Digital technology is important in supporting health services, including improving nursing care, education, and decision making. ^{1 – 6} Digitalization provides convenience and has a positive impact on the health sector, ¹ which is currently experiencing demand for a fast and precise shift. The coronavirus disease 2019 (COVID-19) pandemic has also encouraged the acceleration of the use of digitalization in health services for reasons of physical restrictions. ^{1 , 7 , 8} The use of digital technology in this era aims to reduce the speed of transmission of contact transmission of infection. ^{8 , 9} Some of the developments in digitalization in the COVID-19 era include telemedicine and telenursing. ^{9 , 10} Telenursing has had a positive impact and can be utilized in conducting health education, health consultations, and medical consultations in pre- and post-operating procedures. ^{11 – 14}

Moreover, the development of digital technology is not only used to provide services to patients but also to improve the competency of health workers, including those in the nursing profession. Digital-based education can be conducted through websites, e-learning, webinars, or even material sharing through mobile communication media or social media. ^{13 – 15} This competency improvement was very much needed at the beginning of the pandemic because the new disease resulted in many gaps in knowledge, including how to treat patients, how to use Personal Protective Equipment (PPE), how to reduce virus transmission, and how to improve physical and psychosocial endurance. Digital-based education is widely carried out in the era of COVID-19, considering that the workload of nurses is growing along with the increase in the number of patients, making conventional training activities difficult to carry out. On the other hand, a lot of information and materials are being developed and given out by various parties, which can sometimes be confusing. Therefore, the dissemination of information and learning materials must be managed so that they are useful in supporting nursing care and services. ¹⁶

The ability to filter the validity and reliability of information is one of the digital literacy skills that nurses must have. Digital literacy comprises being able to find, evaluate, and utilize appropriately, ethically, wisely, intelligently, carefully, precisely, and lawfully. ¹⁷ The use of digital-based education or digitalization in health sectors must be managed carefully, with organizations requiring an effective internal control mechanism. ¹⁸ Organizations must accompany the digitalization transformation so that because of the presence of digitalization in the era of COVID-19. For it to have a positive impact, hospitals need to understand digital literacy and develop human resource competencies in digital technology. Digital literacy could improve services for the community so that they can become responsive, innovative, productive, effective, organized, and higher quality. ^{18 , 19}

Based on the results of an interview with the head of the nursing division at a hospital in Jakarta, Indonesia, it was found that while the use of digital technology in nursing care has been implemented, it is still not optimal. During the pandemic, this hospital had a great impetus to learn information about how to treat COVID-19 patients, improve resilience, and enter a new era of adaptation. The busyness of shifts and the current limitations of physical learning have led to an agreement to use an electronic system to improve the competence of nurses, especially in the use of PPE, new treatment methods for COVID-19 patients, efforts to reduce anxiety, and psychosocial support for nurses. Digitalization has also been used to implement integrated reporting through online teleconferencing, which is expected to facilitate effective and collaborative communication.

The hospital does not yet have a policy on how to use digitalization technology in the field of nursing services. The absence of standard procedures raises the risk of misuse of the digital system and the violation of ethical principles. Digital literacy competence must also be improved so that there is no risk of system failure. This study reports on a digital literacy promotion program that aims to increase digital literacy competency in nurses, including improving the ability to use technology appropriately, filter information, and implement ethics in using digital media.

This study used data from the improvement program that was implemented after permission from the hospital and ethical approval were obtained in May 2022, from Ethical Board of Faculty of Nursing, Universitas Indonesia (Number 138/UN2.F12. D1.2.1/PPM.00.02/2022), and all respondents have signed the written informed consent. The respondents understood the purpose, benefits and procedures of the study. The team respected the right of respondents to participate in the improvement program. The questionnaires were filled out anonymously, and participant names are hidden and replaced with code names such as P1, P2 etc. The team ensured confidentiality and explained the benefits of socializing the promotion of digital literacy, which include accompanying the change of service providers with better quality and prioritizing patient safety. In publishing data from the improvement study, the authors will also use ethical principles by maintaining data confidentiality as well as individual and organizational privacy.

