The digital transformation of health care systems is rapidly redefining how care is delivered, documented, and managed worldwide. Across clinical environments, digital health technologies (DHTs)—including electronic medical records (EMRs), virtual care platforms, and artificial intelligence—are increasingly deployed to enhance care coordination, improve efficiency, and respond to growing service demands [1,2]. In Quebec, this shift is occurring amid a persistent nursing shortage that places additional pressure on health care institutions and personnel [3]. Strategic investments in digital infrastructure, such as those outlined in the province’s 2022 to 2025 technological modernization plan and the federal Pan-Canadian Health Data Strategy, have positioned digital tools as key enablers of more responsive, equitable, and sustainable care delivery [4,5].

To ensure that nurses are prepared to operate within these digitized environments, regulatory and educational bodies have issued guidelines calling for the integration of informatics into nursing practice. The Ordre des infirmières et infirmiers du Québec (OIIQ) emphasizes the importance of digital competencies for safe, ethical, and efficient care across both in-person and virtual settings [6,7]. At the national level, the Canadian Association of Schools of Nursing (CASN) has updated its National Nursing Education Framework to include explicit expectations for digital health literacy among nursing graduates [8]. Together, these standards promote the incorporation of information and communications technologies into nursing curricula as both a professional requirement and a pedagogical priority.

Despite these mandates, gaps remain in the actual delivery of digital health training across Canadian nursing programs. While students often demonstrate general digital literacy, studies show that they are underprepared to use clinical information systems, navigate electronic records, or interpret data generated by digital tools in real-world practice [9-11]. Furthermore, many programs offer inconsistent or superficial exposure to health ITs (HITs), contributing to low confidence and proficiency among graduates [11]. These limitations risk widening the gap between institutional expectations and actual clinical readiness, particularly as the pace of digitalization continues to accelerate. Previous studies indicate that, although nursing students tend to have a positive attitude toward digital health, their clinical readiness remains limited due to inconsistent exposure to health information systems. Competency frameworks such as those from the CASN and OIIQ underscore the need for structured, progressive integration of digital training into nursing education [7,8]. These limitations contribute to low confidence and perceived readiness among graduates entering technology-rich clinical environments.

Although several studies have examined nurses’ perceptions of digital health tools, few have focused on nursing students in Quebec, where the educational structure, regulatory environment, and pace of curricular reform differ from those of other Canadian provinces [12]. Given recent efforts at the Université de Montréal (UdeM) to revise its undergraduate nursing program to better align with CASN and OIIQ guidelines, it is crucial to understand students’ current perceptions, competencies, and intentions regarding DHTs. To our knowledge, this is the first study in Quebec to use a cohort-comparative design to examine digital health preparedness among nursing students. Grounded in the technology acceptance model and the OIIQ digital competency framework, this study aimed to identify year-based differences in perceptions and training gaps, thereby informing targeted curricular reforms to support Quebec’s digital health transformation [12,13].

This study was conceptually inspired by the behavioral framework by Paré et al [14] examining medical students’ intention to integrate DHTs, which combines elements from the theory of interpersonal behavior by Triandis [15] and the technology acceptance model [16]. The survey content was further adapted to the nursing context using insights from the 2020 National Survey of Canadian Nurses on the use and impact of DHTs in practice. The final instrument was reviewed and validated in collaboration with experienced nursing professors from the Faculty of Nursing (Faculté des sciences infirmières in French; FSI) at UdeM to ensure relevance and clarity for nursing students.

This study had the following objectives:

This study used a cross-sectional descriptive design. It was conducted at the FSI at UdeM in May 2023. The target population included 1274 students enrolled in the FSI at UdeM. A target sample size of 300 was chosen based on recommended minimum thresholds for descriptive surveys in large student populations [17] to ensure reasonable representation as no formal power calculation was required for this exploratory design. Eligible participants were all students currently enrolled in an undergraduate nursing program who provided informed consent.

It is important to note that participant distribution across academic years was uneven. This reflects actual enrollment sizes within the program during the data collection period.

This study was reviewed and approved by UdeM’s Research Ethics Committee in Sciences and Health (2023-4300) and was supported by the FSI. All participants provided informed consent electronically before starting the survey and could withdraw at any time without consequence. Data were collected anonymously to ensure participant privacy and confidentiality. No financial or other compensation was provided for participation.

