Neonatal nurses’ e-health literacy and technology‑mediated clinical practice: a cross-sectional analysis of digital health competencies and practice patterns

Background
Digital transformation in Level III NICUs demands advanced e‑health literacy, yet evidence tying these competencies to observable nurse behaviors and safety endpoints remains scarce.

Objective
To examine associations between NICU nurses’ e-health literacy levels and their technology-mediated clinical practice patterns through a comprehensive analysis of digital health competencies and observable care delivery behaviors.

Methods
A cross-sectional, multi-site study was conducted with 95 nurses from four Al-Jouf Health Cluster NICUs in Saudi Arabia. Data triangulation combined validated scales (eHEALS, TIGER), structured observations of short care episodes, and a 30-day EHR audit. Hierarchical regression and structural equation modeling were employed to examine the direct, mediated, and moderated relationships among literacy domains, alert-response performance, and system optimization behaviors.

Results
Systems Integration competency showed the strongest associations with technology-mediated care (β = -0.62 for alert response time, β = 0.67 for system optimization, p < 0.001). Nurses in the highest e-health literacy tertile demonstrated 43% faster alert responses (26.3-second improvement, 95% CI [22.1, 30.5]) and superior system optimization behaviors (Cohen’s d = 2.05, 95% CI [1.62, 2.48]). Technology Acceptance Model constructs mediated 35–38% of e-health literacy-clinical outcome relationships. Trust in Technology (β = -0.21, p < 0.01) and Motivation to Use (β = 0.23, p < 0.01) significantly moderated these associations. SEM demonstrated an excellent fit (CFI = 0.961, RMSEA = 0.049). Prior informatics training was associated with enhanced performance across all outcomes (Cohen’s d = 0.58–0.67).

Conclusions
E-health literacy competencies, particularly Systems Integration capabilities, are strongly associated with effective technology-mediated clinical practice in NICUs. These digital competencies relate to critical patient safety indicators, including alert response efficiency and system optimization behaviors. The cross-sectional design limits causal inferences; longitudinal research is needed to establish whether improving e-health literacy leads to enhanced clinical performance.