key: cord-0022189-dto3ld71
authors: Harerimana, A.; Wicking, K.; Biedermann, N.; Yates, K.
title: Integrating nursing informatics into undergraduate nursing education in Africa: A scoping review
date: 2020-09-06
journal: Int Nurs Rev
DOI: 10.1111/inr.12618
sha: 8aeff66262c318a525c5330d9bbe56ece8604813
doc_id: 22189
cord_uid: dto3ld71

BACKGROUND: Information and communication technologies have become omnipresent in healthcare systems globally, and since nurses comprise the majority of the health sector workforce, they are expected to be adequately skilled to work in a technology‐mediated environment. Integrating nursing informatics into undergraduate nursing education is a cornerstone to nursing education and practice in Africa. AIM: This scoping review aimed to evidence the integration of nursing informatics into undergraduate nursing education in Africa. METHODS: A scoping review of the literature used electronic databases including CINAHL Plus databases; EmCare; MEDLINE Ovid; Scopus; ERIC ProQuest; Web of Science; Google; and Google Scholar to locate papers specific to the African context. From a total of 8723 articles, 19 were selected for critique and synthesis. RESULTS: Selected studies indicated that nursing students used several information and communication technologies tools primarily for academic purposes, and rarely for clinical practice. In Africa, the challenges for teaching informatics in nursing education included: limited information and communication technologies skills among faculty and students; poor teaching strategies; and a lack of standardization of nursing informatics competencies. Successful integration of nursing informatics into undergraduate nursing education in African countries depends on restructuring nursing informatics content and teaching strategies, capacity building of the faculty and students in information and communication technologies, political commitment, and collaborative partnership. CONCLUSION: Nursing informatics is scarce in undergraduate nursing education in Africa due to the implementation and adoption challenges. Responding to these challenges requires a multi‐sectoral approach in the revision of undergraduate nursing curricula. IMPLICATION FOR NURSING EDUCATION, PRACTICE, POLICY AND RESEARCH: This study highlights the importance of nursing informatics in undergraduate nursing education, with its challenges and success. Nursing education policies should support the development of well‐standardized nursing informatics content and appropriate teaching strategies to deliver it. Further research is needed to establish which aspects of nursing informatics are integrated into undergraduate nursing education and nursing practice, implementation process, challenges and possible solutions. Collaborative partnerships are vital to developing nursing informatics policies to better prepare graduate nurses for the African healthcare workforce in the digital era.

Information and communication technologies (ICT) have become omnipresent in the healthcare system (Gole et al. 2017; Webster 2020; WHO 2019) , and since nurses comprise the majority of the health sector workforce, they are required to have adequate skills in nursing informatics (NI) such as using computers, accessing and evaluating digital information, and possessing sufficient information management skills (Ibrahim et al. 2019; Robinson-Bassey & Edet 2015; Sapci & Sapci 2017; WHO 2016) . Furthermore, NI includes the use of technology-enabled hand-held devices such as smartphones; tablets, wearable technologies, medical monitoring devices, as well as mobile and web-based health applications (Harerimana & Mtshali 2019a, b; McGonigle & Mastrian 2015; Sermeus 2016; Shin et al. 2018; WHO 2018) . Nursing education institutions are expected to integrate NI into their curricula to prepare nurses who are capable to use technology in the healthcare environment (Darvish et al. 2014; WHO 2016) .

Nursing informatics is a subset of health informatics Sweeney 2017) . Health informatics is 'the integration of health science, information science and cognitive science to assist the management of healthcare information' (Saba & McCormick 2015, p. 232) . Furthermore, NI is defined by the Australian College of Nursing (ACN) (2017, p. 1) as 'the specialty that integrates nursing science with multiple information and analytical sciences to identify, define, manage and communicate data, information, knowledge and wisdom in nursing practice'. Similarly, American Medical Informatics Association [AMIA] (2015) defined NI as the 'science and practice (that) integrates nursing, its information and knowledge, with information and communication technologies to promote the health of people, families, and communities worldwide'. Both health informatics and NI promote the use of technology in clinical settings (Sweeney 2017) .

NI competencies are essential in all aspects of nursing practice (Kinnunen et al. 2017) . The literature indicates that the competencies in NI include computer skills, digital literacy (DL) and health information literacy (HIL), and eHealth literacy (eHL) (Chung & Staggers 2014; Holt et al. 2020; Terry et al. 2019; Tubaishat & Habiballah 2016) . Integrating NI into undergraduate nursing education is instrumental in producing competent nurses who are capable of using technology to provide high-quality care. In addition, NI has been reported to promote evidence-based practice, improve documentation and reduce medical errors (Darvish et al. 2014; Gann 2015) . Nursing informatics is also used as part of teaching and learning capabilities in nursing education (Forman et al. 2020; Harerimana & Mtshali 2020b; Honey & Procter 2017; Terry et al. 2019; WHO 2020) .