UdeM was selected as the research site due to its status as a major higher education institution in Quebec and the diversity of its undergraduate nursing student population. Recruitment was conducted electronically through the FSI, which emailed an initial invitation and one reminder to all eligible students via their institutional addresses. Interested participants accessed the study by clicking a secure link leading to the consent form and the online questionnaire. Participation was voluntary and anonymous. Although IP addresses were not collected to ensure confidentiality, the use of institutional email distribution and limited reminders minimized the risk of multiple entries.

Data were collected through an online self-administered questionnaire designed specifically for this study administered via Qualtrics (Qualtrics International Inc), a platform designed for web-based research that offers basic descriptive statistics tools while ensuring secure data handling.

The questionnaire took approximately 15 minutes to complete and included an open-ended question at the end, allowing participants to share additional comments. Although this open-ended question was included at the end of the questionnaire to capture additional student perspectives, these responses were not systematically analyzed in this study. An exploratory review of these responses was conducted to inductively identify recurring themes and enrich the interpretation of the quantitative findings by reflecting participants’ lived experiences and unprompted perspectives.

The survey was developed to operationalize key constructs from the conceptual framework described above. Specific items were adapted from the study by Paré et al [14] and the 2020 National Survey of Canadian Nurses to align with the nursing context and relevant DHTs. The draft instrument was then reviewed and refined in collaboration with experienced nursing faculty at UdeM to ensure content validity and clarity. The final version included 15 items (Table S1 in Multimedia Appendix 1) and is available in Multimedia Appendix 2.

This study assessed nursing students’ perceptions, competencies, and training needs related to HITs across 4 main categories of variables.

Students were grouped into 3 categories based on their year of study: first year of the integrated diploma of college studies–bachelor’s degree (diplôme d'études collégiales–baccalauréat in French; DEC-BAC) and regular bachelor’s degree (baccalauréat in French; BAC) programs (group 1), second year of the DEC-BAC and BAC programs (group 2), and third year of the DEC-BAC and BAC programs (group 3). All Likert scale variables were treated as continuous variables and analyzed using means and SDs.

For categorical variables, frequencies and percentages were reported for each group as well as for the total sample. Group comparisons were conducted using exact P values from chi-square tests. For continuous variables, valid sample sizes, means, and SDs were presented. Group means for Likert scale variables were compared using one-way ANOVA followed by Tukey post hoc tests where appropriate.

An exception was made for the variable “training coverage—scheduling software,” where the Welch correction for unequal variances was applied and post hoc comparisons were conducted using Games-Howell tests. All statistical analyses were performed using the SPSS software (version 28; IBM Corp), with a significance level set at 5%.

Perceptions of the impact of HITs on the nursing profession were consistent across all groups. Most students believed that DHTs have a positive or very positive impact on key aspects such as quality of care, therapeutic relationships, and productivity (Table S6 in Multimedia Appendix 1).

Of the 136 respondents, 31 (22.8%) provided written responses to the open-ended question. Most comments reflected key patterns observed in the quantitative results, particularly regarding the perceived lack of formal training in DHTs. Several students reported learning to use digital tools only during clinical placements, consistent with the limited curriculum coverage ratings found across cohorts. One respondent noted that “[w]e only learn to use digital tools during internships,” whereas another remarked that “[a]t university, we have no training on the software we encounter in practice.”

Others described barriers to accessing technologies during clinical placements due to their student status:

These comments aligned with cohort-based differences observed in digital tool use and confidence levels.

However, the responses also surfaced dimensions not captured in the structured survey. Several participants mentioned psychosocial or physical impacts of digital tool use, including “less sleep, eye strain, and a more sedentary lifestyle” and “technology sometimes limits social interaction, which affects mental health.” A few students proposed improvements, such as earlier exposure to clinical systems or greater consistency in tools across health care settings:

While broadly aligned with the quantitative trends, these narrative comments introduced experiential nuances, such as well-being, autonomy, and implementation barriers, that were not accessible through the Likert scale items alone.

Both the OIIQ Comité jeunesse and the OIIQ [6,12] emphasize the importance of access to IT that supports nurses’ clinical decision-making, optimizes care processes, and enhances patient safety, as well as maintaining professional and ethical standards.

Similarly, the CASN, through its National Nursing Education Framework [8], underscores the importance of integrating nursing informatics competencies into academic programs to better prepare future professionals for the increasing technological demands of clinical environments.

However, our findings indicate that students perceive their current training as insufficient. Their self-assessed proficiency with digital tools was limited, and coverage of key HITs was generally perceived as weak without a clear progression across academic years despite students showing an interest in these tools and their potential impact on nursing practice.

