{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T06:56:07Z","timestamp":1790751367942,"version":"4.1.0"},"reference-count":30,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T00:00:00Z","timestamp":1790726400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Public Health"],"abstract":"\n Background<\/jats:title>\n Nursing studies have separately linked self-perceived digital literacy with self-reported innovative behavior and the clinical practice environment with creative self-efficacy and innovative behavior. A related association pattern has been reported among Chinese medical students, but joint evidence from multi-institutional nursing samples remains limited.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To evaluate the measurement structure and examine the three-variable association pattern among self-perceived general digital literacy, creative self-efficacy, and self-reported innovative behavior in nursing students recruited from three institutions.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n A multi-institutional cross-sectional online survey conducted from September to December 2025 included 502 undergraduate nursing students from three medical higher-education institutions in Anhui Province, China. Item-level confirmatory factor analyses compared five theoretically plausible measurement models, and convergent and discriminant validity were evaluated before PROCESS Model 4 was applied to observed total scores. The primary analysis used 5,000 bootstrap resamples and eight theory-informed covariates.<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n Self-perceived general digital literacy was correlated with creative self-efficacy (\n r<\/jats:italic>\n \u202f=\u202f0.574) and self-reported innovative behavior (\n r<\/jats:italic>\n \u202f=\u202f0.584), while creative self-efficacy was strongly correlated with self-reported innovative behavior (\n r<\/jats:italic>\n \u202f=\u202f0.834; all\n p<\/jats:italic>\n \u202f&lt;\u202f0.001). The theory-consistent higher-order three-construct model showed acceptable fit (\n \u03c7<\/jats:italic>\n 2<\/jats:sup>\n \u202f=\u202f1314.15, df\u202f=\u202f426, CFI\u202f=\u202f0.935, TLI\u202f=\u202f0.929, RMSEA\u202f=\u202f0.065, SRMR\u202f=\u202f0.068), fitted substantially better than the one-factor model, and significantly outperformed the corresponding model combining creative self-efficacy and innovative behavior (\u0394\n \u03c7<\/jats:italic>\n 2<\/jats:sup>\n \u202f=\u202f151.76, \u0394df\u202f=\u202f2,\n p<\/jats:italic>\n \u202f&lt;\u202f0.001). Their latent correlation was 0.907, HTMT was 0.902 (95% CI, 0.858\u20130.941), and the Fornell-Larcker criterion was not met. In the adjusted observed-score model, the total coefficient, direct coefficient, and bootstrap product term involving creative self-efficacy were 0.145 (95% CI, 0.127\u20130.163), 0.040 (95% CI, 0.025\u20130.055), and 0.105 (95% CI, 0.087\u20130.124), respectively. The product-term confidence interval excluded zero, and its estimate was materially similar without covariate adjustment. A supplementary\n post hoc<\/jats:italic>\n reparameterization based on the observed-score correlations indicated that the data did not uniquely determine the directional ordering.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusion<\/jats:title>\n In this pooled three-institution nursing-student sample, the three self-report constructs showed a coherent cross-sectional association pattern across measurement-model comparisons and adjusted and unadjusted specifications. This finding connects two previously separate lines of nursing evidence and extends the complete pattern beyond a single-campus nursing sample. Creative self-efficacy was a theoretically relevant correlate within the contemporaneous statistical decomposition, not an established temporal or causal mechanism. Longitudinal studies with objective or observer-rated measures are needed to test temporal ordering and educational or practice-relevant implications.