My colleague Kate and I invented the following scenario — a conversation between five people round a café table — as a creative way of laying out the issues nurses need to tackle in the latest stage of the digital revolution:
Kate and I came out of an event we attended together and joined a group of nurses and digital health experts for coffee.
I am an academic, a registered nurse (RN), midwife, and a digital health specialist. I teach university-level digital health to clinicians, computer scientists, engineers and business people. Kate is an RN who has worked as a professional lead and now works in clinical informatics (ie information systems).
We were sitting outside a café and the energy in our conversation rose as the topic of digitally competent nurses in New Zealand was raised. There were five of us and we had more than five opinions.
The first opinion was that society has reached a digital tipping point. We must be digitally competent to participate in society, eg do our banking and tax returns, to navigate the internet for information, to book a flight, to use social media and other online tools. Our behaviour online should be ethical, responsible, legal, and safe.1
As nurses we should have these basic competencies anyway, as digital citizens. Digital competence is no longer an option in society.
Another member of our group raised concern about people being left out of society if they don’t have these skills or can’t afford the technology. Digital inclusion2 is important to nursing from a social determinants perspective. Our work is about equity and justice. Solutions need to be found to support people at risk of digital exclusion, eg Health New Zealand’s “zero data” policy which allows people to access important health websites without incurring data charges on their phone.3
Then the conversation got serious. One of the digital health specialists said that nurses were digital citizens and users of digital technologies in everyday life, and these technologies were increasingly expanding into the workplace. Digital was no longer an option in the workplace.
But for some people, analogue (non-digital) ways of getting on with life take priority. For nurses, this might be their interpersonal interaction with patients in a hospital ward, and physical examination of patients.
One of the nurses at our table said: If I need help with digital, I’ll ask a young person. But this is no longer a useful strategy. We need to integrate digital and analogue ways of working that optimise the impacts of our nursing work.
Another nurse put down his coffee cup, leaned forward and started talking about industrial revolutions. The first was the coal, steam and machine industrial revolution, starting in the late 18th century, which progressed to the second revolution starting in the 1870s which brought in mass production and electrical energy.
We need to integrate digital and analogue ways of working that optimise the impacts of our nursing work.
The third revolution, which introduced automation, computers and electronics, started at the end of the 1960s; while the fourth has been the domain of the internet, computer networks and interactive computer technologies, starting in the 1990s.4
Another nurse reminded us of an earlier revolution triggered by the Gutenberg printing press in the mid-15th century, which changed the creation, access and dissemination of knowledge and ideas.
The fifth industrial revolution
We are now entering the fifth industrial revolution, which focuses on socio-economic and environmental sustainability, and collaborations between humans and machines, supported by artificial intelligence (AI).4
For nurses, Industry 4.0 (ie the fourth industrial revolution) brought us computer connectivity (also known as interoperability, where data can be shared among computers and remain useful), analytics, digitisation of nursing data such as clinical notes, vital signs monitoring and early warning systems. And now, in Industry 5.0, AI is taking centre stage.
Yes, said the nurse who had been listening quietly, but we haven’t really caught up with this in nursing. As well as being digital users, to take advantage of Industry 5.0 we need to get more involved and become digital designers too.5
Wearable devices, video and phone calls, implantable devices and high-fidelity internet connectivity give us options for monitoring patients with long-term health issues in ways that have not yet been fully explored. It now becomes a nursing responsibility to design and configure the tools available to us for nursing, regardless of time and place.
Yes, that’s an old idea,6 and New Zealand doctors have been involved in design and development for decades, but nurses must step up too. The range of digital technologies in health care lends itself to interdisciplinary design that is flexible and optimises the impact of care, especially for those who most need it.
It becomes a nursing responsibility to design and configure the tools available to us for nursing, regardless of time and place.
