Workarounds and Their Implications for Patient Safety

Describe how you as a nursing student, utilizes critical thinking in the classroom and clinical area
April 6, 2021
Discuss the link between the PICOT statement, the research articles, and the nursing practice problem you identified.
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Workarounds and Their Implications for Patient Safety



The Pedagogy

Nursing Informatics and the Foundation of Knowledge, Third Edition drives comprehension through a variety of strategies geared toward meeting the learning needs of students, while also generating enthusiasm about the topic. This interactive approach addresses diverse learning styles, making this the ideal text to ensure mastery of key concepts. The pedagogical aids that appear in most chapters include the following:



Dee McGonigle, PhD, RN, CNE, FAAN, ANEF Chair, Virtual Learning Environments and Professor, Graduate Programs

Chamberlain College of Nursing Member, Informatics and Technology Expert Panel (ITEP)

American Academy of Nursing Member, Serious Gaming and Virtual Environments Special Interest Group for the Society for Simulation in Healthcare (SSH)

Kathleen Mastrian, PhD, RN Associate Professor and Program Coordinator for Nursing

Pennsylvania State University, Shenango Sr. Managing Editor, Online Journal of Nursing Informatics (OJNI)

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Preface Acknowledgments Authors’ Note Contributors


1 Nursing Science and the Foundation of Knowledge Kathleen Mastrian and Dee McGonigle

Introduction Quality and Safety Education for Nurses Summary References

2 Introduction to Information, Information Science, and Information Systems Dee McGonigle and Kathleen Mastrian

Introduction Information Information Science Information Processing Information Science and the Foundation of Knowledge Introduction to Information Systems Information Systems Summary References

3 Computer Science and the Foundation of Knowledge Model June Kaminski

Introduction The Computer as a Tool for Managing Information and Generating Knowledge Components What Is the Relationship of Computer Science to Knowledge? How Does the Computer Support Collaboration and Information Exchange? What Is the Human–Technology Interface? Looking to the Future Summary Working Wisdom Application Scenario Internet and Software Resources References

4 Introduction to Cognitive Science and Cognitive Informatics Dee McGonigle and Kathleen Mastrian

Introduction Cognitive Science Sources of Knowledge Nature of Knowledge How Knowledge and Wisdom Are Used in Decision Making Cognitive Informatics CI and Nursing Practice What Is AI? Summary References

5 Ethical Applications of Informatics Kathleen Mastrian, Dee McGonigle, and Nedra Farcus

Introduction Ethics Bioethics Ethical Issues and Social Media Ethical Dilemmas and Morals Ethical Decision Making Theoretical Approaches to Healthcare Ethics Applying Ethics to Informatics Case Analysis Demonstration New Frontiers in Ethical Issues Summary References


6 Overview of Nursing Informatics Ramona Nelson and Nancy Staggers

Introduction Metastructures, Concepts, and Tools of NI The Future of NI Summary References

7 Informatics Roles and the Knowledge Work of Nursing Julie A. Kenney and Ida Androwich

Introduction The Nurse as a Knowledge Worker The Knowledge Needs and Competencies of Nurses What Is Nursing Informatics Specialty Practice? The Future of Nursing Informatics Summary References

8 Information and Knowledge Needs of Nurses in the 21st Century Lynn M. Nagle, Nicholas Hardiker, Kathleen Mastrian, and Dee McGonigle

Introduction Definition and Goal of Informatics Health Information Technologies Impacting Nursing Nurses Creating and Deriving New Knowledge Generating Nursing Knowledge Challenges in Getting There The Future Summary References

9 Legislative Aspects of Nursing Informatics: HITECH and HIPAA Kathleen M. Gialanella, Kathleen Mastrian, and Dee McGonigle

Introduction Overview of the HITECH Act How a National HIT Infrastructure Is Being Developed How the HITECH Act Changed HIPAA Implications for Nursing Practice Summary References


10 Systems Development Life Cycle: Nursing Informatics and Organizational Decision Making Dee McGonigle and Kathleen Mastrian Introduction Waterfall Model Rapid Prototyping or Rapid Application Development

Object-Oriented Systems Development Dynamic System Development Method Computer-Aided Software Engineering Tools Open Source Software and Free/Open Source Software Interoperability Summary References

11 Administrative Information Systems Marianela Zytkowski, Susan Paschke, Dee McGonigle, and Kathleen Mastrian Introduction Types of Healthcare Organization Information Systems Communication Systems Core Business Systems Order Entry Systems Patient Care Support Systems Department Collaboration and Exchange of Knowledge and Information Summary References

12 The Human–Technology Interface Judith A. Effken, Dee McGonigle, and Kathleen Mastrian Introduction The Human–Technology Interface The Human–Technology Interface Problem Improving the Human–Technology Interface A Framework for Evaluation Future of the Human–Technology Interface Summary References

13 Electronic Security Lisa Reeves Bertin, Dee McGonigle, and Kathleen Mastrian Introduction Securing Network Information Authentication of Users Threats to Security Security Tools Off-Site Use of Portable Devices Summary References

