Integrating Web-Based Technology in Distance Education for Nurses in China: Access and Attitudes to Computers and the Internet. C. E.

Integrating Web-Based Technology in Distance Education for Nurses in China: Access and Attitudes to Computers and the Internet Corresponding author: Betty Cragg Professor, School of Nursing University of Ottawa 451 Smyth Road Ottawa, Ontario, Canada K1H 8M5 Phone: (613) 562-5800 # 8348 Fax: (613) 562-5443 e-mail: bcragg@uottawa. by C. E. (Betty) Cragg Nancy Edwards Song Li Xin Zhao Yue Zou Dao Hui Revision : April 2003

Biography, Information, Acknowledgements Betty Cragg RN EdD. Professor and former Director School of Nursing, University of Ottawa. Her main research interest is in distance education for nurses and responses to delivery methods. Nancy Edwards, RN PhD. Professor and CHSRF/CIHR Chair in Nursing, School of Nursing, University of Ottawa. She has been the Canadian Director of two Canadian International Development Agencyfunded projects in China with Tianjin Medical University and the Yunnan Public Health Bureau. Zhao Yue, RN MScN. Associate Professor and Associate Dean, School of Nursing, Tianjin Medical University. He is also a PhD candidate at the University of Hong Kong. Song Li Xin, RN, MScN. Assistant Professor in the School of Nursing, Tianjin Medical University. She has studied in Canada, and participated in the development of distance education workshops for nurses in Tianjin Municipality. Zou Dao Hui, RN. Professor and former Director, Department of Nursing, Tianjin Medical University. She was Chinese Project Director for the Ottawa/Tianjin institutional linkage project. She has extensive experience as a nurse educator and administrator in China and has been active in Chinese nursing associations. Acknowledgments Funding for this project was provided by a Pan Asia Grant from the International Research Development Centre Don McDonell, Professor, Department of Continuing Education, University of Ottawa Professor Han, Director Computer Services, Tianjin Medical University Qinghua Ma, Research Assistant, University of Ottawa Louise Legault, Research Associate, University of Ottawa Disclaimer: The opinions expressed in this article are those of the authors.

1 Integrating Web-Based Technology in Distance Education for Nurses in China: Access and Attitudes to Computers and the Internet Abstract To increase accessibility to continuing education, nurses around the world are turning to web-based instruction. However, for Internet education to be successful, particularly in developing countries, nurses must have access to computers and the Internet, and have positive attitudes towards this form of learning. As part of a distance education project for nurses in Tianjin Municipality in China, a survey of nurses was conducted to examine sources of professional knowledge, and access and attitudes to computers and the Internet. Attitudes were generally positive and there was evidence of rapidly increasing use of and access to computers and the Internet. This article reports the results of that survey and implications for web-based teaching of Chinese nurses. Key words: Distance education, nurses and computers, nursing education in China, Internet access

2 Integrating Web-Based Technology in Distance Education for Nurses in China: Access and Attitudes to Computers and the Internet Introduction Development of the Internet as a source of educational opportunities has huge potential for nurses throughout the world, particularly those who do not have ready access to educational institutions and specialized expertise. By using the Internet, nurses with little opportunity for direct access to experts and evidence can enhance their knowledge and meet professional requirements for continuing education. Web-based instruction is often promoted as a panacea for learners around the world. In developing countries, there are limited numbers of highly qualified nursing academics and it may be difficult for practitioners to access appropriate learning opportunities because of the distance they live from sources of education. Distance education, particularly web-based learning, seems an attractive solution. For web-based instruction to be effective for nurses, a number of factors must be considered. Nurses must be familiar with computers, have reliable and affordable Internet access, and possess the skills necessary to use the web. In North America, where computers and reliable Internet access have become common, nurse-learners who are new to computers or have problems accessing and using the necessary components of web-based courses become anxious when they encounter problems with the required technology. 1 In developing countries, where computers are less common, and affordable Internet connections are less available, the anxiety may be greater. For nurses to benefit from web-based instruction, it is necessary for educators to address the issues of access to computers and the Internet, and readiness of potential nursing students to learn on-line. Ngor 2, writing about development of design courses for China, identifies issues of