Developed countries such as Australia, Canada, Denmark and the United States of America (USA) have taken significant steps in incorporating NI into the undergraduate curriculum (Cummings et al. 2015) . In Africa, there is a growing need to integrate ICT in the health sector (Adeola & Evans 2018; Asiri 2016; Tchuitcheu et al. 2020) . Furthermore, studies conducted in Ghana, Malawi, Nigeria, Rwanda and South Africa indicated that nursing educational institutions were progressively adopting nursing informatics into undergraduate nursing education (Achampong 2017; Bhebe & de la Harpe 2014; Harerimana & Mtshali 2019a, b; Harerimana & Mtshali 2020a, b; Nishimwe et al. 2016; O'Connor et al. 2016; Robinson-Bassey & Edet 2015) .

In Africa, the integration of informatics in nursing education is in the early stage (Achampong 2017; Harerimana & Mtshali 2019b) . The capacity for implementing NI in developing countries is limited (O'Connor et al. 2016 ). There are challenges which hinder the proper integration of NI in undergraduate nursing education in Africa, including lack of infrastructure and ICT tools, inadequate ICT literacy among nurse educators and students, resistance to change and the lack of policies and guidelines (Achampong 2017; Bello et al. 2017; Harerimana & Mtshali 2017 , 2018a Murgor 2015) . Furthermore, there is a low presence of NI in the undergraduate curriculum, and a lack of standardization of NI competencies to be included in undergraduate nursing education (Achampong 2017; Nishimwe et al. 2016) .

Due to the increasing use of technology in health care in Africa (Faruk et al. 2020; Ladan et al. 2019) , it is crucial to ensure nursing students are competent to use ICT in the clinical setting upon their graduation. Hence, this scoping review sought to obtain evidence about the integration of NI into undergraduate nursing education in Africa.

The scoping review aimed to obtain, critique and synthesize the evidence of the integration of NI in undergraduate nursing education in the context of Africa.

The authors conducted a scoping review on the integration of NI in undergraduate nursing education in Africa. Scoping reviews map a given field, summarizing a range of evidence to convey the breadth and depth of the field with five distinctive steps (Levac et al. 2010, p. 3) . The following essential five steps guided this study: 1 'Identifying the research questions' 2 'Identifying relevant studies' 3 'Selecting the studies' 4 'Charting the data' 5 'Collating, summarizing, and reporting the results' (Levac et al. 2010, p. 3) .

The following inclusion criteria were used: peer-reviewed articles providing information, discussions and policies on the integration of NI in nursing education and/or the challenges and success factors to the integration of NI, be conducted in the context of Africa, be published in English, and be published between 1 September 2009 and 30 September 2019. Exclusion criteria were studies conducted outside Africa and studies about NI in postgraduate or post-registration curricula.

Step one: Identifying the research questions Identification of relevant research questions provides 'a roadmap for subsequent stages. Research questions are broad and seek to provide a breadth of coverage' (Levac et al. 2010, p. 3) . This scoping review addressed the following three research questions:

1 What components of NI are integrated into undergraduate nursing education in Africa? 2 What challenges are impeding the integration of NI in undergraduate nursing education in Africa? 3 What are the success factors for the integration of NI in undergraduate nursing education in Africa?

Step two: Identifying relevant studies Prior to the identification of relevant studies, search strategies were developed which included search terms; databases; time span; language; and type of sources as recommended by Levac et al. (2010) . Publication dates were limited to a period of 10 years (2009-2019) due to the rapid advancement of ICT in Africa.

The following electronic databases were searched: CINAHL Plus databases; EmCare; MEDLINE Ovid; Scopus; ERIC Pro-Quest; Web of Science. Furthermore, a hand search strategy was conducted in Google and Google Scholar to obtain additional articles which might have been missed with the electronic database searches.

