key: cord-0947664-5gi0rxn8
authors: Harerimana, Alexis; Wicking, Kristin; Biedermann, Narelle; Yates, Karen
title: Nursing informatics in undergraduate nursing education in Australia prior to COVID-19: A scoping review
date: 2021-11-27
journal: Collegian
DOI: 10.1016/j.colegn.2021.11.004
sha: 9d1f5ee5bcdf0d29fa1e5402abbe488c8c9e9d15
doc_id: 947664
cord_uid: 5gi0rxn8

BACKGROUND: Technology can support transformational outcomes of high quality and evidenced-based care and education. Embedding nursing informatics into the undergraduate nursing curriculum enhances nursing students’ digital health literacy, whilst preparing them to use health information systems and technological innovations to support their learning both at university and in the clinical environment. AIM: This scoping review aimed to provide an overview of the published literature on how nursing informatics was embedded and integrated into the undergraduate nursing curriculum in Australia prior to COVID-19. METHODOLOGY: A scoping review approach guided this study using the Levac, Colquhoun, and O'Brien framework, and the following databases were searched: CINAHL Plus databases, EMCARE, MEDLINE Ovid, Scopus; ERIC ProQuest, and Web of Science. A total of 26 articles were included: five quantitative studies, eight qualitative studies, and 13 mixed-methods studies. FINDINGS: Few studies focused on the concept of nursing informatics itself, and only two studies described the process of developing curricula that contain nursing informatics competencies and their implementation: the educational scaffolding and modular development approach and a Community of Inquiry Framework (COI). Most studies centred on nursing informatics tools to facilitate teaching and learning in classrooms and skills laboratories. The reported pedagogical strategies were online learning, blended learning, and technology-enabled simulations. Hindrances to nursing informatics being integrated into undergraduate curricula were disparities of the informatics content a lack of guidelines and/or frameworks, and poor digital literacy. CONCLUSION: This study provided a baseline perspective of how NI was embedded and integrated into nursing education in Australia before Covid-19. Overwhelmingly the focus of research to date was found to be mainly on the utilisation of technological tools to support learning and teaching..

contexts, and their digital health-related roles and capabilities are essential in providing quality care in a dynamic healthcare environment (Australian Digital Health Agency, ADHA, 2020). Nursing education institutions are expected to embed nursing informatics into their undergraduate nursing curriculum to prepare students to use technological innovations to support their learning both at university and in the clinical environment (Australian Nursing and Midwifery Federation, ANMF, 2019) . With the advent of the Coronavirus disease pandemic, nursing education institutions rapidly pivoted to online delivery, which required significant confidence and competency in digital literacy (Ekert et al., 2020; Morin, 2020; Seah, Ang, Liaw, Lau, & Wang, 2021) . This scoping review explores how nursing informatics was embedded and integrated into the undergraduate nursing curriculum in Australia prior to COVID-19.

Nursing Informatics (NI) is an emerging concept. NI was created by the merge of three well established scientific fields: information science, computer science and nursing science (Aathi, 2014; Topaz, 2013) . Defining NI is vital to guide the role delineation for nurses interested in nursing informatics and suggest a direction for the practice, education, training and research (Hunter & Bickford, 2011; Staggers & Thompson, 2002) . The Australian College of Nursing (ACN, 2017, p. 1) defined nursing informatics as "the speciality that integrates nursing science with multiple information and analytical sciences to identify, define, manage and communicate data, information, knowledge, and wisdom in nursing practice".

Globally, the definition of NI has evolved over the past few decades; however, a universal definition is still not recognised in the academic arena. Scholars have clustered NI definition into three main themes: information technology-oriented, conceptually oriented, and role oriented definitions (Faustorilla, 2020; McGonigle, Hunter, Sipes, & Hebda, 2014; Staggers & Thompson, 2002) . The information technology-oriented definition asserts that NI is used in all fields of nursing. NI is used in nursing practice to track patient's outcomes, find data trends, and assess workload and interventions (McGonigle et al., 2014) . NI in education supports virtual teaching and learning, assessment, and analytics associated with educational outcomes. Nurse executives use NI to improve workflows, decision support, and manage resources. NI supports nursing research by evaluating patient outcomes, evidence-based practice, standardised terminologies, and virtual knowledge bases (McGonigle et al., 2014) .