14 Nursing Informatics: Improving Workflow and Meaningful Use Denise Hammel-Jones, Dee McGonigle, and Kathleen Mastrian Introduction Workflow Analysis Purpose Workflow and Technology Workflow Analysis and Informatics Practice Informatics as a Change Agent Measuring the Results Future Directions Summary References


15 The Electronic Health Record and Clinical Informatics Emily B. Barey, Kathleen Mastrian, and Dee McGonigle Introduction Setting the Stage Components of Electronic Health Records Advantages of Electronic Health Records Ownership of Electronic Health Records Flexibility and Expandability The Future Summary References

16 Informatics Tools to Promote Patient Safety and Clinical Outcomes Kathleen Mastrian and Dee McGonigle Introduction What Is a Culture of Safety? Strategies for Developing a Safety Culture Informatics Technologies for Patient Safety Role of the Nurse Informaticist Summary References

17 Supporting Consumer Information and Education Needs Kathleen Mastrian and Dee McGonigle Introduction Consumer Demand for Information Health Literacy and Health Initiatives Healthcare Organization Approaches to Education Promoting Health Literacy in School-Aged Children Supporting Use of the Internet for Health Education Future Directions Summary References

18 Using Informatics to Promote Community/Population Health Margaret Ross Kraft, Ida Androwich, Kathleen Mastrian, and Dee McGonigle Introduction Core Public Health Functions Community Health Risk Assessment: Tools for Acquiring Knowledge Processing Knowledge and Information to Support Epidemiology and Monitoring Disease Outbreaks Applying Knowledge to Health Disaster Planning and Preparation Informatics Tools to Support Communication and Dissemination Using Feedback to Improve Responses and Promote Readiness Summary References

19 Telenursing and Remote Access Telehealth Original contribution by Audrey Kinsella, Kathleen Albright, Sheldon Prial, and Schuyler F. Hoss; revised by Kathleen Mastrian and Dee McGonigle Introduction History of Telehealth Nursing Aspects of Telehealth Driving Forces for Telehealth Telehealth Care Telenursing Telehealth Patient Populations Tools of Home Telehealth Home Telehealth Software Home Telehealth Practice and Protocols Legal, Ethical, and Regulatory Issues A Day in the Life of a Home Telenurse The Patient’s Role in Telehealth Telehealth Research The Foundation of Knowledge Model and Home Telehealth Parting Thoughts for the Future and a View Toward What the Future Holds Summary References


20 Nursing Informatics and Nursing Education Heather E. McKinney, Sylvia DeSantis, Dee McGonigle, and Kathleen Mastrian Introduction: Nursing Education and the Foundation of Knowledge Model Knowledge Acquisition and Sharing Hardware and Software Considerations Delivery Modalities Technology Tools Internet Tools: Webcasts, Searching, Instant Messaging, Chats and Online Discussions, Electronic Mailing Lists, and Portals Promoting Active and Collaborative Learning

Knowledge Assessment Methods Knowledge Dissemination and Sharing The Future Exploring Information Fair Use and Copyright Restrictions Summary References

21 Simulation in Nursing Informatics Education Nickolaus Miehl Introduction Nursing Informatics Competencies in Nursing Education A Case for Simulation Incorporating EHRs into the Learning Environment Challenges and Opportunities What Does the Future Hold? Summary References

22 Games, Simulations, and Virtual Worlds for Educators Brett Bixler Introduction Case Scenario Educational Games Educational Simulations Virtual Worlds Choosing Among Educational Games, Simulations, and Virtual Worlds The Future of Games, Virtual Worlds, and Simulations Summary References


23 Research: Data Collection, Processing, and Analysis Heather E. McKinney, Sylvia DeSantis, Kathleen Mastrian, and Dee McGonigle Introduction: Nursing Research and the Foundation of Knowledge Model Knowledge Generation Through Nursing Research Acquiring Previously Gained Knowledge Through Internet and Library Holdings Fair Use of Information and Sharing Informatics Tools for Collecting Data and Storage of Information Tools for Processing Data and Data Analysis The Future Summary References

24 Data Mining as a Research Tool Dee McGonigle and Kathleen Mastrian Introduction: Big Data, Data Mining, and Knowledge Discovery KDD and Research Data Mining Concepts Data Mining Techniques Data Mining Models Benefits of KDD Ethics of Data Mining Summary References

25 Translational Research: Generating Evidence for Practice Jennifer Bredemeyer and Ida Androwich Introduction Clarification of Terms History of Evidence-Based Practice Evidence Bridging the Gap Between Research and Practice Barriers to and Facilitators of Evidence-Based Practice The Role of Informatics Developing EBP Guidelines Meta-Analysis and Generation of Knowledge

The Future Summary References

26 Bioinformatics, Biomedical Informatics, and Computational Biology Dee McGonigle and Kathleen Mastrian Introduction Bioinformatics, Biomedical Informatics, and Computational Biology Defined Why Are Bioinformatics and Biomedical Informatics So Important? What Does the Future Hold? Summary References


27 The Art of Caring in Technology-Laden Environments Kathleen Mastrian and Dee McGonigle Introduction Caring Theories Presence Strategies for Enhancing Caring Presence Reflective Practice Summary References

