Digital transformation has become an integral part of modern healthcare systems, with governments and organisations worldwide adopting technologies to improve efficiency, accessibility and quality of services. In Japan, municipal public health departments are increasingly expected to embrace digital health tools as part of broader public service reforms. Public health nurses, who form the backbone of community health delivery at the municipal level, are central to these efforts. Their work spans health promotion, preventive care, community-based interventions and policy implementation. However, despite the opportunities offered by digital tools, progress in integrating them into public health nursing practice has been slow.
National surveys have revealed that most municipalities face challenges in developing and sustaining the digital competencies of their public health nursing workforce. Many report uncertainty about how to train staff effectively, while others highlight gaps in basic information and communication technology skills. Without systematic approaches to assess competencies and guide targeted training, digitalisation efforts risk being inconsistent, inefficient or inequitable. To address this, the Digital Health Competency Scale for Public Health Nurses (DHCP) was developed and validated, offering a structured, evidence-based tool to support workforce development in municipal public health services.
Identifying the Need for a Specialised Framework
The concept of digital health competency encompasses the knowledge, skills, attitudes and values required to effectively use digital technologies in healthcare contexts. While international frameworks such as the DECODE Framework and the TIGER Initiative provide broad guidance for healthcare providers, their primary focus is on clinical and hospital-based environments. Public health nursing operates in a distinctly different context. It is concerned not only with individual care but also with population-level interventions, equity considerations and the social determinants of health.
Public health nurses in municipal settings must navigate both the healthcare and administrative spheres. This dual role demands competencies that extend beyond technical proficiency, incorporating ethical judgement, community engagement and policy awareness. For example, digitalisation initiatives must take into account the needs of residents who may be excluded from digital services, such as older adults, low-income households or those living in rural areas with limited connectivity. Surveys of supervisory public health nurses have shown that approximately three-quarters of municipalities report limited progress in digital health adoption and around 80% are unsure how to implement effective workforce development strategies.
Given these realities, a generic competency framework designed for hospital nurses or clinical practitioners is insufficient. A tailored approach is needed—one that reflects the unique responsibilities, working environments and societal obligations of public health nurses. The DHCP was conceived to fill this gap, enabling targeted competency assessment and supporting initiatives to embed digital health into public health practice.
Developing and Validating the Scale
The creation of the DHCP followed a multi-phase process to ensure relevance, clarity and scientific rigour. The first phase involved generating a comprehensive pool of potential items through an extensive literature review and expert interviews. The research team examined national and international studies focusing on digital health, competency and public health nursing, as well as competency requirements for administrative roles. This yielded an initial list of 86 items, reflecting observable skills, underlying attitudes and motivational factors. After internal review, this was refined to 42 items.
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In the second phase, the draft scale underwent content validation by a panel of experienced public health nurses from various levels of government, alongside academic experts in medical informatics and community health nursing. These reviewers assessed the items for importance, clarity and applicability, suggesting modifications where necessary. Feedback led to the refinement of wording, removal of double-barrelled items and better alignment with public health nursing contexts. The result was a 28-item scale, ready for field testing.
The third phase involved nationwide validation through a cross-sectional survey of public health nurses in randomly selected municipalities across all prefectures in Japan. Of 2,254 distributed questionnaires, 521 valid responses were received. Statistical analyses included item analysis, exploratory factor analysis to determine the underlying structure and confirmatory factor analysis to test the model’s fit. Redundant or low-loading items were removed, resulting in a final 12-item scale organised into three factors:
- Motivation for digitalisation – capturing interest in digital tools, proactive attitudes towards change and willingness to acquire relevant skills.
- Ethical and adaptive assessment – assessing the ability to evaluate the appropriateness of digital solutions, especially for vulnerable populations.
- Technical skills – measuring proficiency in basic ICT use and the application of digital services in workplace tasks.
The scale demonstrated high internal consistency, with a Cronbach’s alpha of 0.869, and showed positive correlations with established eHealth literacy measures. Known-group validity testing confirmed that public health nurses who had received ICT training scored significantly higher on the DHCP than those without such training.
Applications for Workforce Development
The validated DHCP offers practical benefits at multiple levels. For individual nurses, it provides a structured means of self-assessment, encouraging reflection on personal strengths and areas for improvement. This can inform targeted learning goals and career development plans. For educators and trainers, the scale offers a diagnostic tool to design and tailor training programmes, ensuring that content addresses the most pressing competency gaps. It also allows for monitoring progress over time, enabling continuous quality improvement in training delivery.
At the organisational level, municipal health departments can use the DHCP to map the digital health competency profile of their workforce. This information can guide resource allocation, policy development and the integration of digital tools into service delivery. The inclusion of ethical and adaptive assessment as a core competency ensures that digitalisation strategies are implemented with an emphasis on equity and inclusion. Public health nurses are thus better equipped to ensure that no resident is excluded from the benefits of digital health services.
Furthermore, the DHCP can serve as a foundation for national workforce development policies, supporting evidence-based planning and standardised competency benchmarks. Its application could extend to performance evaluation frameworks, professional accreditation processes and research into effective digital health interventions in public health contexts.
The Digital Health Competency Scale for Public Health Nurses represents a significant advancement in supporting digital transformation within municipal public health services. By providing a validated, context-specific measure, it enables targeted capacity building and fosters a workforce that is both digitally proficient and socially responsive. As municipalities continue to implement digital strategies, equipping public health nurses with the competencies identified in the DHCP will be essential for delivering effective, equitable and future-ready health services.
Source: International Journal of Medical Informatics
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