The conceptually oriented NI definition demonstrated a shift from technology-focused definitions to pro-active and model-driven definitions, which combine computer science, information science, and nursing science to support the practice of nursing and the delivery of nursing care (Faustorilla, 2020) .

The role oriented definition views NI as a speciality where the role of NI specialists is primarily related to the insertion of computer technologies into the healthcare system to support patients, nurses and other healthcare professionals in decision-making in all roles and settings to achieve the desired outcomes (American Nurses Association, 2015; Staggers & Thompson, 2002) .

Using informatics tools in nursing practice has been a driving force for tertiary educational institutions to devise approaches to produce nursing graduates who have adequate digital skills and competencies to use technological innovations in health information systems (Brown, Morgan, Mason, Pope, & Bosco, 2020; Collins, Britnell, Ditzel, & Honey, 2017; Knox, 2019; Pearce, 2017) .

Digital literacy refers to the capabilities which "fit an individual for living, learning and working in a digital society (Terry, Davies, Williams, Tait, & Condon, 2019, p. 258) . Digital literacy also refers to "competencies on the use of digital technologies for searching, organising, understanding and creating information with digital devices" (Khosrow-Pour, 2013) . Digital literacies have multiple facets and encompass information literacycapabilities to find, interpret, evaluate, manage and share information (JISC, 2014) ; ICT literacycapabilities to adapt and use digital devices, applications and services (JISC, 2014) ; learning skillscapabilities to study and learn effectively in a technology-rich environment, formal and informal (JISC, 2014) . Furthermore, digital literacy includes digital communication and collaboration, career and identity management, media literacy and digital scholarship (JISC, 2014) . Digitally literate nurses are capable of providing quality care in clinical settings (Brown et al., 2020) . Embedding NI within undergraduate nursing curricula is important to develop nursing students' digital skills (Brown et al., 2020; Cummings, Shin, Mather, & Hovenga, 2016; Honey, Collins, & Britnell, 2020) , and NI competencies should meet demands from practice through education (Peltonen et al., 2019) .

Internationally, developed countries such as Australia, Canada, Denmark, New Zealand, and the United States of America have undertaken reforms to undergraduate nursing curricula to include NI (ADHA, 2020; Borycki, Cummings, Kushniruk, & Saranto, 2017; Cummings, Borycki, & Madsen, 2015; Monsen et al., 2019) . In those countries, schools of nursing are required to provide evidence that NI has been included in their curricula in order to obtain accreditation of the nursing programme (Borycki & Foster, 2014; Cummings et al., 2016) . However, in developing countries such as those from Africa, nursing informatics is scarce in undergraduate nursing education due to the implementation and adoption challenges (Harerimana, Wicking, Biedermann, & Yates, 2020) .

Meeting international health informatics education standards is desirable due to the health industry's globalisation and increased workforce mobility across countries (Hübner et al., 2018) . Hence, the design of NI content is encouraged to be in line with international standards, such as those from Technology Informatics Guiding Education reforms (TIGER), the Canadian Association of School of Nursing (CASN), and the American Medical Informatics Association (AMIA) (Cummings et al., 2016; Cummins, Gundlapalli, Murray, Park, & Lehmann, 2016; Hübner et al., 2018) .

In Australia, NI's integration in nursing education is underpinned by the country's health and education context. The Australian Government is committed to achieving an optimum healthcare system and ensuring a digitally connected healthcare system (Australian College of Nursing, ACN, 2017; Australian Digital Health Agency, ADHA, 2017; ADHA, 2020). Australian health policy reform focuses on health informatics requirements in the health sector (ADHA, 2017 (ADHA, , 2020 Australia Nursing and Midwifery Federation, ANMF, 2015; Foster, 2015) . Furthermore, the healthcare system is phasing out paper-based documentation (ACN, 2017) and adopting electronic health records (ACN, 2017; Borycki, Foster, Sahama, Frisch, & Kushniruk, 2013) . Hence, an increasing need exists to train digitally literate healthcare professionals (ADHA, 2017 (ADHA, , 2020 Kuek & Hakkennes, 2020; Mather, Douglas, & Jacques, 2018) .