The ethics of doing this kind of design work need to be worked through carefully, and nurses are well-positioned for this kind of thinking.7 Ethical issues can arise, for example, where AI algorithims perpetuate bias, or AI tools mishandle patient data, or AI systems make decisions that are not properly understood.
At the café table, the other digital health expert weighed in with her thoughts on how the nursing voice was absent from much of the development of digital information systems, resulting in a lack of focus on nursing.
Nurses have historically been an afterthought in the design, implementation and evaluation of digital health systems.
Now there is an opportunity for nurses to bring their design thinking into software development and make a difference, regardless of their specialisation or preferred nursing environment.
Examples where nursing design input would be valuable include decision support systems, robotic wound care trolleys to support hospital nurses, flexible medication management systems, and patient assessment tools that speed up and deepen our ability to do nursing work.
Well, said the third nurse, in my opinion, we need strong nursing leadership.8 Throughout the world, medical digital health has taken the lead. We need the nurse’s input to create excellent interfaces with software so that we can use these tools quickly and without the exhausting cognitive load that comes with software that is not designed for nurse users, workflows, processes and contexts.
The responsibility traditionally held by doctors to represent other clinicians is unfair to both doctors and the nurses and allied healthcare professionals with whom they work. It is time for nurses, doctors and allied health clinicians to work together on design, implementation and evaluation of digital technologies in health care and in nursing.
Feeling empowered
It was time to go. I summarised the conversation so that we all felt empowered to go forth and make a difference in digital nursing.
Nurses have historically been an afterthought in the design, implementation and evaluation of digital health systems. Some nurses have pioneered nursing information systems — Florence Nightingale herself used data to create change and improve outcomes.
Others have taken leadership roles in implementation and evaluation, but our voice is not clearly heard in investment decisions and technology design.
With the rise and democratisation of AI for digital citizens, and the design potential of AI and human-computer collaboration in the workplace, nurses must take and create opportunities to become digital designers and leaders. They can promote interprofessional collaboration in the design of future digital health applications and models of care.
Karen Day, RN, RM, PhD, FHiNZ, FIASHI, is a senior lecturer in health systems in the School of Population Health, at the University of Auckland.
Kate Yeo, RN, MHSc, is a clinical informatics director for Digital Services at Health New Zealand — Te Whatu Ora.
References
- Öztürk, G. (2021). Digital citizenship and its teaching: A literature review. Journal of Educational Technology and Online Learning, 4(1), 31–45.
- Sieck, C. J., Sheon, A., Ancker, J. S., Castek, J., Callahan, B., & Siefer, A. (2021). Digital inclusion as a social determinant of health. NPJ digital medicine, 4(1), 52.
- Health New Zealand — Te Whatu Ora. (2025, 28/3/2025). Zero Data.
- Akubo, A. A., Odiji, O. L., & Muhammed, M. B. (2025). Fifth Industrial Revolution and an Overview of its Impact on Human Resources. In Human Capital Analytics: Exploring the HR Spectrum in Industry 5.0, 65-80.
- Hants, L., Bail, K., & Paterson, C. (2023). Clinical decision‐making and the nursing process in digital health systems: an integrated systematic review. Journal of Clinical Nursing, 32(19-20), 7010-7035.
- Fornazin, M., Penteado, B. E., de Castro, L. C., & de Castro Silva, S. L. F. (2021). From Medical Informatics to Digital Health: A Bibliometric Analysis of the Research Field. AMCIS.
- Whittaker, R., Dobson, R., Jin, C. K., Style, R., Jayathissa, P., Hiini, K., Ross, K., Kawamura, K., Muir, P., & Waitematā AI Governance Group. (2023). An example of governance for AI in health services from Aotearoa New Zealand. NPJ Digital Medicine, 6(1), 164.
- Burgess, J.-M., & Honey, M. (2022). Nurse leaders enabling nurses to adopt digital health: Results of an integrative literature review. Nursing Praxis in Aotearoa New Zealand, 38(3).