28 Emerging Technologies and the Generation of Knowledge Peter J. Murray, W. Scott Erdley, Dee McGonigle, and Kathleen Mastrian Introduction Looking Back from the Future Historical Overview Some Technologies of Today Some Views of What Will Affect the Future Some Emerging Technologies and Other Issues That Will Impact Nursing and Health Care 491 Summary References

29 Nursing Informatics and the Foundation of Knowledge Dee McGonigle and Kathleen Mastrian Introduction Foundation of Knowledge Revisited Knowledge Use in Practice Summary References

Abbreviations Glossary Index


The idea for this text originated with the development of nursing informatics (NI) classes, the publication of articles related to technology-based education, and the creation of the Online Journal of Nursing Informatics (OJNI), which Dee McGonigle cofounded. Like most nurse informaticists, we fell into the specialty; our love affair with technology and gadgets and our willingness to be the first to try new things helped to hook us into the specialty of informatics. The rapid evolution of technology and its transformation of the ways of nursing prompted us to try to capture the essence of NI in a text.

As we were developing the first edition, we realized that we could not possibly know all there is to know about informatics and the way in which it supports nursing practice, education, administration, and research. We also knew that our faculty roles constrained our opportunities for exposure to changes in this rapidly evolving field. Therefore, we developed a tentative outline and a working model of the theoretical framework for the text and invited participation from informatics experts and specialists around the world. We were pleased with the enthusiastic responses we received from some of those invited contributors and a few volunteers who heard about the text and asked to participate in their particular area of expertise.

In the second edition, we invited the original contributors to revise and update their chapters. Not everyone chose to participate in the second edition, so we revised several of the chapters using the original work as a springboard. The revisions to the text were guided by the contributors’ growing informatics expertise and the reviews provided by textbook adopters. In the revisions, we sought to do the following:

• Expand the audience focus to include nursing students from BS through DNP programs as well as nurses thrust into informatics roles in clinical agencies.

• Include, whenever possible, an attention-grabbing case scenario as an introduction or an illustrative case scenario demonstrating why the topic is important.

• Include important research findings related to the topic. Many chapters have research briefs presented in text boxes to encourage the reader to access current research.

• Focus on cutting-edge innovations, meaningful use, and patient safety as appropriate to each topic. • Include a paragraph describing what the future holds for each topic.

New chapters that were added to the second edition included those focusing on technology and patient safety, system development life cycle, workflow analysis, gaming, simulation, and bioinformatics.

In this, the third edition, we reviewed and updated all of the chapters, reordered some chapters for better content flow, eliminated duplicated content, split the education and research content into two sections, integrated social media content, and added two new chapters: Data Mining as a Research Tool and The Art of Caring in Technology-Laden Environments.

We believe that this text provides a comprehensive elucidation of this exciting field. Its theoretical underpinning is the Foundation of Knowledge model. This model is introduced in its entirety in the first chapter (Nursing Science and the Foundation of Knowledge), which discusses nursing science and its relationship to NI. We believe that humans are organic information systems that are constantly acquiring, processing, and generating information or knowledge in both their professional and personal lives. It is their high degree of knowledge that characterizes humans as extremely intelligent, organic machines. Individuals have the ability to manage knowledge— an ability that is learned and honed from birth. We make our way through life interacting with our environment and being inundated with information and knowledge. We experience our environment and learn by acquiring, processing, generating, and disseminating knowledge. As we interact in our environment, we acquire knowledge that we must process. This processing effort causes us to redefine and restructure our knowledge base and generate new knowledge. We then share (disseminate) this new knowledge and receive feedback from others. The dissemination and feedback initiate this cycle of knowledge over again, as we acquire, process, generate, and disseminate the knowledge gained from sharing and reexploring our own knowledge base. As others respond to our knowledge dissemination and we acquire new knowledge, we engage in rethinking and reflecting on our knowledge, processing, generating, and then disseminating anew.

The purpose of this text is to provide a set of practical and powerful tools to ensure that the reader gains an understanding of NI and moves from information through knowledge to wisdom. Defining the demands of nurses and providing tools to help them survive and succeed in the Knowledge Era remains a major challenge. Exposing nursing students and nurses to the principles and tools used in NI helps to prepare them to meet the challenge of practicing nursing in the Knowledge Era while striving to improve patient care at all levels.

The text provides a comprehensive framework that embraces knowledge so that readers can develop their knowledge repositories and the wisdom necessary to act on and apply that knowledge. The text is divided into seven sections.

• The Building Blocks of Nursing Informatics section covers the building blocks of NI: nursing science, information science, computer science, cognitive science, and the ethical management of information.

• The Perspectives on Nursing Informatics section provides readers with a look at various viewpoints on NI and NI practice as described by experts in the field.

• The Nursing Informatics Administrative Applications: Precare and Care Support section covers important functions of administrative applications of NI.

• The Nursing Informatics Practice Applications: Care Delivery section covers healthcare delivery applications including electronic health records (EHRs), clinical information systems, telehealth, patient safety, patient and community education,

and care management. • The Education Applications of Nursing Informatics section presents subject matter on how informatics supports nursing

education. • The Nursing Informatics: Research Applications section covers informatics tools to support nursing research, including data

mining and bioinformatics. • The Imagining the Future of Nursing Informatics section focuses on the future of NI, emphasizes the need to preserve caring

functions in technology-laden environments, and summarizes the relationship of informatics to the Foundation of Knowledge model and organizational knowledge management.