In the context of nursing education in Australia, nursing organisations and accreditation bodies lead the reforms in education to equip nursing students with informatics skills, enabling them to work in digitalised health environments (ACN, 2017; Australian Nursing and Midwifery Accreditation Council, ANMAC, 2014; ANMF, 2015) . There are increasing demands for universities to produce digitally-competent graduates who can use ICT to deliver quality healthcare (ACN, 2017; ADHA, 2020; Borycki et al., 2013) .

The development of a nursing curriculum inclusive of NI is a rigorous process to meet national and international requirements (Cummings et al., 2016) . A study conducted in Australia by Cummings et al. (2016) found that this process requires mapping all content against nursing competencies and recommendations from ANMAC. Furthermore, the course content and the context of each NI component are checked to ensure the alignment with the degree requirements (Cummings et al., 2016) . ANMAC (2018, p. 13 ) recommends that nursing programmes should "reflect contemporary practices in health education and respond to emerging trends including health informatics and digital health technologies and is based on research or other forms of evidence". Hence, this recommendation establishes the baseline for NI competencies to be taught as an important step in developing the curriculumcomputer literacy, information literacy and information management (ANMF, 2015; Choi & De Martinis, 2013) .

There are challenges in creating a proficient nursing workforce with adequate skills and comfort to use technology (ACN, 2020). Globally, there is "a gap in informatics expertise among nursing students, practising staff and faculty" (O'Connor & LaRue, 2021, p. 1) . A distinct lack of guidelines for developing NI content and non-adherence to standards and criteria for teaching nursing informatics hinders the development of NI competencies in nursing education (Atthill, 2015; Forman, Armor, & Miller, 2020) . Furthermore, NI definition's ambiguity significantly impacts informatics practice and education (Staggers & Thompson, 2002) . In light of those challenges, a broader literature review is required to explore the body of knowledge around the integration of NI into undergraduate nursing education.

The scoping review aims to provide an overview of published literature about how NI was embedded and integrated into the undergraduate nursing curriculum in Australia prior to COVID-19.

In order to understand the state of the integration of nursing informatics in Australian undergraduate nursing education before COVID-19, the authors conducted a scoping review. Scoping reviews map a given field, summarising a range of evidence to convey the field's breadth and depth (Levac, Colquhoun, & O'Brien, 2010) . This study followed a scoping review framework from Levac et al. (2010) . In scoping reviews, guidelines are recommended to facilitate the scoping review reporting and transparency. Furthermore, a methodological framework for scoping reviews provide recommendations for clarity at each stage, which increases consistency (Brien, Lorenzetti, Lewis, Kennedy, & Ghali, 2010; Levac et al., 2010) . The scoping review framework by Levac et al. (2010) is a refined framework from Arksey and O'Malley, which has six steps describing the methodological approach to use when conducting a scoping review. For this study, the following essential five steps were used:

1. Identifying the research questions;

2. Identifying relevant studies;

3. Selecting the studies; 4. Charting the data; 5. Collating, summarising, and reporting the results (Levac et al., 2010, p. 3) .

In this study, the following inclusion criteria were used: peer-reviewed articles on the integration of This scoping review focused on Australia due to its rapid advancement of digital health, both in clinical practice and in the education of healthcare professionals. The 2018 World Health Organization Collaborating Centre (WHOCC) for Education and Research Capacity conference demonstrated that Australia was a role model in the region, with the presence of NI in undergraduate curricula being a requirement for nursing programme accreditation. Due to multiple educational systems across the globe, choosing one exemplar country with a strong educational system and a track record in digital health was crucial for this scoping review to enable learning best practice approaches.

This scoping review provides a foundation for a broader PhD cross case analysis study, investigating how NI is embedded into undergraduate nursing education in low and high-income regions, for which the authors also conducted a similar scoping review in Africa (Harerimana et al., 2020) .

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). The following research questions were addressed in this scoping review:

1. What were the expectations for integrating NI into undergraduate nursing programmes in Australia prior to COVID-19? 2. How was nursing informatics integrated into undergraduate nursing education in Australia prior to 3. What were the factors facilitating and hindering the integration of NI in undergraduate nursing education in Australia prior to COVID-19?