3 infrastructure and policy, access to information technology, attitudes of teachers and students, and full access to the Internet as factors to be considered before beginning electronic education. Chinese officials have identified technological development and access as priorities 3. Potential learners must also be ready to use the technology for computer-based education to be successful. Even if the conditions of reliable, affordable access to the Internet exist, other factors must also be considered in planning nursing programs. Nursing education and practice occur in the context of societies with great variations of culture, language, and health care systems. It is therefore important that nurses in Internet-based programs are able to learn in programs that take the social, cultural and linguistic contexts of their practice into account. Nurses around the world can access vast amounts of material via the Internet; most of it is in English and much is from developed countries. Practitioners and students need support in integrating this information into the realities of their situation. It is important that nursing educators, particularly in less developed regions, build capacity to create web-based educational materials that are sensitive to nurses particular practice contexts. In 1989, the School of Nursing, University of Ottawa in Ottawa, Canada embarked on a 12-year project with the School of Nursing, Tianjin Medical University in Tianjin, People s Republic of China. 4 Tianjin is the third largest municipality in China, located in the Northeast region of the country. It has a population of more than 9 million, residing in both urban and rural areas. Funded by the Canadian International Development Agency, the project with Tianjin Medical University was designed to increase capacity for delivery of baccalaureate and graduate nursing education in China. One aspect of the project was development of distance education for nurses living in the outlying areas of the municipality. An audiographic teleconferencing system was established at four outlying sites within Tianjin Municipality to permit wider distribution of

4 educational opportunities for Registered Nurses such as Associate Degree Programs, and specialized courses on topics such as gerontology and palliative care. 5 Use of the Internet could further expand access within and beyond Tianjin Municipality. Web-based courses, discussion groups, mail lists, web sites and hotlinks to other sites were identified as possible uses of the web for nursing education in China. In preparation for development of such strategies, a research group of Canadian and Chinese partners decided it was necessary to identify the existing knowledge and access of nurses to computers and the Internet in Tianjin. A Pan Asia grant from the International Development Research Center was obtained in 1999 to explore the possibilities. The data would be useful to educators initiating nursing distance education by Internet in China. The objectives of the study were to assess barriers and facilitators of web-based distance education and to examine predictors of computer and Internet use among nurses in Tianjin Municipality. Predictors considered were: 1) nurses attitudes, knowledge, and skills in use of computers and the Internet, 2) nurses access to computers and the Internet, and 3) nurses preferred sources of practice knowledge. A survey was conducted among nurses in Tianjin Municipality to assess the existing barriers and facilitators of web-based distance education. This paper reports survey results and examines implications for planning web-based educational opportunities for nurses in China and other developing countries. Methods Two groups of registered nurses were randomly selected for the study: 1) nurses working in urban, peri-urban, or rural hospitals and 2) nurses studying in the associate degree program at Tianjin Medical University. In China, diploma-prepared nurses wishing to upgrade their

5 qualifications to the university level enroll in an associate degree program. This group of students was chosen because there are few university-educated nurses working in the hospitals. As graduates, these nurses will be important participants in continuing education of the type proposed. For the hospital nurses, a multi-stage stratified random sampling procedure was used. A list of all government-run health facilities in Tianjin Municipality was created. Based on location, facilities were categorized into 3 groups: urban, peri-urban and rural. A random sample of 10 hospitals was selected from each of the 3 groups. Within each sampled institution, nurses were stratified into 2 groups: staff nurses and nurses in clinical teaching or management positions. Ten nurses were randomly sampled from each hospital (5 staff and 5 clinical teaching or management). In the second phase, all nurses enrolled in part-time or full-time studies in the associate degree program of Tianjin Medical University were sampled. The survey instrument was developed and administered in 2 phases during 1999 and 2000. Respondents completed a written questionnaire that examined patterns of computer and Internet access and use, determined the preferred sources of practice knowledge, and documented socio-demographic characteristics. Existing instruments on sources of practice knowledge, and on computer and Internet access and utilization were identified in the literature and on the web. Four were selected: Sources of Practice Knowledge 6, Attitudes Toward Computers Questionnaires 7, Computer and Internet Confidence Scales, 8 and the Computer and Internet Comfort Level Scales. 9 Minor modifications were made for clarity and to reflect present circumstances. An Attitudes Toward the Internet questionnaire was developed with items that paralleled the Attitudes Towards Computers instrument. 7 Respondents were asked about 18 sources of practice knowledge. One item on this scale was changed from the original published version of the scale. 6 The original item listed