These observations suggest a concerning disconnect between the evolving expectations of the health care system and students’ perceived preparedness despite the clear guidelines set forth by both the OIIQ and CASN. This aligns with findings by Kleib et al [11], who identified persistent gaps in digital health education that were exacerbated by pedagogical approaches that often overestimate students’ technological competencies and fail to adequately prepare them for clinical realities.

The narrative comments reinforced this disconnect by providing concrete examples of students’ perceived lack of preparation, particularly in relation to clinical software. The comments also highlighted barriers that were not captured in the structured survey, such as restricted access to digital tools during placements and the personal toll of technology use on well-being. These experiential accounts complement the quantitative findings and emphasize that perceived readiness is shaped not only by curricular content but also by the conditions of access, support, and emotional experience within clinical environments.

The fact that many participants in our study believed that high-level proficiency was unnecessary for the effective use of HITs may reflect a limited understanding of their relevance in nursing practice. Kleib et al [11] emphasize that, while students often demonstrate basic digital literacy, this does not necessarily translate into clinical competence. Consequently, students may underestimate the complexity and significance of digital tools in real-world settings. These findings highlight the pivotal role of nursing educators in bridging this gap by explicitly integrating digital competencies into nursing curricula and grounding them within authentic clinical contexts to foster both awareness and applied proficiency.

Despite these challenges, the surveyed students remained generally optimistic about the role of HITs, with most believing that these technologies will have a positive or even very positive impact on the nursing profession. This optimism reflects a growing awareness of the digital shift in health care and aligns with the strategic directions promoted by the OIIQ and CASN, who advocate for stronger digital health training in nursing education [7,8].

Beyond these overarching findings, notable differences emerged between academic years in terms of access to digital tools, proficiency with specific technologies, and perceived curriculum coverage. This study identified several statistically significant differences in how students from each cohort perceived and interacted with HITs.

The 18- to 25-year age group predominated across all cohorts, particularly in group 3, where it represented 83% (19/23) of the participants. Group 3 students also reported greater access to digital tools, especially laptops, and more advanced use of EMRs, virtual reality, and databases. These findings are consistent with the broader and more in-depth training coverage that this group reported for these tools.

The observed differences in competencies and training exposure likely reflect curricular progression, with third-year students benefiting from more extensive clinical placements, capstone projects, and practical assignments that integrate digital tools. In addition, group 3 students may have greater opportunities for independent learning and part-time work in health care settings, reinforcing their proficiency with EMRs and clinical databases. In contrast, group 1 students are typically at the beginning of their program, focused on foundational theoretical content with limited hands-on exposure to applied digital health systems.

Group 2 students stood out for their more frequent use of digital tools and a higher reported need for advanced competencies in health care robotics. Meanwhile, group 1 students reported better coverage related to scheduling software, likely reflecting academic needs specific to first-year studies.

Taken together, these findings reveal a persistent and concerning gap between current digital health needs and the perceived preparedness of nursing students, echoing the concerns expressed by the OIIQ [7]. They underscore the importance of continuing efforts to integrate digital health competencies into nursing education in a structured and strategic manner.

This study reveals a significant gap between institutional expectations and perceptions of digital health training by nursing students, particularly in their proficiency with essential tools such as EMRs and clinical databases. Despite recognizing the value of digital technologies, students reported limited curricular coverage and confidence in using them.

These findings call for targeted reforms in nursing education, including the integration of hands-on training, digital simulations, and interactive modules. To address these gaps more concretely, nursing programs could implement several specific measures: (1) dedicated simulation laboratories focused on EMRs and clinical software; (2) mandatory digital health literacy modules that introduce students to national and provincial informatics frameworks; and (3) interprofessional digital health workshops that mirror real-world collaborative settings involving nurses, physicians, and allied health professionals. These recommendations are further supported by students’ own accounts, which reflect both a desire for earlier, more practical exposure to digital tools and a recognition of the limitations in their current training environment.

The current curriculum revision at UdeM offers a timely opportunity to evaluate the implementation outcomes of such changes. Future studies using a clearly defined pretest-posttest design, with precise cohort tracking to distinguish students enrolled before, during, or after curriculum reforms and collecting detailed data on external exposure to HITs (eg, work settings) could help assess the true impact of these reforms.

Broader research across institutions and through mixed methods or longitudinal approaches will be crucial to strengthening the evidence base literature. In an increasingly technology-driven health care landscape, equipping the next generation of nurses with robust digital competencies is no longer optional and has become a professional imperative.