Prior to the identification of relevant studies, search strategies were developed, which included where to search, what terms to use, sources to be searched, time span and language as recommended by Levac et al. (2010) . Publication dates were limited to a period ranging from 1 st January 2010 to 31 st December 2019. The beginning of 2020 marked the beginning of the impact of COVID-19 on the way nursing education was delivered in the 2020 academic year, in which ICT uptake by nursing education providers was obligatory.

The following electronic databases were searched: CINAHL Plus databases; EMCARE; MEDLINE Ovid; Scopus; ERIC ProQuest; Web of Science. Additionally, a search was conducted in Google Scholar to obtain additional articles which might have been missed with the other electronic database searches.

Key terms were developed mainly from MeSH Headings (MH) and customised keywords to suit the search strategies of different databases. The following were the key terms used in this study: 

Twenty-six articles included in this study were read several times, to ascertain that all necessary information was included. According to Levac et al. (2010, p. 3), it is vital to develop a data-charting form and use it to extract the information from each study. In this study, extracted data were presented in the form of a table which contained: Authors, year of publication, study design, population and sample size, and key findings (Table 1) .

Step five: Collating, summarising and reporting the results

In this stage, extracted data were analysed using descriptive analysis and an inductive thematic synthesis approach recommended by Cruzes and Dyba (2011) . To extract data, an organising matrix was created into which relevant segments of the text of each study were inserted, and later condensed (Table 1) . Each study report was uploaded into NVIVO (version 12), and the findings for each study were systematically coded and later grouped into common themes related to the research objectives.

Themes were created from a comprehensive review of all the codes from all selected papers. Themes were then organised into higher-order themes, and their relationships described. To achieve trustworthiness, each step of the framework for a scoping review was followed (Levac et al., 2010) .

The research questions were answered based on the evidence obtained from a collaborative synthesis of the data.

Of the 26 empirical studies included in this study, 50% (n=13) used mixed methods, 30.8% (n=8) used qualitative, and 19.2% (n=5) used quantitative methods. The majority of the selected studies were conducted with a focus on nursing students (76.9%; n=20), followed by faculty (15.4%; n=4); of both faculty and students (3.8%, n=1), and lastly, one study focussed the undergraduate nursing curriculum itself (3.8%, n=1). The majority of nursing students in the dataset were female, representing 80 to 90%. The age group ranged from 18 to 50 years, with the majority of them being under 25 years of age. There were variations in the sample of nurse educators, and in one study, more than 48% had extended experience in curriculum development of more than six years.

The selected 26 studies covered a wide range of technology usage in nursing education, and some of them covered multiple aspects simultaneously (Table 1) . Few topics focused on the concept NI (n=1), readiness to use NI (n=1), the process for embedding technology in the undergraduate curricula (n=2).

The majority of selected studies focused on informatics tools to support learning and teaching, which included clinical simulation (n=9), online or virtual learning (n=11), blended learning (n=7), digital assessmentphotographs/photo essays (n=2), e-role play (n=1), and digital formative assessment (n=1). Other few studies focused on educators' experiences (n=2) and students' digital skills (n=1).

Four main themes arose from the summary of the data, some of which included subthemes. Themes and subthemes were discussed in turn with supporting evidence from relevant studies. These themes are (1) Expectations for integrating NI in undergraduate nursing education, (2) NI in undergraduate nursing programmes, (3) Facilitating factors, and (4) Inhibiting factors.

Embedding nursing informatics in undergraduate nursing education is expected to impact nursing education and practice positively. NI is used to enhance teaching and learning in the classroom, 

Exploring how NI is integrated into nursing education goes hand in hand with understanding the structure of undergraduate nursing programmes. In Australia, the undergraduate nursing programme is subdivided into two programme types: bachelors of nursing (BN) and double degrees (nursing and either midwifery, paramedicine, or early childhood education, for example). One study indicated that nursing programme duration ranges from six semesters for single degrees and eight semesters for double degrees (Bogossian et al., 2018) . Furthermore, Bogossian et al. (2018) reported that the majority of nursing programmes are offered in an on-campus mode in either face to face or blended delivery. A BN degree's total hours ranged from 1484 to 7600 hours, with theoretical instructions covering 355 to 3600, clinical experience from 760 to 1600, and simulated clinical experiences from 0-296. Conversely, the total hours for a double degree programme ranges from 1492 to 3280, with theoretical hours covering 509 to 1260 hours, clinical experience from 800 to 1600 hours and simulated clinical experience from 103 to 320 hours (Bogossian et al., 2018) .