6 magazines, television and the Internet as media forms. In the current study, information from media was defined as magazines, television, and radio. The Internet was added as a separate item. The multidimensional Attitudes Toward Computers Questionnaire 7 assessed four dimensions of attitudes: a) comfort (feeling of comfort with computer and its use), b) efficacy (feeling of competence with computer, c) interest (extent to which participants are interested in learning about and using computers), and d) utility (belief that computers are useful). The research team developed items for an additional dimension (affordability). The Attitudes Towards Internet Questionnaire followed the same format and content as the Computer questionnaire with the word Internet substituted for the word computer and one item, It is too expensive to learn how to use computers omitted because of ambiguity of meaning. Items on the Computer and Internet Confidence Scales 8 and the Computer and Internet Comfort Level Scales 9 each contained parallel wording. A summary of all instruments used in the study is provided in Table 1. The questionnaire was prepared in English, translated into Chinese and back-translated into English, and then reviewed by colleagues in China for face validity. Ethics approval was obtained in Canada, since at the time Tianjin Medical University did not have an ethics committee. Surveys were distributed by mail and in person. Analyses: SPSS-PC was used for all statistical analyses. Descriptive analyses were completed to examine characteristics of the sample, and patterns of computer and Internet use; and to summarize scores for scales. Psychometric properties of three scales (Sources of Practice Knowledge, Attitudes Towards Computers, and Attitudes Towards the Internet) were assessed

7 on this sample of Chinese nurses using Cronbach=s alpha and factor analysis. Bivariate and multivariate analyses assessed socio-demographic, knowledge and attitudinal predictors of computer and Internet use (both use in general and use at work). Chi-square statistics and independent t-tests were used to compare the sociodemographic, knowledge, and attitudinal characteristics of users and non-users of computers and the Internet. Logistic regression models were used to examine predictors of computer and Internet use. The outcome variables for the models were defined as experience using a computer or the Internet (yes or no). Collinearity among predictor variables was assessed. Age was found to be highly correlated with work experience and excluded from subsequent analyses. Predictor items with a p value of 0.25 or lower were included in preliminary logistic regression models. With the exception of level of English language reading ability, all demographic predictors were entered as categorical variables. Household income was coded as a categorical variable (less than 400, 401-500, 501-700, 701-1000, more than 1000 Yuan per month) and current employer was coded as university, city, suburban hospital, or county hospital. Students were included in the university category of employer since they were considered to have access to computers in that setting. The remaining predictor variables (English, sources of practice knowledge, attitudes towards computers, computer/internet comfort and confidence levels) were entered as continuous variables. Models were run using a stepwise procedure. Model testing proceeded until a nonsignificant chi-square was obtained. Results A total of 498 nurses completed the questionnaire. Two hundred and ninety-one (58%) were hospital-based and the remainder were associate degree students. The vast majority (n=489, 97%) were women and 445 (89%) were under 40 years of age. Two hundred and

8 seventy (54%) reported an average household monthly income of 700 Yuan per month or less (less than $100US). Most (n=281, 56%) were staff nurses and one quarter (n=114) listed student as their work status. One hundred and fifty six (72%) were prepared at the associate or baccalaureate degree levels. Thirty-six (7%) of the respondents reported good or excellent English language reading skills. Ratings of English or Chinese typing skills produced similar reports, with 62 (13%) and 72 (15%) respectively reporting good or excellent skills. One fifth (n=100) reported having participated in distance education in the past five years, with paperbased (correspondence) courses being the most frequently cited delivery method. The Sources of Practice Knowledge questions revealed that the most frequently chosen sources were: information learned in nursing school (n=339, 68%), textbooks (n=279, 56%), and clinical experience (n=219, 44%). Information from the Internet (including on-line journals) (n=4, 1%) and information from software or CD databases (n=5, 1%) were the least commonly cited sources. Patterns of computer use and access showed that three quarters of the respondents (n=370, 74%) reported computer use and of these, 256 (72%) had begun using a computer in the past 12 months. Among those who had experience using computers, 122 (24%) had used a computer at work although only 66 (19%) had used this work computer on a daily basis. Computer use was most frequently reported at work followed by use at home, at school and in public places (eg. Cybercafé). Education/learning and entertainment were reported as the main purposes for computer use at home; education/learning and work/business were the main purposes for computer use at work. One hundred and fifteen (23%) of respondents reported owning a computer and seventy-eight (16%) reported plans to purchase a computer within the next six months. Friends, family members, and colleagues were identified as the main sources of