The introduction to each section explains the relationship between the content of that section and the Foundation of Knowledge model. This text places the material within the context of knowledge acquisition, processing, generation, and dissemination. It serves both nursing students (BS to DNP/PhD) and professionals who need to understand, use, and evaluate NI knowledge. As nursing professors, our major responsibility is to prepare the practitioners and leaders in the field. Because NI permeates the entire scope of nursing (practice, administration, education, and research), nursing education curricula must include NI. Our primary objective is to develop the most comprehensive and user-friendly NI text on the market to prepare nurses for current and future practice challenges. In particular, this text provides a solid groundwork from which to integrate NI into practice, education, administration, and research.

Goals of this text are as follows: • Impart core NI principles that should be familiar to every nurse and nursing student • Help the reader understand knowledge and how it is acquired, processed, generated, and disseminated • Explore the changing role of NI professionals • Demonstrate the value of the NI discipline as an attractive field of specialization

Meeting these goals will help nurses and nursing students understand and use fundamental NI principles so that they efficiently and effectively function as current and future nursing professionals. The overall vision, framework, and pedagogy of this text offer benefits to readers by highlighting established principles while drawing out new ones that continue to emerge as nursing and technology evolve.


We are deeply grateful to the contributors who provided this text with a richness and diversity of content that we could not have captured alone. Joan Humphrey provided social media content integrated throughout the text. We especially wish to acknowledge the superior work of Alicia Mastrian, graphic designer of the Foundation of Knowledge model, which serves as the theoretical framework on which this text is anchored. We could never have completed this project without the dedicated and patient efforts of the Jones & Bartlett Learning staff, especially Amanda Martin and Becky Myrick. Both fielded our questions and concerns in a very professional and respectful manner.

Dee acknowledges the undying love, support, patience, and continued encouragement of her best friend and husband, Craig, and her son, Craig, who has also made her so very proud. She sincerely thanks her cousins Camille, Glenn, Mary Jane, and Sonny, and her dear friends for their support and encouragement, especially Renee.

Kathy acknowledges the loving support of her family: husband Chip; children Ben and Alicia; sisters Carol and Sue; and parents Bob and Rosalie Garver. Kathy also acknowledges those friends who understand the importance of validation, especially Katie, Bobbie, Kathy, Anne, and Barbara.

Authors’ Note

This text provides an overview of nursing informatics from the perspective of diverse experts in the field, with a focus on nursing informatics and the Foundation of Knowledge model. We want our readers and students to focus on the relationship of knowledge to informatics and to embrace and maintain the caring functions of nursing—messages all too often lost in the romance with technology. We hope you enjoy the text!


Ida Androwich, PhD, RN, BC, FAAN Loyola University Chicago School of Nursing Maywood, IL

Emily Barey, MSN, RN Director of Nursing Informatics Epic Systems Corporation Madison, WI

Lisa Reeves Bertin, BS, EMBA Pennsylvania State University Sharon, PA

Brett Bixler, PhD Pennsylvania State University University Park, PA

Jennifer Bredemeyer, RN Loyola University Chicago School of Nursing Skokie, IL

Steven Brewer, PhD Assistant Professor, Administration of Justice Pennsylvania State University Sharon, PA

Sylvia M. DeSantis, MA Pennsylvania State University University Park, PA

Eric R. Doerfler, PhD, NP Pennsylvania State University School of Nursing Middletown, PA

Judith Effken, PhD, RN, FACMI University of Arizona College of Nursing Tucson, AZ

William Scott Erdley, DNS, RN Niagara University Niagara University, NY

Nedra Farcus, MSN, RN Pennsylvania State University, Altoona Altoona, PA

Kathleen M. Gialanella, JD, RN, LLM Law Offices Westfield, NJ Associate Adjunct Professor Teachers College, Columbia University New York, NY Adjunct Professor

Seton Hall University, College of Nursing & School of Law South Orange & Newark, NJ

Denise Hammel-Jones, MSN, RN-BC, CLSSBB Greencastle Associates Consulting Malvern, PA

Nicholas Hardiker, PhD, RN Senior Research Fellow University of Salford School of Nursing & Midwifery Salford, UK

Glenn Johnson, MLS Pennsylvania State University University Park, PA

June Kaminski, MSN, RN Kwantlen University College Surrey, British Columbia, Canada

Julie Kenney, MSN, RNC-OB Clinical Analyst Advocate Health Care Oak Brook, IL

Margaret Ross Kraft, PhD, RN Loyola University Chicago School of Nursing Maywood, IL

Wendy L. Mahan, PhD, CRC, LPC Pennsylvania State University University Park, PA

Heather McKinney, PhD Pennsylvania State University University Park, PA

Nickolaus Miehl, MSN, RN Pennsylvania State University Erie, PA

Peter J. Murray, PhD, RN, FBCS Coachman’s Cottage Nocton, Lincoln, UK

Lynn M. Nagle, PhD, RN Assistant Professor University of Toronto Toronto, Ontario, Canada

