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 of 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 (see a dis- cussion of cognitive informatics for more information). 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 experi- ences the environment and learns by acquiring, processing, generating, and dis- seminating 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
Introduction 9
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 re-explore 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 (a computer term used to quantify data), data, and information in a random representation. 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 in- tersection 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 ex- pertise growing as the processing of knowledge ensues. Early on in nurses’ education, conscious attention is focused mainly on knowledge acquisition, and beginning nurses depend on their instructors and others to process, generate, and disseminate knowl- edge. 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 dis- semination of their work. In this sense, nurses are committed to lifelong learning and the use of knowledge in the practice of nursing science.
The Foundation of Knowledge model (Figure 1-2) permeates this text, reflecting the understanding that knowledge is a powerful tool and that nurses focus on informa- tion as a key building block of knowledge. The application of the model is described 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, provid- ing 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,
10 CHAPteR 1 Nursing Science and the Foundation of Knowledge
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.
Figure 1-2 Foundation of Knowledge Model Designed by Alicia Mastrian
KA – Knowledge acquisition KD – Knowledge dissemination KG – Knowledge generation KP – Knowledge processing
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Bits Data
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Bits Data Information
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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 tablet or smartphone, or that resides 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 tech- nology and evidence to support and inform his practice. It is also possible in this sce- nario 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 vac- cines. Clinical information technologies that support and inform nursing practice and nursing administration are an important part of nursing informatics.
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 applica- tion 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 mat- ters. It is developed through knowledge, experience, insight, and reflection. Wisdom is sometimes thought of as the highest form of common sense, resulting from accumu- lated 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 effective- ness 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 teach- ing 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 pro- fessional 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.
12 CHAPteR 1 Nursing Science and the Foundation of Knowledge
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 vari- ous 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 tablet or smartphone, in the cloud (a virtual information storage system), or on 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, administra- tors 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) suggested 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, Whitman-Price, Kennedy, and Godwin (2012) conducted research among senior nursing students to determine perceptions of personal phone use to access healthcare information dur- ing clinical. Their study indicated that ready access to electronic resources enhanced clinical decision making and confidence in patient care. 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 made 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 that has lasted 100 years will have to change, and that change will be mandated for all areas of nursing” (p. 353). Bassendowski (2007) specifically addressed the potential for the generation of knowledge in educational endeavors as faculty apply new technologies to teaching and the focus shifts away from individual to group instruction that pro- motes sharing and processing of knowledge.
Several key national groups continue to promote the inclusion of informatics content in nursing education programs. These initiatives include the Vision Series by the National League for Nursing (NLN; 2015); recommendations in the Quality and Safety Education for Nurses (QSEN) learning modules (2014a); the Technology Informatics Guiding Education Reform (TIGER) Initiative (Healthcare Information and Management Systems Society, 2016); and Nursing Informatics Deep Dive by the American Association of Colleges of Nursing (AACN; 2016). These organizations focus on the need to integrate informatics competencies into nursing curricula to prepare future nurses for the tasks of managing data, information, and knowledge; alleviating errors and promoting safety; supporting decision making; and improving the quality of patient care. Nurse educators are challenged to prepare informatics- competent nurses who can practice safely in technology-laden settings.
The TIGER (2007) initiative identified steps toward a 10-year vision and stated a key purpose: “to create a vision for the future of nursing that bridges the quality chasm with information technology, enabling nurses to use informatics in practice
Introduction 13
and education to provide safer, higher-quality patient care” (p. 4). The pillars of the TIGER vision include the following:
• Management and Leadership: Revolutionary leadership that drives, empowers, and executes the transformation of health care.
• Education: Collaborative learning communities that maximize the possibilities of technology toward knowledge development and dissemination, driving rapid deployment and implementation of best practices.
• Communication and Collaboration: Standardized, person-centered, technology- enabled processes to facilitate teamwork and relationships across the continuum of care.
• Informatics Design: Evidence-based, interoperable intelligence systems that sup- port education and practice to foster quality care and safety.
• Information Technology: Smart, people-centered, affordable technologies that are universal, useable, useful, and standards based.
• Policy: Consistent, incentives-based initiatives (organizational and governmen- tal) that support advocacy and coalition-building, achieving and resourcing an ethical culture of safety.
• Culture: A respectful, open system that leverages technology and informatics across multiple disciplines in an environment where all stakeholders trust each other to work together toward the goal of high quality and safety (p. 4).