This study reports on quality improvement programs that have been carried out in hospitals after the pandemic and the new post-pandemic era in May to July 2022. The activity was carried out for five weeks using an Assessment, Development and Design Program, Implementing and Evaluation (ADDIE) approach. The ADDIE approach was chosen because from previous studies it was concluded that ADDIE can make it easier for trainees and nurses to follow the directions in a structured manner and can improve their competency. ADDIE also improve clinical leadership of head nurse. ^{20 – 22}

The ADDIE approach starts with an assessment and then continues to problem analysis using The Fishbone approach. The FGD aims to identify the room’s readiness to use digitalization and the problems that arise when implementing digitalization in health services. Problem identification was carried out using structured interview techniques and assessment using digital literacy questionnaires at the person center. Interviews were conducted with nine heads of rooms and one manager of the nursing division. ³⁹ A purposeful sampling procedure was conducted. An invitation with information about the study was deliver to the heads of wards, and all participants knew the reasons for doing the research. All the participant the selected were from wards that have treated Covid-19 patients. Questions in the interview include ⁴² : 1) Does the hospital already have a policy on the use of digitalization? 2) What is the current competency of nurses in using digital technology? 3) What is the availability of infrastructure and staff support that helps and facilitates the implementation of digitalization in the hospital? Before carrying out the FGD, bracketing was carried out by carrying out interview practice. Bracketing aims to help researchers discuss emotionally charged research questions and topics.

The FGD was conducted in the meeting room to avoid disturbances that might arise during the process and was held for about 60 minutes. All information from the participants were recorded by tape recording. At the end of the meeting, a number of unclear questions were asked again. All data in this study have been verified and reached saturation at the end of the interview. The FGD ended when all questions were answered, and all participants submitted their information. Transcipts were read twice to catch any writing error, then the data were organised, extracted to find meaningful using fishbone tema approach. Data validity test were performed by checked from participant. A Fishbone diagram is created after the FGD data has been examined and is used to list the various root causes that may be associated with a problem. As a result, this diagram helps differentiate the root cause from the various contributing elements. The main application of this visual is in dispersion analysis. By analyzing additional causes of each primary cause and how they impact the quality attribute, dispersion analysis thoroughly investigates each of them. A cause-and-effect fishbone diagram focuses on a highlighted problem or symptom and shows the root cause. Through a Fishbone we can identify real problems and their underlying causes, thereby enabling the creation or selection of alternative action plans.

The second step of promotion programs consist of design and development programs. Designing and developing the program involved using a drafting procedure, producing learning materials, and then continue by nurse expert face validation. The development of learning media includes digital security, digital security, digital identity, and digital welfare.

The third step was implemented with face-to-face training in one day and continued with online simple share material learning by WhatsApp group communication. Every day, the nurse manager delivered reminders about the ethical conduct using digital health and open discussion for barrier in implementation digital for patient education and nursing electronic documentation.

An evaluation of the digital literacy competency of nurses was carried out using the original questionnaire developed by the researcher. ⁴¹ The questionnaire was refered from “A Health and Care Digital Capabilities Framework” by NHS, London, which includes four sub-variables, namely, digital security literacy, digital well-being, digital security, and digital privacy. The six domains of digital literacy in person-centered care are communication, collaboration, and participation; teaching, learning, and self-development; information, data, and media literacy; creation, innovation, and scholarship; and technical skills. ²³ The validity of the questionnaire is in the range of 0.497–0.897, while the reliability value is 0.975. A purposeful and convenient sampling procedure was conducted. The questionnaire was filled out by 25 nurses who met the criteria, and the questionnaires were given before and after implementation. Analysis of before and after implementation using the Excel (MS Office Version 2020). ⁴¹

The stages of the ADDIE digital literacy promotion approach were assessment, design and development, implementation, and evaluation (see Table 1).

Digital literacy is a basic competency that must be possessed by nurses who use digital technology in nursing services. Digital literacy involves competence in using digital technology appropriately and wisely. ¹⁸ The use of digital technology ideally increases productivity, improves communication and coordination, and increases innovation and creativity. ^{2 , 4} Digital literacy is very much needed in the 4.0 digital era and also in the era of COVID-19. The results of the study at the beginning of the pandemic found that the use of digital technology in the treatment room was still minimal. ^{7 , 11} However, following a surge in cases, digital technology became an important medium to improve the competency of nurses in handling and using PPE. ^{7 , 11 , 15 , 19 , 24 , 25}