9 technical knowledge or assistance with computers. Eighty-two respondents (17%) reported using the Internet. Among this group of users, 61 (79%) had been using the Internet for less than a year. Only 45 (55% of Internet users) reported access to the Internet at work, while a smaller number (n=21, 26%) had access to the Internet at home. Limited access was indicated by the fact that only 38 (46% of users) had their own e-mail address. Eight (10% of users) reported sending or receiving e-mail on a daily basis. One quarter of those using the Internet reported doing Internet searches in either English or Chinese on a weekly basis. Internet access was most frequent at home followed by public access centers (eg. Cybercafé), school, and work. Phone lines were the most common means of connecting with the Internet. Family members and friends were the main sources of technical knowledge or assistance for Internet use. The average monthly cost of Internet access: o at home = 53 Yuan o at school = 13 Yuan o public location = 26 Yuan Attitudes towards computer use were generally positive. Over 349 (70%) of respondents indicated they would be able to learn how to use a computer. Three hundred and eighty six (77%) indicated that learning about computers would be worthwhile. There were some barriers cited. Two thirds (n=332) thought computers were too fast, 106 (22%) indicated it was too expensive to own a computer, and 170 (34%) indicated they were eager to learn computer skills, but would have no opportunity to use such skills. Respondents were more tentative in their assessment of the Internet. Less than half (n=241, 48%) agreed with the statement, ALearning about the Internet is (would be) a worthwhile and necessary project@. Expense and lack of opportunity were identified as barriers

10 to learning Internet skills. Responses to computer and Internet comfort and confidence scales indicated higher levels of anxiety related to Internet than to computer use. Confidence scores were higher for using computers than for using the Internet. The psychometric properties of the Sources of Practice Knowledge, Attitudes Towards Computers and Attitudes Towards the Internet were assessed. With the exception of the affordability sub-scale of the Attitudes towards Computers and the Internet scales, all sub-scales had adequate to excellent levels of reliability (Cronbach=s alpha ranged from.70 to.87) (see Table 1). A three-factor solution emerged for the Practice Knowledge scale: formal, informal and media sources. Results of bivariate analysis showed that overall computer use was significantly associated with the type of job (nurse teachers and students more often reported using a computer than either staff nurses or nurse managers), age (younger respondents more frequently indicated that they used a computer than older respondents), education level of both father and mother (higher education of either parent was associated with a higher rate of use) and level of English reading ability (those with better English language reading skills were more likely to report computer use). Similar predictors were found for reported computer use at work with the exception of education level of either parent. A higher education level was not associated with computer use at work. However, a higher average household income level was associated with more computer use at work. Similar predictors were found for overall reported Internet use. Internet use at work was significantly associated with work experience, with rates of use being highest for those with 11-15 years of work experience. (Insert Tables 2 and 3 about here.) Those who used computers had more positive attitudes towards computers, lower levels

11 of anxiety towards use and were more confident in their use of computers than those who did not. However, on the Internet scales that asked similar questions, there were few differences on these measures between Internet users and non-users. Logistic regression analysis revealed several predictors of computer use. Those with lower levels of household income, those who preferred using formal sources of knowledge to inform clinical practice and those who reported lower comfort levels (anxiety levels) in using the computer were less likely to report computer use. Those who worked in a university or were students and those with high computer confidence scores were more likely to report computer use (see Table 4). (Father s education, while significant in bivariate analysis, was excluded from logistic regression analysis due to the number of cases with missing data.) Models to examine predictors of Internet use (at work or home) were constrained by the small percentage of respondents who reported using the Internet. In preliminary modeling, significant predictors were father=s level of education, current employment, media as a source of practice knowledge and confidence using computers. Due to small numbers, independent models to examine predictors of Internet use at work could not be tested. Discussion Accessibility and adequate development of on-line opportunities will be necessary to make the Internet a useful means for wide distribution of education opportunities for Chinese nurses in Tianjin Municipality. There are indications that things are changing rapidly in the access to and acceptance of computers. Attitudes to computers were positive and although 256 (51%) of respondents had been using the computer for less than a year, 78 (16%) planned to purchase a computer in the next six months. Other factors that may need to be considered are: acceptance of distance education for delivering nursing knowledge, and nurses use of the