<\/jats:p>\n <\/jats:sec>","DOI":"10.3389\/fpubh.2026.1938122","type":"journal-article","created":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T06:05:39Z","timestamp":1790748339000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Self-perceived digital literacy, creative self-efficacy, and self-reported innovative behavior among undergraduate nursing students in Anhui, China: a multi-institutional cross-sectional study"],"prefix":"10.3389","volume":"14","author":[{"given":"Tong","family":"Wu","sequence":"first","affiliation":[{"name":"School of Nursing, Wannan Medical University","place":["Wuhu, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xudong","family":"Fan","sequence":"additional","affiliation":[{"name":"School of Nursing, Wannan Medical University","place":["Wuhu, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Xinle","family":"Zhou","sequence":"additional","affiliation":[{"name":"School of Nursing, Wannan Medical University","place":["Wuhu, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yingying","family":"Wang","sequence":"additional","affiliation":[{"name":"Department of Emergency, Yijishan Hospital of Wannan Medical University","place":["Wuhu, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Miao","family":"Wang","sequence":"additional","affiliation":[{"name":"School of Nursing, Wannan Medical University","place":["Wuhu, China"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1965","published-online":{"date-parts":[[2026,9,30]]},"reference":[{"key":"ref1","volume-title":"Global Strategy on Digital Health 2020\u20132027","year":"2025"},{"key":"ref2","volume-title":"Competency Frameworks and Standards for Digital Health: A Landscape Analysis","year":"2026"},{"key":"ref3","volume-title":"The 14th Five-Year Plan for National Health [in Chinese]","year":"2022"},{"key":"ref4","volume-title":"A Global Framework of Reference on Digital Literacy Skills for Indicator 4.4.2","author":"Law","year":"2018"},{"key":"ref5","doi-asserted-by":"publisher","first-page":"580","DOI":"10.2307\/256701","article-title":"Determinants of innovative behavior: a path model of individual innovation in the workplace","volume":"37","author":"Scott","year":"1994","journal-title":"Acad Manag J"},{"key":"ref6","doi-asserted-by":"publisher","first-page":"656","DOI":"10.1111\/jan.15801","article-title":"A cross-sectional study of discipline-based self-perceived digital literacy competencies of nursing students","volume":"80","author":"Martzoukou","year":"2024","journal-title":"J Adv Nurs"},{"key":"ref7","doi-asserted-by":"publisher","first-page":"1717234","DOI":"10.3389\/fpubh.2026.1717234","article-title":"Subtypes of digital literacy and their association with innovative behavior among Chinese undergraduate nursing students: a latent profile analysis","volume":"14","author":"Wang","year":"2026","journal-title":"Front Public Health"},{"key":"ref8","doi-asserted-by":"publisher","first-page":"964","DOI":"10.12182\/20240760302","article-title":"Configurational pathways through which digital literacy enables innovative behavior among medical students: a fuzzy-set qualitative comparative analysis [in Chinese]","volume":"55","author":"Hu","year":"2024","journal-title":"J Sichuan Univ Med Sci Ed"},{"key":"ref9","doi-asserted-by":"publisher","first-page":"191","DOI":"10.1037\/0033-295X.84.2.191","article-title":"Self-efficacy: toward a unifying theory of behavioral change","volume":"84","author":"Bandura","year":"1977","journal-title":"Psychol Rev"},{"key":"ref10","doi-asserted-by":"publisher","first-page":"1137","DOI":"10.5465\/3069429","article-title":"Creative self-efficacy: its potential antecedents and relationship to creative performance","volume":"45","author":"Tierney","year":"2002","journal-title":"Acad Manag J"},{"key":"ref11","doi-asserted-by":"publisher","first-page":"105656","DOI":"10.1016\/j.nedt.2022.105656","article-title":"Relationship among clinical practice environment, creative self-efficacy, achievement motivation, and innovative behavior in nursing students: a cross-sectional study","volume":"120","author":"Xiang","year":"2023","journal-title":"Nurse Educ Today"},{"key":"ref12","doi-asserted-by":"publisher","first-page":"1194","DOI":"10.1186\/s12909-025-07799-z","article-title":"The relationship between digital literacy and innovative behavior among Chinese medical students: the chain mediating roles of diversity experience and creative self-efficacy","volume":"25","author":"Wu","year":"2025","journal-title":"BMC Med Educ"},{"key":"ref13","doi-asserted-by":"publisher","first-page":"e296","DOI":"10.1371\/journal.pmed.0040296","article-title":"The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies","volume":"4","author":"von Elm","year":"2007","journal-title":"PLoS Med"},{"key":"ref14","doi-asserted-by":"publisher","first-page":"e34","DOI":"10.2196\/jmir.6.3.e34","article-title":"Improving the quality of web surveys: the checklist for reporting results of internet E-surveys (CHERRIES)","volume":"6","author":"Eysenbach","year":"2004","journal-title":"J Med Internet Res"},{"key":"ref15","doi-asserted-by":"publisher","first-page":"149","DOI":"10.3389\/fpubh.2018.00149","article-title":"Best practices for developing and validating scales for health, social, and behavioral research: a