Ramona Nelson, PhD, RN-BC, FAAN, ANEF Professor Emerita, Slippery Rock University President, Ramona Nelson Consulting Pittsburgh, PA

Nancy Staggers, PhD, RN, FAAN Professor, Informatics University of Maryland Baltimore, MD

Jeff Swain Instructional Designer Pennsylvania State University University Park, PA

Denise D. Tyler, MSN/MBA, RN-BC Implementation Specialist

Healthcare Provider, Consulting ACS, a Xerox Company Dearborn, MI

The Editors also acknowledge the work of the following first edition contributors (original contributions edited by McGonigle and Mastrian for second edition):

Kathleen Albright, BA, RN Strategic Account Manager at GE Healthcare Philadelphia, PA

Schuyler F. Hoss, BA Northwest Healthcare Management Vancouver, WA

Audrey Kinsella, MA, MS Information for Tomorrow Telehealth Planning Services Asheville, NC

Susan M. Paschke, MSN, RN The Cleveland Clinic Cleveland, OH

Sheldon Prial, RPH, BS Pharmacy Sheldon Prial Consultance Melbourne, FL

Jackie Ritzko Pennsylvania State University Hazelton, PA

Marianela Zytkowsi, MSN, RN The Cleveland Clinic Cleveland, OH

Section I

Building Blocks of Nursing Informatics

Chapter 1 Nursing Science and the Foundation of Knowledge Chapter 2 Introduction to Information, Information Science, and Information Systems Chapter 3 Computer Science and the Foundation of Knowledge Model Chapter 4 Introduction to Cognitive Science and Cognitive Informatics Chapter 5 Ethical Applications of Informatics

Nursing professionals are information-dependent knowledge workers. As health care continues to evolve in an increasingly competitive information marketplace, professionals—that is, the knowledge workers—must be well prepared to make significant contributions by harnessing appropriate and timely information. Nursing informatics (NI), a product of the scientific synthesis of information in nursing, encompasses concepts from computer science, cognitive science, information science, and nursing science. NI continues to evolve as more and more professionals access, use, and develop the information, computer, and cognitive sciences necessary to advance nursing science for the betterment of patients and the profession. Regardless of their future roles in the healthcare milieu, it is clear that nurses need to understand the ethical application of computer, information, and cognitive sciences to advance nursing science.

To implement NI, one must view it from the perspective of both the current healthcare delivery system and specific, individual organizational needs, while anticipating and creating future applications in both the healthcare system and the nursing profession. Nursing professionals should be expected to discover opportunities to use NI, participate in the design of solutions, and be challenged to identify, develop, evaluate, modify, and enhance applications to improve patient care. This text is designed to provide the reader with the information and knowledge needed to meet this expectation.

Section I presents an overview of the building blocks of NI: nursing, information, computer, and cognitive sciences. Also included in this section is a chapter on ethical applications of healthcare informatics. This section lays the foundation for the remainder of the book.

The Nursing Science and the Foundation of Knowledge chapter describes nursing science and introduces the Foundation of Knowledge model as the conceptual framework for the book. In this chapter, a clinical case scenario is used to illustrate the concepts central to nursing science. A definition of nursing science is also derived from the American Nurses Association’s definition of nursing. Nursing science is the ethical application of knowledge acquired through education, research, and practice to provide services and interventions to patients to maintain, enhance, or restore their health, and to acquire, process, generate, and disseminate nursing knowledge to advance the nursing profession. Information is a central concept and health care’s most valuable resource. Information science and systems, together with computers, are constantly changing the way healthcare organizations conduct their business. This will continue to evolve.

To prepare for these innovations, the reader must understand fundamental information and computer concepts, covered in the Introduction to Information, Information Science, and Information Systems and Computer Science and the Foundation of Knowledge Model chapters, respectively. Information science deals with the interchange (or flow) and scaffolding (or structure) of information and involves the application of information tools for solutions to patient care and business problems in health care. To be able to use and synthesize information effectively, an individual must be able to obtain, perceive, process, synthesize, comprehend, convey, and manage the information. Computer science deals with understanding the development, design, structure, and relationship of computer hardware and software. This science offers extremely valuable tools that, if used skillfully, can facilitate the acquisition and manipulation of data and information by nurses, who can then synthesize these resources into an ever-evolving knowledge and wisdom base. This not only facilitates professional development and the ability to apply evidence-based practice decisions within nursing care, but, if the results are disseminated and shared, can also advance the profession’s knowledge base. The development of knowledge tools, such as the automation of decision making and strides in artificial intelligence, has altered the understanding of knowledge and its representation. The ability to structure knowledge electronically facilitates the ability to share knowledge structures and enhance collective knowledge.

As discussed in the Introduction to Cognitive Science and Cognitive Informatics chapter, cognitive science deals with how the human mind functions. This science encompasses how people think, understand, remember, synthesize, and access stored information and knowledge. The nature of knowledge, including how it is developed, used, modified, and shared, provides the basis for continued learning and intellectual growth.

The Ethical Applications of Informatics chapter focuses on ethical issues associated with managing private information with technology and provides a framework for analyzing ethical issues and supporting ethical decision making.