12 Internet and computer-based information as sources of practice knowledge. The Chinese nurses cited Internet and computer-based materials as their least used sources of practice knowledge. This response may reflect lack of access or negative attitudes to gleaning information from such sources. There is heavy reliance on nationally prescribed textbooks in Chinese university education. When Chinese nurses= reports of sources of practice knowledge were compared with a sample of Canadian nurses, 6 Chinese nurses were more likely to report information from a textbook as an important source (2 nd by Chinese and 11 th by Canadians). Canadian nurses were more likely to identify information from in-services and conferences as an important source of practice knowledge (ranked 15 th by Chinese and 4 th by Canadian nurses). Both groups assigned low rankings to the categories Aarticles published in nursing research journals@ and Aarticles published in nursing journals@. Undergraduate students in China have very limited access to journal articles and continuing education opportunities for Chinese nurses have also been limited. Multivariate analysis showed that certain factors were related to computer use as opposed to Internet use. Those who used formal sources of knowledge were more likely to use computers, while use of media as a knowledge source was a predictor of Internet use. Father=s education, and therefore probably income and access, was a predictor of computer use, comfort, and confidence. Internet use is at an earlier stage of technology diffusion than computer use among Chinese nurses. While few nurses can access and benefit from web-based instruction at present, it is predicted that the situation in China will change rapidly as the necessary infrastructure and greater Internet stability are developed. Attitudes towards computer and Internet use are generally positive, but financial and accessibility barriers influence both attitudes and patterns of

13 use. With the majority of household incomes at less than 700 Yuan ($100US) a month and access charges at home averaging 53 Yuan, the cost of linking to the Internet represents a large proportion (7.6% or more) of these families incomes. Since the Internet is mainly Englishbased, and a low proportion of respondents were comfortable with reading and typing in English, development of Chinese resources for nurses will be important for success. To realize the potential for the Internet as a vehicle for nursing continuing education, training in the use of computers and the Internet is essential. Even in North America, many nurses have difficulties with computer and Internet use and require technical and personal support to succeed in Internet courses. 1 Ensuring supports for Chinese nurses in both rural and urban locations will be necessary to help them succeed in using the Internet to learn. With friends, family and colleagues cited by the Chinese nurses as the major sources for technical support in using computers and the Internet, a strategy for diffusion of skills could involve targeting nurses who have these supports as initial trainees. They could then, in turn, support a second cohort of nurses who lack these home resources. Use of computer technology as a means of delivering continuing education requires learners with positive attitudes and the necessary skills to access and participate in their courses. They must also have easy access to computers and the Internet, and stability in the system. Problems with access and maintenance of Internet connections for learners create frustrations and negative perceptions of this delivery method. Chinese officials project exponential increases in use of the Internet. 10 Government support and emphasis on technological progress will facilitate the development of a suitable environment for nurses to access Internet learning. With increased technical capacity throughout China, nurses who seek to use the Internet as a source of continuing education will soon find more reliable connections and improved accessibility. They

14 will need culturally and linguistically appropriate materials to go with them. Conclusion: Nurses worldwide are beginning to turn to the Internet for educational opportunities. In many countries, nurses have limited access to education and expertise because of their distance from educational providers, the concentration of experts in particular locations, and life demands that limit mobility. Distance education via the Internet offers enormous potential to meet such nurses= desire to maintain and increase competence through education and their access to information. However, before relying on this method of delivery, it is important to assess the existing and potential access of nurses to computers and the Internet and their comfort level. It is also important to develop the capacity of local educators to meet the contextual requirements of effective nursing education for any particular national or cultural group. For on-line professional upgrading for nurses to succeed, technological access and abilities must be fostered by educators, employers and governments. Nurses must also be ready and willing to assume the challenges presented by a new learning environment. Educators must develop skills to use a new medium while recognizing practical limitations and cultural sensibilities. When these conditions are met, the enormous potential of the Internet will be realized. Nursing educators will be able to access global resources and respect local needs.