primer","volume":"6","author":"Boateng","year":"2018","journal-title":"Front Public Health"},{"key":"ref16","doi-asserted-by":"publisher","first-page":"209","DOI":"10.1186\/s12874-022-01694-7","article-title":"Sample size calculation for prevalence studies using Scalex and ScalaR calculators","volume":"22","author":"Naing","year":"2022","journal-title":"BMC Med Res Methodol"},{"key":"ref17","doi-asserted-by":"publisher","first-page":"233","DOI":"10.1111\/j.1467-9280.2007.01882.x","article-title":"Required sample size to detect the mediated effect","volume":"18","author":"Fritz","year":"2007","journal-title":"Psychol Sci"},{"key":"ref18","volume-title":"Digital Literacy of Undergraduates at Double First-Class Universities and its Influencing Factors [master\u2019s thesis; in Chinese]","author":"Liu","year":"2019"},{"key":"ref19","volume-title":"The Effect of Academic Achievement on Innovative Behavior among University Students [master\u2019s thesis; in Chinese]","author":"Ma","year":"2021"},{"key":"ref20","first-page":"88","article-title":"The interactive effects of organizational innovation climate and incentive preference on employee innovative behavior","volume-title":"Manage World","author":"Liu","year":"2009"},{"key":"ref21","doi-asserted-by":"publisher","first-page":"115","DOI":"10.1007\/s11747-014-0403-8","article-title":"A new criterion for assessing discriminant validity in variance-based structural equation modeling","volume":"43","author":"Henseler","year":"2015","journal-title":"J Acad Mark Sci"},{"key":"ref22","volume-title":"Introduction to Mediation, Moderation, and Conditional Process Analysis: A Regression-based Approach","author":"Hayes","year":"2022"},{"key":"ref23","doi-asserted-by":"publisher","first-page":"211","DOI":"10.1007\/s10654-019-00494-6","article-title":"Principles of confounder selection","volume":"34","author":"VanderWeele","year":"2019","journal-title":"Eur J Epidemiol"},{"key":"ref24","doi-asserted-by":"publisher","first-page":"46","DOI":"10.1186\/s41239-022-00346-6","article-title":"Assessing digital competence and its relationship with the socioeconomic level of Chilean university students","volume":"19","author":"Silva-Quiroz","year":"2022","journal-title":"Int J Educ Technol High Educ"},{"key":"ref25","doi-asserted-by":"publisher","first-page":"816","DOI":"10.1080\/00273171.2011.606716","article-title":"Bias in cross-sectional analyses of longitudinal mediation: partial and complete mediation under an autoregressive model","volume":"46","author":"Maxwell","year":"2011","journal-title":"Multivar Behav Res"},{"key":"ref26","doi-asserted-by":"publisher","first-page":"879","DOI":"10.1037\/0021-9010.88.5.879","article-title":"Common method biases in behavioral research: a critical review of the literature and recommended remedies","volume":"88","author":"Podsakoff","year":"2003","journal-title":"J Appl Psychol"},{"key":"ref27","doi-asserted-by":"publisher","first-page":"7541","DOI":"10.1111\/jan.70329","article-title":"Co-designing and evaluating a digital competencies toolkit for nursing students","volume":"82","author":"Martzoukou","year":"2026","journal-title":"J Adv Nurs"},{"key":"ref28","doi-asserted-by":"publisher","first-page":"803","DOI":"10.1186\/s12909-024-05785-5","article-title":"Online digital health and informatics education for undergraduate nursing students in China: impacts and recommendations","volume":"24","author":"Shen","year":"2024","journal-title":"BMC Med Educ"},{"key":"ref29","doi-asserted-by":"publisher","first-page":"e58170","DOI":"10.2196\/58170","article-title":"Digital health education and training for undergraduate and graduate nursing students: scoping review","volume":"7","author":"Kleib","year":"2024","journal-title":"JMIR Nurs"},{"key":"ref30","doi-asserted-by":"publisher","first-page":"422","DOI":"10.3761\/j.issn.1672-9234.2026.04.006","article-title":"Paradigm and practice for cultivating innovation ability in nursing students [in Chinese]","volume":"23","author":"Han","year":"2026","journal-title":"Chin J Nurs Educ"}],"container-title":["Frontiers in Public Health"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1938122\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,30]],"date-time":"2026-09-30T06:05:43Z","timestamp":1790748343000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fpubh.2026.1938122\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,30]]},"references-count":30,"alternative-id":["10.3389\/fpubh.2026.1938122"],"URL":"https:\/\/doi.org\/10.3389\/fpubh.2026.1938122","relation":{},"ISSN":["2296-2565"],"issn-type":[{"value":"2296-2565","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,30]]},"article-number":"1938122"}}