The material within this book is placed within the context of the Foundation of Knowledge model (shown in Figure I-1 and periodically throughout the book, but more fully introduced and explained in the Nursing Science and the Foundation of Knowledge

chapter). The Foundation of Knowledge model is used throughout the text to illustrate how knowledge is used to meet the needs of healthcare delivery systems, organizations, patients, and nurses. It is through interaction with these building blocks—the theories, architecture, and tools—that one acquires the bits and pieces of data necessary, processes these into information, and generates and disseminates the resulting knowledge. Through this dynamic exchange, which includes feedback, individuals continue the interaction and use of these sciences to input or acquire, process, and output or disseminate generated knowledge. Humans experience their environment and learn by acquiring, processing, generating, and disseminating knowledge. When they then share (disseminate) this new knowledge and receive feedback on the knowledge they have shared, the feedback initiates the cycle of knowledge all over again. As individuals acquire, process, generate, and disseminate knowledge, they are motivated to share, rethink, and explore their own knowledge base. This complex process is captured in the Foundation of Knowledge model. Throughout the chapters in the Building Blocks of Nursing Informatics section, readers are challenged to think about how the model can help them to understand the ways in which they acquire, process, generate, disseminate, and then receive feedback on their new knowledge of the building blocks of NI.

Figure I-1 Foundation of Knowledge Model Source: Designed by Alicia Mastrian.

Chapter 1

Nursing Science and the Foundation of Knowledge Kathleen Mastrian and Dee McGonigle


1. Define nursing science and its relationship to various nursing roles and nursing informatics. 2. Introduce the Foundation of Knowledge model as the organizing conceptual framework for the text. 3. Explain the relationships among knowledge acquisition, knowledge processing, knowledge generation, knowledge dissemination, and wisdom.

Key Terms

Borrowed theory Building blocks Clinical databases Clinical practice guidelines Conceptual framework Data Data mining Evidence Feedback Foundation of Knowledge model Information Knowledge Knowledge acquisition Knowledge dissemination Knowledge generation Knowledge processing Knowledge worker Nursing informatics Nursing science Nursing theory Relational database Transparent wisdom

Introduction Nursing informatics is defined as the combination of nursing science, information science, and computer science. This chapter focuses on nursing science as one of the building blocks of nursing informatics, although in this text the traditional definition of nursing informatics is extended to include cognitive science as one of the building blocks. The Foundation of Knowledge model is also introduced as the organizing conceptual framework of this text, and the model is tied to nursing science and the practice of nursing informatics. To lay the groundwork for this discussion, consider the following patient scenario:

Tom H. is a registered nurse who works in a very busy metropolitan hospital emergency room. He has just admitted a 79-year- old man whose wife brought him to the hospital because he is having trouble breathing. Tom immediately clips a pulse oximeter to the patient’s finger and performs a very quick assessment of the patient’s other vital signs. He discovers a rapid pulse rate and a decreased oxygen saturation level in addition to the rapid and labored breathing. Tom determines that the patient is not in immediate danger and that he does not require intubation. Tom focuses his initial attention on easing the patient’s labored breathing by elevating the head of the bed and initiating oxygen treatment; he then hooks the patient up to a heart monitor. Tom continues to assess the patient’s breathing status as he performs a head-to-toe assessment of the patient that leads to the nursing diagnoses and additional interventions necessary to provide comprehensive care to this patient.

Consider Tom’s actions and how and why he intervened as he did. Tom relied on the immediate data and information that he

acquired during his initial rapid assessment to deliver appropriate care to his patient. Tom also used technology (a pulse oximeter and a heart monitor) to assist with and support the delivery of care. What is not immediately apparent, and some would argue is transparent (done without conscious thought), is the fact that during the rapid assessment, Tom reached into his knowledge base of previous learning and experiences to direct his care, so that he could act with transparent wisdom. He used both nursing theory and borrowed theory to inform his practice. Tom certainly used nursing process theory, and he may have also used one of several other nursing theories, such as Rogers’s science of unitary human beings, Orem’s theory of self-care deficit, or Roy’s adaptation theory. In addition, Tom may have applied his knowledge from some of the basic sciences, such as anatomy, physiology, psychology, and chemistry, as he determined the patient’s immediate needs. Information from Maslow’s hierarchy of needs, Lazarus’s transaction model of stress and coping, and the health belief model may have also helped Tom practice professional nursing. He gathered data, and then analyzed and interpreted those data to form a conclusion—the essence of science. Tom has illustrated the practical aspects of nursing science.

The American Nurses Association (2003) defines nursing in this way: “Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations” (p. 6). Thus the focus of nursing is on human responses to actual or potential health problems and advocacy for various clients. These human responses are varied and may change over time in a single case. Nurses must possess the technical skills to manage equipment and perform procedures, the interpersonal skills to interact appropriately with people, and the cognitive skills to observe, recognize, and collect data; analyze and interpret data; and reach a reasonable conclusion that forms the basis of a decision. At the heart of all of these skills lies the management of data and information. This definition of nursing science focuses on the ethical application of knowledge acquired through education, research, and practice to provide services and interventions to patients to maintain, enhance, or restore their health and to acquire, process, generate, and disseminate nursing knowledge to advance the nursing profession.