15 References 1. Cragg CE, Humbert J, Doucette S. Technological support and the adult learner, 2000. Ottawa: Office of Learning Technologies, Human Resources Development Canada. 2. Ngor ALCY, The prospects for using the Internet in collaborative design education with China. Higher Education, 2001; 42: 47-60. 3. Chen, Z.W. CERNET: Starter of China Internet. China Scholars Abroad, 2000; 9: 34-35. 4. Edwards N, Bunn H, Morales-Mann E, Papai P, Davies B. International collaborative workshops: A 6-year partnership between Canada and China. Nurse Educator. 2000;25(2):88-94. 5. Edwards N, Hui, ZD, Xin SL. Continuing education for nurses in Tianjin Municipality, The People s Republic of China. J Continuing Education in Nursing. 2001;32;1:31-37. 6. Estabrooks CA. Will evidence-based nursing practice make practice perfect? Canadian Journal of Nursing Research, 1999; 30: 273-294. 7. Jay GM, Willis SL. Influence of direct computer experience on older adults attitudes toward computers. Journal of Gerontology,1992; 4: 250-257. 8. Murphy CA, Coover, C, Owen SV. Development and validation of the computer selfefficacy scale. Educational and Psychological Measurement, 1989; 36: 328-330. 9. Heinssen RK, Glass CR, Knight LA. Assessing computer anxiety: Development and validation of the computer anxiety rating scale. Computers in Human Behaviour, 1987; 3: 49-59. 10. Xu Y, Wang, F. E-9 Beijing announcement : The promises for new century. China Scholars Abroad, 2001; 10: 31-34

16 Table 1. Survey Instrument Scales # items Subscales Cronbach s estimate from current study Background & Personal 18 Information Sources of Practice Knowledge (1) 18 formal informal media sources Computer Resources 23 Internet Resources 30 Attitudes Towards Computers (2) 26 comfort efficacy interest utility beliefs Attitudes Towards Internet (2) Computer Comfort Level (2) Internet Comfort Level (2) Confidence with Computer Operations (2) Confidence with Internet (2) affordability 25 comfort efficacy interest utility beliefs affordability.83.76.70.74.85.77.72.64.73.86.87.87.53 17.93 10.95 19.96 15.98 Note: 1. Response options assessed using a Likert Scale: 1=Never, 5=Always 2. Response options assessed using a Likert Scale: 1=Strongly disagree 5=Strongly agree

17 Table 2. Socio-demographic, knowledge, and attitudinal determinants of computer use. Determinants Main duty: N (%) Nursing Teaching Management Student Age: N (%) 18-25 26-30 31-40 over 40 Household income (Yuan): N (%) Less than 400 401-500 501-700 701-1000 more than 1000 Father s education: N (%) Certification Diploma Associate degree B.A. or higher Mother s education: N (%) Certification Diploma Associate degree B.A. or higher Working experience: N(%) 0-5 years 6-10 years 11-15 years 16-20 years 21-25 years 26-30 years Highest education: N(%) Diploma Associate degree B.A. All Participants (N = 496) 280 (57%) 21 (4%) 71 (14%) 121 (25%) 204 (42%) 107 (22%) 128 (26%) 53 (11%) 89 (19%) 66 (14%) 110 (23%) 133 (28%) 83 (17%) 102 (24%) 176 (41%) 85 (20%) 62 (15%) 129 (32%) 198 (49%) 52 (13%) 28 (7%) 203 (42%) 85 (17%) 84 (17%) 71 (15%) 19 (4%) 27 (6%) 134 (27%) 245 (50%) 113 (23%) Do not use computer (N = 126) 80 (64%) 2 (2%) 23 (18%) 20 (16%) 41 (33%) 28 (22%) 30 (24%) 26 (21%) 24 (20%) 23 (19%) 27 (23%) 33 (28%) 13 (11%) 34 (35%) 48 (49%) 15 (15%) 1 (1%) 41 (43%) 47 (49%) 6 (6%) 2 (2%) 41 (33%) 19 (4%) 19 (4%) 25 (5%) 9 (2%) 11 (2%) 48 (10%) 66 (13%) 10 (2%) Use computer (N = 370) Significance 200 (54%) 19 (5%) 48 (13%) 101 (27%) 163 (44%) 79 (22%) 98 (27%) 27 (7%) 65 (18%) 45 (12%) 83 (23%) 100 (28%) 71 (20%) 68 (21%) 128 (39%) 70 (21%) 61 (98%) 88 (28%) 151 (49%) 46 (15%) 26 (8%) 162 (44%) 66 (14%) 65 (13%) 46 (9%) 10 (3%) 16 (3%) 86 (23%) 179 (49%) 103 (21%) X 2 (3) = 11.15 p =.011 X 2 (3) = 18.97 X 2 (3) = 7.11 p =.13 X 2 (3) = 25.31 X 2 (3) = 13.20 p =.004 X 2 (5) = 15.48 p =.009 X 2 (2) = 24.44