Furthermore, key terms were developed mainly from MeSH Headings (MH) and customized keywords, to suit the search strategies of different databases. The following were the key terms used in this study: 1 (MH "Nursing Informatics") OR (MH "Health Informatics+") OR (MH "Medical Informatics") OR (MH "Informatics+") 2 (MH "Education, Nursing+") OR (MH "Education, Nursing, Baccalaureate+") OR (MH "Education, Nursing, Continuing") OR (MH "Education, Nursing, Graduate+") OR (MH "Education, Nursing, Practical") OR (MH "Education, Nursing, Associate") OR (MH "Education, Nursing, Diploma Programs") OR "Nursing Education" 3 (MH "Africa+") 4 (S1 AND S2) 5 (S3 AND S4)

Step three: Selecting relevant papers From the search, a total of 8723 articles were retrieved, including 8700 from databases and 23 from hand searches. After removing the 2617 duplicates, 6106 remained for title screening. Ninety-one articles were chosen for further screening of the abstract based on the inclusion and exclusion criteria. After the abstract screening and assessing the full text, 19 articles were considered relevant to be included in the data set for analysis (Fig. 1 ). The selection of articles was mainly based on the research question and minimum standards of quality were considered based on the 'Mixed Methods Appraisal Tool (MMAT)' (Hong et al. 2018, p. 2) . In this study, quantitative, qualitative and mixed methods articles published in peer-reviewed journals were considered.

EndNote TM X9, a computer-based management software program, was used to rate each citation in order to indicate whether the citation was assessed as potentially relevant or not. The rating ranged from 1 to 5, with the latter indicating the likelihood to be included. Selection of studies was done through discussion and consensus among research team members, and the inclusion and exclusion criteria guided the process.

Of the 19 articles included in the study, 11 were quantitative studies, seven were qualitative studies, and one was a mixed methods study. Figure 1 reports the final number of selected studies after completing the appraisal, and a Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) flow diagram was used (Moher et al. 2009, p. 3) . Selecting relevant papers was in line with the recommendations from Levac et al. (2010) who stated that selecting the studies should be guided by the eligibility criteria, research questions and the familiarity of the subject matter through reading the title, abstract and the full paper.

Step four: Charting the data Nineteen articles included in this study were read several times, to ascertain that all necessary information was included. Extracted data were presented in the form of a table which contained: Authors, year of publication, country, study design, population and sample size, and key findings. According to Levac et al. (2010) , it is vital to develop a data charting form and use it to extract the information from each study.

Step five: Collating, summarizing and reporting the results In this stage, NVIVO (Version 12), 'a qualitative data analysis computer software package' (Hilal & Alabri 2013, p. 182) , was used to organize extracted data and assisted in coding extracted data into different themes. According to Levac et al. (2010, p. 6) , this step involves 'collating, summarizing and reporting the results'. Furthermore, it involves using 'a thematic construction to provide an overview of the breadth of the literature' (Levac et al. 2010, p. 3) . In this study, the thematic analysis helped to identify, analyse and narrate the patterns from the dataset. Furthermore, the above-stated research questions guided the data analysis. In this study, a numerical summary was provided indicating the characteristics of the studies including number of the selected studies, countries of the study, type of the study design, characteristics of the population and categories emerging from the study (Arksey & O'Malley 2005) . Table 1 shows the characteristics of the included studies.

Nineteen selected articles were from eight African countries. The majority of the articles were from South Africa (6) and Nigeria (5). Two articles each were from Ghana and Egypt, while a single study was from each of these countries: Libya, Malawi, Namibia and Rwanda. Eleven studies used a quantitative research approach, another 7 were qualitative, and only one study used mixed methods. The targeted population were undergraduate nursing students in 11 studies, faculty in 6 studies, and the curricula in two studies.

In selected studies, the majority of nursing students were between 20-25 years, and females represented between 50.7% and 90. One of the six studies whose population was faculty indicated the demographics of the population, and it was noted that 50% of the sample was between 40-49 years, and the majority (84%) had a bachelor's degree. Furthermore, the same study indicated that 97% of the faculty were female (Akpabio & Ella 2015) .

Upon completion of the analysis of the selected articles about the integration of NI into undergraduate nursing programmes, the following categories emerged: (1) components of informatics used, (2) challenges and (3) Nishimwe et al. 2016) and social media platforms such as WhatsApp (Pimmer et al. 2018) .

Selected studies revealed that these ICT tools and applications were used by undergraduate nursing students, mainly for academic purposes and rarely in clinical practice (Elewa & El Guindy 2017; Harerimana & Mtshali 2018b; Harerimana & Mtshali 2019b; Pimmer et al. 2018) . In education, students used informatics tools for communication and collaboration with peers and the faculty, accessing online resources and course content from learning management systems, and completing academic work such as assignments and projects (Buabeng-Andoh 2018; Harerimana & Mtshali 2018b; Harerimana & Mtshali 2019b) . In clinical practice, informatics tools were mainly used to access health information, communicate and collaborate with peers, clinical instructors, nurses and experts, as well as reflect on their clinical practice (Ajuwon et al. 2018; Pimmer et al. 2018; Willemse 2015; Willemse et al. 2019) .