The integration of NI into undergraduate nursing education is recommended by the ANMAC;

however, the process differs across educational institutions (Cummings et al., 2016; Smadi, Parker, Gillham, & Muller, 2019; Turnbull, Royal, & Purnell, 2011) . The majority of the studies in this review focused on the integration of informatics tools in nursing education to support teaching and learning in classroom and simulation sessions through face-to-face, online or blended learning. Two studies highlighted the process followed to integrate technology into undergraduate nursing curricula (Cummings et al., 2016; Smadi et al., 2019) , and one study focused explicitly on embedding NI into the curricula (Cummings et al., 2016) . The educational scaffolding and modular development framework guided the inclusion of NI into the curriculum (Cummings et al., 2016) . Cummings et al. (2016) reported that NI was overtly found in 21 of 25 units of the entire programme in a three-year degree. The inclusion of NI in the nursing curriculum was guided by TIGER and the Canadian Association of Schools of Nursing entry-level competencies (Cummings et al., 2016) . In another study, a Community of Inquiry framework (COI) was used to investigate its applicability in online and blended courses in nursing schools in Australia (Smadi et al., 2019) . The COI framework addresses the nexus of pedagogy, technology and learner's needs (Smadi et al., 2019) .

Nursing students used digital devices such as computers, laptops, iPads, iPods, and Smartphones to communicate, access educational applications, and learning materials in the face to face classes, virtual classes and clinical laboratories (Brown & McCrorie, 2015a; Ferguson et al., 2016; Mawson, 2014) . Furthermore, these devices enabled students to communicate and collaborate with their peers and the faculty through social media platforms such as Facebook, Skype, Twitter, and YouTube (Bogossian et al., 2018; Ferguson et al., 2016; Mather, Douglas, & Jane, 2017) . Social media facilitated safe collaboration, independent learning, access to resources, and collaboration during group work and assignments (Ferguson et al., 2016; Mather et al., 2017) . Students used social media, journals, television, and radio as sources of information (Mather et al., 2017) .

Nursing graduates are expected to be digitally literate, and improving their NI-related skills is important at the educational level (Shin, Cummings, & Ford, 2018) . Nursing students are assumed to be technologically savvy, and they acquire knowledge from high school, which later they use to support their learning; however, international students from less-resourced countries may not have the knowledge and skills to use digital tools (McNally et al., 2019; Terry et al., 2018) . Digital literacy includes computer literacy and information literacy (Shin et al., 2018) . Computer literacy is concerned with operating mechanical components of the computers and using computer programmes and applications (Shin et al., 2018) ; whereas, information literacy determines when the information is required and where to locate it. Information literacy supports the integration of evidence-based practice into clinical settings (Shin et al., 2018) . Shin et al. (2018) indicated that nursing graduates acquired NI skills during orientation programmes and their 6-month transition into the ward. Delayed access to hospital computer systems was a barrier to NI's implementation in practice (Shin et al., 2018) . Developing nursing students' information literacy required multidisciplinary approaches and However, the teaching faculty reported insufficient digital literacy, lack of skills to teach in a virtual environment, and to design learning and assessment activities (Oprescu et al., 2017) .

In nursing education, the mode of delivery of instructions included online learning and blended learning. Technology-supported teaching strategies are essential to develop nursing students'

competencies (Andrew et al., 2015; Klein et al., 2019; Raymond, Jacob, Jacob, & Lyons, 2016; Turnbull et al., 2011) . Online or virtual delivery of instructions facilitated teaching students remotely and access to library resources and recordings irrespective of location and time (Andrew et al., 2015; Raymond et al., 2016) . Furthermore, virtual learning facilitated students' academic and social engagement by asking questions, sharing their opinions, getting instant feedback, and collaborating with peers and teachers (Andrew et al., 2015; Raymond et al., 2016) . The access to the web-based application was either synchronously in real-time or asynchronous with a time delay (Andrew et al., 2015; Todhunter, Hallawell, & Pittaway, 2013; Warland et al., 2012) .