18 Current employer: N(%) Student University City hospital Suburban hospital County hospital Others Level of English reading: N (%) Poor Fair Average Good/excellent 21 (25%) 23 (5%) 245 (50%) 42 (9%) 50 (10%) 8 (2%) 51 (11%) 139 (29%) 261 (54%) 36 (7%) 16 (13%) 1 (1%) 58 (47%) 11 (9%) 35 (29%) 2 (2%) 15 (12%) 46 (38%) 56 (46%) 4 (3%) 105 (29%) 22 (6%) 187 (51%) 31 (9%) 15 (4%) 6 (2%) 36 (10%) 93 (25%) 205 (56%) 32 (9%) X 2 (5) = 68.16 X 2 (3) = 10.88 p =.012

19 Sources of practice knowledge: (SD) Formal Informal Media 2.8 (0.6) 3.0 (0.6) 1.8 (0.6) 2.9 (0.4) 3.1 (0.5) 1.8 (0.6) 2.7 (0.6) 2.9 (0.6) 1.8 (0.6) t(477) = 3.22 p =.001 t(461) = 2.77 p =.006 Non Significant Attitudes Towards Computers: (SD) Level of comfort Level of efficacy Level of interest Utility beliefs Affordability 3.6 (0.8) 4.1 (0.8) 4.3 (0.7) 4.3 (0.7) 4.0 (0.8) 3.3 (0.6) 3.7 (0.9) 3.9 (0.8) 4.0 (0.8) 3.7 (0.8) 3.7 (0.8) 4.2 (0.8) 4.4 (0.6) 4.4 (0.6) 4.1 (0.7) t(466) = -5.75 t(468) = -5.61 t(468) = -5.90 t(470) = -6.17 t(469) = -3.86 Computer comfort level: (SD) 2.0 (0.7) 2.3 (0.7) 1.8 (0.6) t(454) = 6.49 Computer confidence level: (SD) 3.5 (1.0) 3.0 (0.8) 3.7 (1.0) t(445) = -7.19 Note. Total number may not equal 498 due to missing data.