Eight studies have shown that the emphasis is mainly placed on developing basic computer literacy, and the academic use of nursing informatics. Four studies reported the type of content and competencies in NI included in the undergraduate curriculum (Achampong 2017; Akpabio & Ella 2015; Elewa & El Guindy 2017; Nishimwe et al. 2016 ). The reported content included historical background of NI, ICT tools, using patients' electronic records at different stages of the nursing process, using Internet and search tools, NI standards and lastly, IT terminologies and contemporary issues related to nursing and midwifery informatics (Achampong 2017) . Furthermore, one study reported that NI should include the application of informatics in education, telemedicine and ethics in informatics and hospital information system (Elewa & El Guindy 2017) .

Nursing informatics competencies are scarce in undergraduate nursing education in Africa (Ndinoshiho 2010; Nishimwe et al. 2016) . The implementation of NI tools and concepts in undergraduate nursing education has encountered challenges related to lack of ICT skills and competencies among nursing faculty to teach informatics, along with a lack of standardization of NI competencies. The inadequate delivery of NI was reported to be related to a lack of clear learning goals, insufficient practical aspects of NI and teaching NI in isolation (Achampong 2017; Elewa & El Guindy 2017) . Other challenges included the following: limited access to ICT tools such One study indicated that due to poor preparation of the students to use informatics in clinical practice in Africa, there is a growing negative attitude towards the use of mobile devices in clinical environments (Willemse et al. 2019) . One study identified that students use their mobile devices irresponsibly and unethically by posting confidential information and procedures to social media (Nyangeni et al. 2015) .

In Africa, nursing informatics in nursing education is under-researched, and two articles pointed out this issue (Bhebe & de la Harpe 2014; Olajubu et al. 2015) . The majority of the selected articles (58%) were from only two countries, namely South Africa and Nigeria. None of the studies indicated the process of implementing NI in undergraduate nursing curricula. One study indicated the guidelines which informed the choice of competencies to include in the undergraduate nursing curriculum, namely the guidelines from Technology Informatics Guiding Educational Reforms (TIGER) and International Medical Informatics Association (IMIA) (Achampong 2017) . Furthermore, only six of the 19 studies included the faculty (Achampong 2017; Akpabio & Ella 2015; Bhebe & de la Harpe 2014; O'Connor et al. 2016; Olajubu et al. 2015; Pimmer et al. 2018) , and only two studies covered the capacity building of the teaching faculty in NI (Achampong 2017; O'Connor et al. 2016) .

Educational reforms in nursing appear to favour the integration of NI; however, they were in their early stages in many African countries (Achampong 2017; Akpabio & Ella 2015; Bhebe & de la Harpe 2014; Elewa & El Guindy 2017) . Evidence from the selected studies showed that only two countries in Africa -Ghana and Nigeriahave successfully made reforms to undergraduate nursing education to include NI competencies. The nursing councils of these countries played an essential role in the accreditation of the developed curricula (Achampong 2017; Olajubu et al. 2015) .

Restructuring NI content and mode of delivery are essential in nursing education in African countries (Achampong 2017; Bhebe & de la Harpe 2014; Harerimana & Mtshali 2019b) . One study recommended that the content development and delivery of NI should be in line with the recommendations of IMIA and TIGER (Achampong 2017) . Three studies identified that there is a need for a standardized list of competencies in NI, and they should be integrated at all levels of education (Achampong 2017; Akpabio & Ella 2015; Nishimwe et al. 2016) .

Capacity building of the teaching faculty was reported by two studies to be an essential driver to the incorporation of NI in undergraduate nursing education in Africa. Nursing faculty need to be educated in NI, either through on-the-job training or formal education, to be able to teach informatics competencies in undergraduate nursing education (Achampong 2017; O'Connor et al. 2016) .

Collaborative partnerships between universities in Africa, and those from developed countries such as the USA and Canada, were reported to be pivotal to NI (Bhebe & de la Harpe 2014; O'Connor et al. 2016) . For this partnership to be successful, mutual goals need to be put in place and take into consideration education and healthcare needs (Olajubu et al. 2015) . Furthermore, political commitment was essential in ensuring that a conducive environment is created and resources and opportunities are provided for a smooth integration of NI in nursing education (Achampong 2017; Bhebe & de la Harpe 2014; Olajubu et al. 2015) .