Nursing is an information-intensive profession. The steps of using information, applying knowledge to a problem, and acting with wisdom form the basis of nursing practice science. Information is composed of data that were processed using knowledge. For information to be valuable, it must be accessible, accurate, timely, complete, cost-effective, flexible, reliable, relevant, simple, verifiable, and secure. Knowledge is the awareness and understanding of a set of information and ways that information can be made useful to support a specific task or arrive at a decision. In the case scenario, Tom used accessible, accurate, timely, relevant, and verifiable data and information. He compared that data and information to his knowledge base and previous experiences to determine which data and information were relevant to the current case. By applying his previous knowledge to data, he converted those data into information, and information into new knowledge—that is, an understanding of which nursing interventions were appropriate in this case. Thus information is data made functional through the application of knowledge.

Humans acquire data and information in bits and pieces and then transform the information into knowledge. The information- processing functions of the brain are frequently compared to those of a computer, and vice versa (an idea discussed further in the Introduction to Cognitive Science and Cognitive Informatics chapter). Humans can be thought of as organic information systems that are constantly acquiring, processing, and generating information or knowledge in their professional and personal lives. They have an amazing ability to manage knowledge. This ability is learned and honed from birth as individuals make their way through life interacting with the environment and being inundated with data and information. Each person experiences the environment and learns by acquiring, processing, generating, and disseminating knowledge.

Tom, for example, acquired knowledge in his basic nursing education program and continues to build his foundation of knowledge by engaging in such activities as reading nursing research and theory articles, attending continuing education programs, consulting with expert colleagues, and using clinical databases and clinical practice guidelines. As he interacts in the environment, he acquires knowledge that must be processed. This processing effort causes him to redefine and restructure his knowledge base and generate new knowledge. Tom can then share (disseminate) this new knowledge with colleagues, and he may receive feedback on the knowledge that he shares. This dissemination and feedback builds the knowledge foundation anew as Tom acquires, processes, generates, and disseminates new knowledge as a result of his interactions. As others respond to his knowledge dissemination and he acquires yet more knowledge, he is engaged to rethink, reflect on, and reexplore his knowledge acquisition, leading to further processing, generating, and then disseminating knowledge. This ongoing process is captured in the Foundation of Knowledge model, which is used as an organizing framework for this text.

At its base, the model contains bits, bytes (computer terms for chunks of information), data, and information in a random representation (Figure 1-1). Growing out of the base are separate cones of light that expand as they reflect upward; these cones represent knowledge acquisition, knowledge generation, and knowledge dissemination. At the intersection of the cones and forming a new cone is knowledge processing. Encircling and cutting through the knowledge cones is feedback that acts on and may transform any or all aspects of knowledge represented by the cones. One should imagine the model as a dynamic figure in which the cones of light and the feedback rotate and interact rather than remain static. Knowledge acquisition, knowledge generation, knowledge dissemination, knowledge processing, and feedback are constantly evolving for nurse scientists. The transparent effect of the cones is deliberate and is intended to suggest that as knowledge grows and expands its use becomes more transparent—a person uses this knowledge during practice without even being consciously aware of which aspect of knowledge is being used at any given moment.

Experienced nurses, thinking back to their novice years, may recall feeling like their head was filled with bits of data and information that did not form any type of cohesive whole. As the model depicts, the processing of knowledge begins a bit later (imagine a timeline applied vertically) with early experiences on the bottom and expertise growing as the processing of knowledge ensues. Early on in nurses’ education, conscious attention is focused mainly on knowledge acquisition, and they depend on their instructors and others to process, generate, and disseminate knowledge. As nurses become more comfortable with the science of nursing, they begin to take over some of the other Foundation of Knowledge functions. However, to keep up with the explosion of information in nursing and health care, they must continue to rely on the knowledge generation of nursing theorists and researchers and the dissemination of their work. In this sense, nurses are committed to lifelong learning and the use of knowledge in the practice of nursing science.

Figure 1-1 Foundation of Knowledge Model Source: Designed by Alicia Mastrian.

The Foundation of Knowledge model permeates this text, reflecting the understanding that knowledge is a powerful tool and that nurses focus on information as a key building block of knowledge. The application of the model is described in each section of the text to help the reader understand and appreciate the foundation of knowledge in nursing science and see how it applies to nursing informatics. All of the various nursing roles (practice, administration, education, research, and informatics) involve the science of nursing. Nurses are knowledge workers, working with information and generating information and knowledge as a product. They are knowledge acquirers, providing convenient and efficient means of capturing and storing knowledge. They are knowledge users, meaning individuals or groups who benefit from valuable, viable knowledge. Nurses are knowledge engineers, designing, developing, implementing, and maintaining knowledge. They are knowledge managers, capturing and processing collective expertise and distributing it where it can create the largest benefit. Finally, they are knowledge developers and generators, changing and evolving knowledge based on the tasks at hand and the information available.