20 Table 3 Socio-demographic, attitude and knowledge determinants of Internet use. Determinants: Internet use Main duty: N (%) Nursing Teaching Management Student Age: N (%) 18-25 26-30 31-40 over 40 Household income (Yuan): N (%) Less than 400 401-500 501-700 701-1000 more than 1000 Father s education: N (%) Certification Diploma Associate degree B.A. or higher Mother s education: N (%) Certification Diploma Associate degree B.A. or higher Working experience: N(%) 0-5 years 6-10 years 11-15 years 16-20 years 21-25 years 26-30 years Highest education: N(%) Diploma Associate degree B.A. Current employer: N(%) Student University City hospital All Participants (N = 456) 253 (56%) 21 (5%) 68 (15%) 112 (25%) 178 (39%) 98 (22%) 125 (28%) 52 (12%) 84 (19%) 58 (13%) 99 (22%) 128 (29%) 77 (17%) 99 (25%) 152 (39%) 79 (20%) 60 (15%) 125 (34%) 172 (46%) 46 (12%) 28 (8%) 178 (40%) 78 (17%) 80 (18%) 71 (16%) 18 (4%) 26 (6%) 133 (29%) 208 (46%) 112 (25%) 114 (25%) 23 (5%) 218 (48%) Do not use internet (N = 374) 221 (59%) 12 (3%) 58 (16%) 81 (22%) 137 (37%) 80 (22%) 106 (29%) 49 (13%) 64 (17%) 48 (13%) 89 (24%) 111 (30%) 55 (15% 89 (28%) 133 (42%) 55 (17%) 39 (12%) 113 (38%) 139 (46%) 30 (10%) 19 (6%) 132 (36%) 60 (16%) 71 (19%) 66 (18%) 18 (5%) 23 (6%) 119 (32%) 182 (49%) 70 (19%) 81 (71%) 12 (3%) 182 (49%) Use Internet (N = 82) Significance 32 (39%) 9 (11%) 10 (12%) 31 (38%) 41 (51%) 18 (22%) 19 (24%) 3 (4%) 20 (25%) 10 (13%) 10 (13%) 17 (22%) 22 (28%) 10 (14%) 19 (26%) 24 (32%) 21 (28%) 12 (17%) 33 (47%) 16 (23%) 9 (13%) 46 (57%) 18 (22%) 9 (11%) 5 (6%) -- 3 4%) 14 (17%) 26 (32%) 42 (51%) X 2 (3) = 21.25 X 2 (3) = 9.04 p =.029 X 2 (4) = 14.04 p =.007 X 2 (3) = 25.92 X 2 (3) = 17.86 X 2 (5) = 21.75 p =.001 X 2 (2) = 37.98 33 (40%) 11 (13%) 36 (44%) X 2 (5) =

21 Suburban hospital County hospital Others Level of English reading: N (%) Poor Fair Average Good/excellent 42 (9%) 50 (11%) 4 (1%) 47 (11%) 130 (29%) 239 (53%) 33 (7%) 41 (11%) 49 (13%) 4 (1%) 43 (12%) 111 (30%) 195 (53%) 19 (5%) 1 (1%) 1 (1%) -- 4 (5%) 19 (24%) 44 (54%) 14 (18%) 39.62 X 2 (3) = 17.21 p =.001 Sources of practice knowledge: (SD) Formal Informal Media 2.8 (0.6) 3.0 (0.6) 1.8 (0.6) 2.8 (0.6) 3.0 (0.6) 1.7 (0.5) 2.7 (0.7) 2.8 (0.6) 2.0 (0.7) Non significant t(423) = 2.09 p =.037 t(438) = -3.17 p =.002 Attitudes Towards Computers: (SD) Level of comfort Level of efficacy Level of interest Utility beliefs Affordability 3.6 (0.8) 4.1 (0.8) 4.3 (0.7) 4.3 (0.7) 4.0 (0.8) 3.1 (0.5) 3.6 (0.8) 3.8 (0.8) 3.8 (0.8) 3.5 (0.8) 3.9 (0.8) 4.1 (0.8) 4.5 (0.6) 4.5 (0.6) 4.0 (0.7) t(383) = -8.02 t(382) = -4.59 t(384) = -8.34 t(385) = -8.03 t(388) = -5.35 Computer comfort level: (SD) 2.0 (0.7) 2.5 (0.7) 1.6 (0.6) t(384) = 10.21 p <.001 Computer confidence level: (SD) 3.6 (1.0) 2.6 (0.9) 3.2 (1.2) t(384) = -4.05 p <.001 Note. Total number may not equal 498 due to missing data.

22 Average household income Less than 400 Yuan 401-500 Yuan 501-700 Yuan 701-1000 Yuan 1000 Yuan (1) Current employer University or student City or suburban hospital County hospital (2) Table 4: Predictors of Computer Use: Results of Logistic Regression Predictor Odds Ratio 95% CI.22.26.48.54 1 23.86 5.19 1.07,.72.09,.70.19, 1.21.22, 1.32 7.36, 77.31 2.41, 11.15 Preference for formal sources of.49.28,.89 knowledge to inform practice (3) Computer Comfort level (4).48.31,.73 Computer confidence (5) 2.13 1.55, 2.94 Constant 3.72 Notes: 1. Reference category is high income (> 1000 Yuan per month) 2. Reference category county hospital 3. Reference category is low preference for formal sources of knowledge 4. Reference category is high computer comfort levels 5. Reference category is low computer confidence levels.