Blended learning combined online and face-to-face learning and teaching (Andrew et al., 2015; McNally et al., 2019; Smadi et al., 2019; Terry et al., 2016; Terry et al., 2018) . A study by Terry et al.

(2018) observed blended learning improved students' performance significantly more than face to face (on-campus) or online as standalone.

Online and blended teaching and learning were positively perceived; however, teaching and assessment in virtual classes were more challenging (Oprescu et al., 2017; Warland et al., 2012) .

Other challenges to online and blended learning were time constraints, poor digital literacy, lack of expertise and guidelines to teach in virtual classes and simulation laboratories (Bogossian et al., 2018; Raymond et al., 2016; Warland et al., 2012) .

Numerous online platforms and computer-assisted learning programmes (CAL) supported teaching and learning activities, and assessment ( 

Enabling factors such as collaborative partnership, institutional support, and readiness to embrace Institutional support to both students and faculty was also reported to be instrumental in implementing NI (Ferguson et al., 2016; Smadi et al., 2019; Turnbull et al., 2011) . Support was offered through ICT platforms such as Learnline, LMS, and social media (Ferguson et al., 2016; Turnbull et al., 2011) .

Student support was also provided through face-to-face interactions or "drop-in" sessions (Turnbull et al., 2011) .

Staff readiness to embrace technology was reported to be a cornerstone to the success of NI. The presence of specialists in NI and experts in online course development helped the faculty develop adequate course content (Cummings et al., 2016) ; and the availability of educators' training packages were reported to improve their digital literacy and competencies to teach NI to the students (Cummings et al., 2016) .

The studies in this review revealed challenges that hindered the incorporation of NI into undergraduate nursing curricula. These included disparities of the content of NI in Australia (Cummings et al., 2016) , along with a lack of nurse educators' skills in NI, particularly in the use of informatics tools in education and simulation (Bogossian et al., 2018; Cummings et al., 2016; Oprescu et al., 2017) . For instance, clinical simulations were hindered by a lack of technical support, time constraints, sufficient academic support, appropriate and sufficient equipment, lack of simulation experiences, and access to a dedicated simulation environment (Bogossian et al., 2018) .

Another inhibiting factor was the lack of guidelines and/or frameworks to develop NI and guide the Students' poor ICT literacy and limited access to ICT tools and applications were also reported to be a challenge (Brown & McCrorie, 2015b; Raymond et al., 2016) . Evidence shows that there is limited exposure to NI due to a lack of opportunity to interact with NI during the clinical placement, mainly caused by ethical issues to access patient data in health systems in hospitals (Shin et al., 2018) .

Although there is evidence of the integration of NI in undergraduate nursing education, few studies described the process of developing a curriculum that integrates the NI competencies expected among nursing students (Cummings et al., 2016; Smadi et al., 2019; Turnbull et al., 2011) .

With the rapid advancement of technology and rapid transformation of the health sector, practice to support the nursing process, quality care, and electronic nursing documentation (Jouparinejad, Foroughameri, Khajouei, & Farokhzadian, 2020; Laitinen, Koivu, Nykänen, & Kimaro, 2020; Smaradottir, 2018) .

In this scoping review, a few studies explored the actual concept of NI, competencies in NI, and the process for developing and implementing the NI curriculum. NI is fundamental in all healthcare systems levels (Australian Digital Health Community, ADHC, 2017). Nursing students' preparation to carry out NI tasks requires their capacity building in computer literacy and information literacy (Shin et al., 2018) . O'Connor and LaRue (2021, p. 3) explained that core informatics competencies for students to achieve included six domains: health service literacy, information and communication technology literacy, information management, information system management, and patient/health literacy. The capacity building in nursing informatics should be done during students' orientation, both on campus and in clinical settings, and the role of the experienced staff in NI are pivotal to graduates' informatics practice (Shin et al., 2018) . Furthermore, it is crucial to state "the core competencies students will gain each year, and they spiral upwards towards achieving the overall knowledge of becoming a nursing practitioner competent in the knowledge and practice of digital health" (O'Connor & LaRue, 2021, p. 3).

In Australia, nursing organisations and experts in nursing informatics have described the NI competencies and digital capabilities for nurses and midwives (ADHA, 2020; AHIEC, 2011; Cummings et al., 2016) . Embedding NI into undergraduate nursing curricula should consider national and international initiatives in health/ nursing informatics (Cummings et al., 2016) . The ADHA (2020) developed a framework that depicts the domains and capability levels to support individuals and organisations' digital health development. This framework could be used as a tool to guide nursing education institutions to devise strategies to integrate digital health into their curricula.