In the case scenario, at first glance one might label Tom as a knowledge worker, a knowledge acquirer, and a knowledge user. However, stopping here might sell Tom short in his practice of nursing science. Although he acquired and used knowledge to help him achieve his work, he also processed the data and information he collected to develop a nursing diagnosis and a plan of care. The knowledge stores Tom used to develop and glean knowledge from valuable information are generative (having the ability to originate and produce or generate) in nature. For example, Tom may have learned something new about his patient’s culture from the patient or his wife that he will file away in the knowledge repository of his mind to be used in another similar situation. As he compares this new cultural information to what he already knows, he may gain insight into the effect of culture on a patient’s response to illness. In this sense, Tom is a knowledge generator. If he shares this newly acquired knowledge with another practitioner, and as he records his observations and his conclusions, he is then disseminating knowledge. Tom also uses feedback from the various technologies he has applied to monitor his patient’s status. In addition, he may rely on feedback from laboratory reports or even other practitioners to help him rethink, revise, and apply the knowledge about this patient that he is generating.

To have ongoing value, knowledge must be viable. Knowledge viability refers to applications (most technology based) that offer easily accessible, accurate, and timely information obtained from a variety of resources and methods and presented in a manner so as to provide the necessary elements to generate new knowledge. In the case scenario, Tom may have felt the need to consult an electronic database or a clinical guidelines repository that he has downloaded on his personal digital assistant (PDA) or that reside in the emergency room’s networked computer system to assist him in the development of a comprehensive care plan for his patient. In this way, Tom uses technology and evidence to support and inform his practice. It is also possible in this scenario that an alert might appear in the patient’s electronic health record or the clinical information system (CIS) reminding Tom to ask about influenza and pneumonia vaccines. Clinical information technologies that support and inform nursing practice and nursing administration are an important part of nursing informatics and are covered in detail in the Nursing Informatics Administrative Applications: Precare and Care Support and Nursing Informatics Practice Applications: Care Delivery sections of this text. Technologies that support and inform nursing education and nursing research are covered in the Education Applications and Research Applications of Nursing Informatics sections respectively.

This text provides a framework that embraces knowledge so that readers can develop the wisdom necessary to apply what they have learned. Wisdom is the application of knowledge to an appropriate situation. In the practice of nursing science, one expects actions to be directed by wisdom. Wisdom uses knowledge and experience to heighten common sense and insight to exercise sound judgment in practical matters. It is developed through knowledge, experience, insight, and reflection. Wisdom is sometimes thought of as the highest form of common sense, resulting from accumulated knowledge or erudition (deep, thorough learning) or enlightenment (education that results in understanding and the dissemination of knowledge). It is the ability to apply valuable and viable knowledge, experience, understanding, and insight while being prudent and sensible. Knowledge and wisdom are not synonymous: Knowledge abounds with others’ thoughts and information, whereas wisdom is focused on one’s own mind and the synthesis of experience, insight, understanding, and knowledge. Wisdom has been called the foundation of the art of nursing.

Some nursing roles might be viewed as more focused on some aspects rather than other aspects of the foundation of knowledge. For example, some might argue that nurse educators are primarily knowledge disseminators and that nurse researchers are knowledge

generators. Although the more frequent output of their efforts can certainly be viewed in this way, it is important to realize that nurses use all of the aspects of the Foundation of Knowledge model regardless of their area of practice. For nurse educators to be effective, they must be in the habit of constantly building and rebuilding their foundation of knowledge about nursing science. In addition, as they develop and implement curricular innovations, they must evaluate the effectiveness of those changes. In some cases, they use formal research techniques to achieve this goal and, therefore, generate knowledge about the best and most effective teaching strategies. Similarly, nurse researchers must acquire and process new knowledge as they design and conduct their research studies. All nurses have the opportunity to be involved in the formal dissemination of knowledge via their participation in professional conferences, either as presenters or as attendees. In addition, some nurses disseminate knowledge by formal publication of their ideas. In the cases of conference presentation and publication, nurses may receive feedback that stimulates rethinking about the knowledge they have generated and disseminated, in turn prompting them to acquire and process data and information anew.

All nurses, regardless of their practice arena, must use informatics and technology to inform and support that practice. The case scenario discussed Tom’s use of various monitoring devices that provide feedback on the physiologic status of the patient. It was also suggested that Tom might consult a clinical database or nursing practice guidelines residing on a PDA or a clinical agency network as he develops an appropriate plan of action for his nursing interventions. Perhaps the CIS in the agency supports the collection of data about patients in a relational database, providing an opportunity for data mining by nursing administrators or nurse researchers. In this way, administrators and researchers can glean information about best practices and determine which improvements are necessary to deliver the best and most effective nursing care (Swan, Lang, & McGinley, 2004).

The future of nursing science and nursing informatics is closely associated with nursing education and nursing research. Skiba (2007) suggests that techno-savvy and well-informed faculty who can demonstrate the appropriate use of technologies to enhance the delivery of nursing care are needed. Along those lines, Greenfield (2007) conducted research among nursing students to determine the effectiveness of PDA technology applied to medication administration. Her study makes a good case for incorporating such technology into nursing curricula. Girard (2007) discussed cutting-edge operating room technologies, such as nanosurgery using nanorobots, smart fabrics that aid in patient assessment during surgery, biopharmacy techniques for the safe and effective delivery of anesthesia, and virtual reality training. She makes an extremely provocative point about nursing education: “Educators will need to expand their knowledge and teach for the future and not the past. They must take heed that the old tried-and-true nursing education methods and curriculum