This scoping review indicated the evidence of the integration of NI into undergraduate nursing education in Africa. In this study, three themes emerged: components of informatics tools used, challenges and success factors. Selected articles showed that ICT tools including laptops, tablets, mobile phones and applications are used by nursing students mainly for academic purposes, and rarely in clinical practice (Elewa & El Guindy 2017; Harerimana & Mtshali 2018b; Harerimana & Mtshali 2019b; Pimmer et al. 2018) . In Africa, studies indicated that the focus was mainly on developing basic computer skills of nursing students, and few studies described NI content integrated into undergraduate nursing curricula (Achampong 2017; Akpabio & Ella 2015; Elewa & El Guindy 2017; Nishimwe et al. 2016) . The negative attitude and the sparse use of informatics tools in clinical settings were associated with low implementation of NI in the nursing schools (Achampong 2017; Nishimwe et al. 2016; Nyangeni et al. 2015; Willemse et al. 2019) .

The evidence from this study indicated that successful integration of NI in undergraduate nursing education depended on several factors such as the adequate restructuring of NI content and mode of delivery and aligning expected competencies with the international standards such as those recommended by TIGER and IMIA. Studies showed that the use of informatics tools in nursing schools was a possible driver for integration in nursing curriculum (Buabeng-Andoh 2018; Harerimana & Mtshali 2019b; Irinoye et al. 2016) . Other reported success factors were developing informatics skills for both students and the faculty (Achampong 2017; Akpabio & Ella 2015; Elewa & El Guindy 2017; Nishimwe et al. 2016) ; and collaborative partnership and political commitment (Achampong 2017; Bhebe & de la Harpe 2014; O'Connor et al. 2016; Olajubu et al. 2015) .

This scoping review indicated that there is limited literature on the integration of informatics into undergraduate nursing education in Africa. Only 19 articles were located in a period ranging from 2009 to 2019. These articles were from eight African countries, of which 58% were from South Africa and Nigeria, two economic powers on the continent. It was noted that only six studies involved the faculty, and only two focussed on the faculty capacity development in NI. The majority of the studies were at the exploratory level and not predictive. None of the selected articles indicated the process or a blueprint for the successful implementation of NI into undergraduate nursing curricula.

This study highlights the importance of nursing informatics in undergraduate nursing education, with its challenges and success. Nursing education policy should support the development of the evidence-informed standards of NI competencies and content. Policymakers can use the results from this scoping review for establishing policies that foster the integration of NI in nursing education and devise strategies to integrate NI in clinical practice to facilitate the provision of quality care and services.

Nursing education institutions should ensure that NI is integrated into undergraduate nursing curricula. The course content should be developed and delivered effectively. The balance should be made between theory and practice when teaching informatics. Developing informatics skills of both students and faculty are essential in nursing education and practice. Due to limited literature, it is essential to conduct research that helps us to understand what aspects of NI are integrated into undergraduate nursing education, the process of the implementation, the challenges encountered and possible solutions, along with where the gaps in informatics currently lie in undergraduate nursing curricula in Africa.

The development of policies based on collaborative partnerships is vital to the successful integration of NI in undergraduate nursing education. Guided by evidence-based practice, educators, nursing councils and other healthcare bodies should develop more feasible frameworks to guide the timely integration of contemporary and meaningful NI into undergraduate nursing education. The outcome of NI integration is to better prepare graduate nurses for the African healthcare workforce and for the digital era.

This scoping review included published studies only, and the majority of them were from two countries (South Africa and Nigeria), which limits the generalization of the findings to the entire continent of Africa. Limitations also include omission of some relevant studies, particularly those published in a language other than English; or published before September 2009 and after September 2019.

Due to the importance attached to the integration of NI in undergraduate nursing education, developing the ICT skills of nursing students should go beyond teaching basic computer skills and focus on the application of ICT skills in clinical practice. Developing the computer skills of students and faculty, provision of the necessary support and resources, and restructuring NI content and mode of delivery are crucial factors to successfully teaching NI to undergraduate students. Furthermore, a collaborative partnership between developed and developing countries was reported to be essential for NI due to the importance of setting platforms for sharing expertise and resources. This scoping review revealed that there is limited literature around NI in undergraduate nursing education in Africa. Many of the studies were exploratory and not predictive, and none of the studies pointed out the process or blueprint used to facilitate the integration of NI into undergraduate nursing curricula. Hence, further studies need to be conducted to analyse the integration of NI into undergraduate nursing curricula in developed countries, in order to explore best practice to integrate informatics in the education of nurses. 

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Authors acknowledge the Department of Home Affairs and Australian Government for providing the Visa to Alexis Harerimana in order to study a doctorate by research in health at James Cook University, Townsville, Australia. We also acknowledge the College of Healthcare Sciences (CHS) at James Cook University for offering appropriate supervision and infrastructure support.