Integrating informatics competencies into undergraduate curricula will ensure that students are equipped with the necessary skills to work in a digital health environment (ADHA, 2017 (ADHA, , 2020 .

Adequate integration of NI into the undergraduate nursing curriculum was hindered by numerous factors such as the disparity of NI content in Australia (Cummings et al., 2016) , lack of skills to teach NI (Bogossian et al., 2018; Cummings et al., 2016; Oprescu et al., 2017) , and a lack of standardised guidelines and frameworks to help develop NI content and guide the integration of technology in the curriculum (Andrew et al., 2015; Cummings et al., 2016; Smadi et al., 2019) . Furthermore, challenges included students' poor computer literacy and limited access to ICT tools during students' clinical placements (Brown & McCrorie, 2015b; Raymond et al., 2016; Shin et al., 2018) . Restrictions and rules hindered students' use of informatics tools in the clinical environment to access hospitals' health systems. Having clearly articulated NI competencies, policy and guidelines may address the lack of skills and awareness of NI among the workforce (Harerimana et al., 2020; Honey & Procter, 2017) .

This scoping review provides a baseline for how NI was embedded and integrated into nursing education in Australia before Covid-19 compelled universities to adopt an extensive reliance on ICT to deliver their education. Hence, a follow-up study is recommended to explore the impact of these unprecedented times on the rapid and forced integration of ICT and informatics on nursing education.

In this scoping review, selected articles were limited to peer-reviewed studies published in English, ranging from 1st January 2010 to 31st January 2019. Although this review described the protocol that guided the scoping review process, some studies might have been missed. Additionally, this scoping review considered only empirical research; thus, it may not capture fully or provide an accurate reflection of the work that nursing programmes had done to incorporate NI into their curricula prior to COVID-19.

In recent years, NI has been identified as a subject that could be taught to nurses. The current scoping review revealed that prior to Covid-19, most empirical studies in Australia focused on how technology was integrated into undergraduate nursing education to facilitate learning and teaching in classroom simulation laboratories and clinical environments. A small number of empirical papers explored the concepts of NI and how it was embedded into the curriculum. Embedding NI into nursing education was hindered by numerous challenges such as disparities of the NI content, poor digital literacy, lack of guidelines and/ or frameworks to guide the integration of NI in the nursing curriculum, and the paucity of the NI empirical studies around the actual integration process. With an increasing digitalised health sector, nursing schools are expected to produce digitally competent nursing graduates. Successful integration of NI would require the availability of evidence-based NI standards, frameworks and technology readiness to advance nursing education and practice at the same pace of technology advancements. Embedding NI in the undergraduate program is fundamental to ensuring optimal nursing education and quality healthcare delivery in a technology-led environment.

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Digital explanations and nursing students' perception of learning science

Alignment of American Association of Colleges of Nursing Graduate-Level Nursing Informatics Competencies With American Medical Informatics Association Health Informatics Core Competencies

Nursing education after COVID-19: Same or different?

Integrating informatics into undergraduate nursing education: A case study using a spiral learning approach

Professional development needs of nurse educators. An Australian case study

Digital literacy

The current state of Nursing Informatics-An international cross-sectional survey

The Virtual Maternity Clinic: A teaching and learning innovation for midwifery education

Peer learning a pedagogical approach to enhance online learning: A qualitative exploration

High fidelity patient silicone simulation: a qualitative evaluation of nursing students' experiences

Curriculum changes for preregistration nursing education in times of COVID-19: For the better or worse? Nurse education today

Health information technology and digital innovation for national learning health and care systems

A qualitative study of new graduates' readiness to use nursing informatics in acute care settings: clinical nurse educators' perspectives

The applicability of community of inquiry framework to online nursing education: A cross-sectional study

Patient accessible electronic health records: impacts on nursing documentation practices at a university hospital

The evolution of definitions for nursing informatics: a critical analysis and revised definition

The Ward': a simulation game for nursing students

Photo-essay as an assessment strategy for learning about the determinants of health: Students' experiences