Digital technology is also used for communication and coordination so that in a disaster situation there is information coming from one command center. In addition, several hospitals have also implemented increased use of electronic documentation, electronic patient education, and even telenursing. ^{9 , 19} The positive side of using technology is that it can help nurses improve nursing care, namely by reducing human errors, improving human attutide, increasing patient safety, and increasing role competence ^{24 , 26} ; on the other hand, the acceleration of this technology must be accompanied by digital readiness. ²⁴ Digital literacy is needed so that the use of digital technology when carrying out nursing services can be done ethically, and can increase effectiveness and efficiency. ^{24 , 25}

Nurses’ digital literacy in the aspects of skills, attitude, productivity, innovation, and creativity is still below 75%. This is certainly very worrying because it will have an impact on service quality. This condition is following previous research that found that low digital literacy has an impact on the duration of service response and subsequently on the quality of patient care. Previous studies have also identified that low levels of digital literacy lead to a lack of staff engagement with information systems. ²⁷ Bad computer skills and poor experience in using digital technology can affect staff attitudes toward digital literacy. ²⁸ Therefore, a low level of digital literacy is an obstacle to the development of hospital information systems and smart hospitals, whereas good digital literacy could increase productivity. Previous research has shown that nurses who can use digital technology have contributed to an increase in more effective care services. ²⁹

The promotion of digital literacy begins with reviewing the problem and then establishing a problem-solving plan. This study used the ADDIE approach because it provides a systematic pathway to improve nurses’ digital literacy. A previous study noted that the ADDIE approach also made a positive perception in the nurse continuing professional development. ³⁰ Moreover, ADDIE can also can be used in clinical learning and improve other nurse competencies. ³¹

The ADDIE approach in the study started with assessment and then continued to problem analysis using a fishbone approach. The fishbone cause and effect diagram is a tool used to analyze the root cause of a problem and organize mutual relationships. ³¹ Product quality after the initial assessment is the need for literacy digital promotion for a nurse.

The second stage of the study was design and development, which developed standard procedures for the use of digital technology. Standard digital procedures help determine the management of activities that use digital technology. Based on previous studies, standard procedures are important tools designed to improve service quality and serve as guidelines for the use of digital tools and technology in nursing services. ^{32 , 33} In addition, it is necessary to conduct socialization in the implementation stage. The training program was conducted on how to use digitalization in the field of nursing services. Socialization components included digital security, digital identity, and digital welfare. The promotion of digital literacy is expected to aid in increasing digital literacy competence, especially in improving communication skills, coordination, innovation, and the use of technology to increase the productivity of health services. ³²

The evaluation of the digital literacy promotion program with ADDIE aproach showed changes in increasing competency in attitudes and behavior. The term ‘attitude’ in this study refers to the ability to appreciate the information and use professional ethics in communicating digitally and on social media. However, in general, there was no change observed in digital technology skills nor in increased productivity in useful services. The interview results show a low involvement of staff in using digital technology to support service productivity, so there is a risk of resistance to change. The reluctance to use innovation and digital skills to increase productivity may be because the nursing staff is not familiar with the use of information technology. Nurses need time to change patterns and adjust their attitudes and behaviors and therefore also require encouragement and self-commitment. ^{32 , 34 – 36}

The development of staff digital literacy is also influenced by the competency of nurse managers. The manager’s interpersonal role, which is highly coherent with the involvement of nursing staff, will increase the adaptation of digital literacy. ³² Leader support is needed in influencing staff and providing encouragement for using digital media, communication tools, or networks in a healthy, ethical, wise, careful, precise, and law-abiding way. ¹⁸ It is important to monitor and evaluate an information system in order to measure the extent to which the application of the latest technologies is working in hospitals. This is supported by Hariyati’s research, which showed that monitoring and evaluation can reduce errors in digital use. ³⁷

Digital technology is an indispensable tool to improve service quality. In the COVID-19 era, the use of digital technology is increasing in light of the fact that digitalization can facilitate coordination and communication, and is widely used for educational materials on treating patients, using PPE, and reducing anxiety. The use of technology must be adequately managed, and the competency of its users must be improved so that digitalization can be used appropriately and wisely. The promotion of digital literacy for nursing staff in this study aimed to increase competency in using digital technology in nursing services. However, while it improved behavioral aspects in the use of digital technology, progress was not observed regarding improving skills that are more comprehensive in terms of increasing productivity, innovation, and creativity. Nursing managers need to establish a follow-up strategy to improve nursing digital literacy in order to use it to improve communication, coordination, and service productivity. The result of the digital literacy promotion with ADDIE aproach showed changes in increasing competency in attitudes and behavior.