduced by the NMC over the past few years. According to Lin (2011), there is an on-going rapid change in the way care is delivered, and this change is triggered by an increased prevalence of long-term diseases as well as an increasingly aging population. Similarly, rapid technological advancement has led to a shift in healthcare delivery from acute care to self-management, integrated care, and prevention which is delivered by a multi-professional team within the community (Grant et al, 2009). To keep up with these changes and meet the challenges that accompany them, future nurses must be equipped with the necessary technical knowledge and skills. However, Elder & Koehn (2009) claim that there is a paucity of research evidence highlighting the level of preparation of nursing students, especially those undertaking pre-registration programs, with these skills and knowledge. Scholars have been able to predict specific areas where future nurses will have to increase their IT skills and knowledge to keep up with the quality demands of care. According to Niyomkar (2012), one such area is telecare and telehealth which are increasingly becoming important to health systems as they rapidly adopt various elements of e-health such as social networking and health informatics to meet the evolving demands of the healthcare system.

Therefore, currently pre-registered nursing students (who are the future nurses) must be prepared to by equipping themselves with IT skills and knowledge. However, little is known about the level of preparation of the pre-registration nursing students with the IT skills (Ikolo & Okiy, 2012). Similarly, Lin (2011) argues that for future nurses to deliver safe care, they must underpin their practice on knowledge base emanating from evidence-based practice. Thus, future nurses must be aware of existing research and scientific evidence, which may include the use of technology-based applied knowledge e.g. DNA mapping. A possible implication of this future trajectory is that the current technological knowledge and skills level of pre-registered nurses must be assessed and determined in order to identify any knowledge gaps in preparation for the delivery of effective care in future. Digital knowledge is not only important in nursing practice but also in the education process of pre-registered nurses. With the rise of student-centred learning approach (SCLA), the use of ICT and other digital platforms have been highly regarded as key promoters of SCLA, thus highlighting the need for high-level student capabilities in handling digital materials (Ikolo & Okiy, 2012). Moreover, according to Niyomkar (2012), most colleges and universities have adopted digital learning platforms, where students are required to access books, journals, and other learning materials online. Therefore, having effective knowledge in handling this material is pivotal to the ultimate grades of the students. Worryingly, whereas it is widely recognized that digital learning is an important element of pre-registered nurse learning, little is known about the pre-registered nurses’ ability to adjust or accommodate DL into the education system. Hence, there is a need to explore the existing literature on pre-registered nurses’ levels of DL through a literature review.

Aim of the Study

The main aim of this study is to investigate the level of digital literacy among pre-registration nursing students.

Research Objectives

i. To identify the level of digital literacy among pre-registration nursing students

ii. To explore the attitudes and perceptions of pre-registered nursing students with regards to digital literacy

iii. To identify barriers that impedes the development of digital literacy among pre-registration nursing students

Research Questions

i. What is the level of digital literacy among pre-registration nursing students?

ii. What are the attitudes and perceptions of pre-registered nursing students with regards to digital literacy?

iii. What are the barriers that impede the development of digital literacy among pre-registration nursing students?

Significance of the Study

Indeed, there is evidence that the introduction of ICT courses in nursing educational institutions have had a positive impact on clinical practice, nursing education and research. According to Zarei et al (2012), undertaking ICT courses have enabled students to prepare for the fast-changing working environment within the nursing practice profession. But, Elder & Koehn (2009) observe that most of these courses have majorly focused on developing fundamental skills in computer operations such as database management and word processing. Concurrently, there have been little efforts, if any, to develop health programs that formally capture e-health and highlight the potential benefits of ICT in educational, administrative and clinical applications. Therefore, this study argues that whereas the introduction of ICT in pre-registration nursing programs has an important contribution to the nursing practice, the incorporation of systematic learning components of e-health largely determines the uptake of e-health in the practice of nursing, so is the acquisition of digital knowledge by pre-registered nursing students necessary to execute e-health within practice. Thus, by studying the level of DL among pre-registered nursing students, the study will be a source of knowledge and information to education policymakers and curriculum developers about any gaps that exist within the pre-registration nursing education in regards to the necessary technological skills and knowledge for future practice. This study will also add to the existing literature and knowledge about DL and among pre-registered nursing students, as well as set stage for future research on the same topic area.

References

Attwell G. & Hughes J. (2010) Pedagogic approaches to using technology for learning: literature review, Research Gate, 1-86.

Beetham, H., & Sharpe, R. (2007). An Introduction to Rethinking Pedagogy for a Digital Age. In H. In H. B. R. Sharpe (Ed.), Rethinking Pedagogy for a Digital Age: Designing and Delivering e-learning. London: Routledge.

Deltsidou, A., Gesouli-voltyraki, E., Mastrogiannis, D., & Noula, M. (2010). Undergraduate nursing students' computer skills assessment: a study in Greece. Health Science Journal, vol. 4, issue 3, pp. 182-188.

Edirippulige S, Smith A, Beattle H, Davies E, Wootton R (2007) Preregistration

Grant, D. M., Malloy, A. D., & Murphy, M. C. (2009). A Comparison of Students Perceptions of their Computer Skills to their Actual Abilities. Journal of Information Technology Education, vol. 8, 141-160.

Hobbs SD(2002) Measuring Nurses' Computer Competency: An Analysis of Published Instruments. CIN: Computers, Informatics, Nursing 20: 63-73.

Ikolo, V. E., & Okiy, R. B. (2012). Gender Differences in Computer Literacy Among Clinical Medical Students in Selected Southern Nigerian Universities. Library Philosophy and Practice, 5-1.

Lin, T. C. (2011). A computer literacy scale for newly enrolled nursing college students: Development and validation. Journal of Nursing Research, 305-317.

Michel-verkerke, M. (2010). Computer Literacy of Health Professionals: Fact or Phantasy? World Congress on Social Media, Mobile Apps, Internet/Web 2.0. Medicine20Congress.

NHSIA. 2002a. Learning to Manage Health Information, A theme for Clinical Education, Moving Ahead. Birmingham: NHS Information Authority.

NHSIA. 1999. Information for Practice. The National Information Management Agenda and You. Bristol: NHS Information Authority, Education, Training and Development Programme.

NHSIA. 2002a. Learning to Manage Health Information, A theme for Clinical Education, Moving Ahead. Birmingham: NHS Information Authority.

Park, Jin-Hee, Lee, Eunha Bae, Sun Hyoung (2014) Factors Influencing Learning Achievement of Nursing Students in E-learning. J Korean Acad Nurs 40: 182-190

Park, Jin-Hee, Lee, Eunha Bae, Sun Hyoung (2014) Factors Influencing Learning Achievement of Nursing Students in E-learning. J Korean Acad Nurs 40: 182-190.

Rajalahti, E., Heinonen, J. and Saranto, K. (2014) ‘Developing nurse educators’ computer skills towards proficiency in nursing informatics’, Informatics for Health & Social Care, 39(1), pp. 47–66. doi: 10.3109/17538157.2013.834344.

Topkaya, S. G., & Kaya, N. (2014). Nurses' computer literacy and attitudes towards the use of computers in health care. Journal of Nursing Interventions, 1-9.

Zarei, J., Rokhafruz, D., & Dianat, M. (2012). The Study of Computer Literacy in Students of General Medicina at Ahvaz University of Medical Sciences. Journal of Health Administration, vol.15, number 47, pp. 67-76.